Public board meeting (Wed, 17th Jan 2018 - 11:00 am) 

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Apologies and declarations of interest

[Mr Peter Wyman - 0:00:16]

OK Good Morning everybody welcome to the January Board can I make a particular welcome to our two new board members Lousais and John Oldham really welcome good to have you on board. We have an apology from Paul Rew who is ill, Paul if you

Minutes of the meeting held on 19 December 2017

happen to be as spending your sick leave watching this I hope the discussion makes you feel better. Are there any declarations of interest that anybody needs too to make? OK that’s good. Minutes of our meeting of the 19th of December are they a true

Matters Arising and action log

and accurate record of everything we discussed? Excellent thank you they are therefore approved. Matters arising there’s an action log and they are either all in progress or have been done so I don’t think there is anything we need to raise now if people are

Chief Executive's Report

[ David Behan - 0:01:35]

content and that takes us David to your report please. OK thanks Peter and I wonder if I could almost start at the end of the report and then and then jump back to the top of it so two things at the beginning. Firstly is
just to say that now at 11 o’clock the news of the announcement of the appointment of Kirsty Shaw as the Chief operating Officer for CQC will go out, Kirsty will join us on the 1st March I understand so I have to say Peter and
I did the appointment together and I think she was an outstanding candidate and I’ve got a great optimism about the contribution she’ll make so this is taking over substantially the role that Eileen did but slightly tweaking the role to give a greater focus on
the overall performance of the organisation and helping in that so I am really pleased to be able to make that announcement. Then I just want publicly to congratulate Andrea on a CBE in the New Year’s honours list I’m sure many on the Board would
support that and I know she says Twitter has exploded I don’t quite know what that means it couldn’t explode far enough as far as I am concerned but anyway it has exploded I think in a nice way which is great and I think it’s
the recognition of what Andrea has done for us at CQC and I think reflects well on the Directorate but I think it’s also for your public service career aswell so many congratulations. Thank you very much. So if we go back to the top of
the report now there is a performance report which I think we are now getting into tradition of a Chief inspectors beginning to introduce this and Kate will do the money bit on this but I think Andrea is going to kick off because the first

[ Andrea Sutcliffe - 0:03:46]

bit is wrong registration. Thank you so just to look at the performance report and just to pull out and three items for you, although obviously there may well be other questions that you would want to ask. The first is on registration and to note
that our activity continues to increase and it’s slightly awkwardly worded in the report but hopefully you can kind of see the sense of it which is that from each quarter throughout this year we have seen an increase in activity and that obviously puts pressure
on the team in terms of hitting the timeliness targets but we are continuing to be better performing than last year in our timeliness targets, dipped a little bit in November but you know there is a kind of a rhythm of this and in terms
of how it goes so I would like to commend the team for their continued effort to improve. Clearly the work that we are doing around the processes and procedures to strip out some of the bureaucracy around this which will help to speed up our
timeliness also looking at the work that we’re doing with the digital team to support the registration team both within my Directorate but obviously the very important bit of registration that happens in NCSC as well and so we will continue to see kind of improvement
over the next two years but I just wanted to draw that out and to make the point about the increased activity. The second area is an Adult social Care inspection and just to reflect that we have had significant turnover and vacancies within the team
there and that has impacted on our capacity but what has also impacted on our capacity to go to the services that we said that we would go to within certain time periods has been prioritising risk so we are returning to our inadequates and requires
improvements within the 6 and 12 months that we said that we would but unfortunately we’re not getting back to the goods and outstanding within the two years that we said that they would in all cases we are in some because we are responding to
the risks that have been raised with us and you can see in the report that of the good services that we are going back to 23 percent of them are deteriorating, 20 percent requires improvement and 3 percent to inadequate and that is on slide
8 and that obviously puts pressure on the team in terms of we weren’t expecting that level of deterioration in terms of the activity and and generally and particularly those that are dropping down to inadequate usually means that there is enforcement action that’s happening there
as well which is an increase of activity for the team too, again just wanted to highlight that. And last but not least is on the reports and we continue to make progress towards get into the 90 percent within the key performance indicator target of
getting reports out within 10 weeks and 50 days and the team are continuing to do that. We are monitoring that carefully and particularly monitoring how long it’s taking us to get outstanding and inadequate reports out which is where there is obviously a significant level
of scrutiny and sometimes particularly on the inadequate side things the significant level of challenge but the teams are receiving weekly reports identifying where the delays are, where the outliers are and inspectors and inspection managers are following those up to make sure that we do
that as quickly as possible. So shall we just pause there, is there

[Mr Peter Wyman - 0:07:42]

any questions or comments for Andrea? Lewis? I do have a question but it’s not specifically for Andrea, just on the issue that you just

[Professor Louis Appleby - 0:07:52]

raised, a couple things if I can. On
the issue of the change in ratings which I think is an interesting phenomenon of where on the whole there is a sense that ratings get better on re-inspection there is also quite a variation and the variation is across sectors and its applies to more
or less all the ratings so the outcome although I think we can be reasonably positive about what happens next the variation is enough for us to wonder why and I just wonder whether we’ve now got, across all the sectors not just in social care
services and not just specifically about social care, we’ve now got enough examples for us to draw some broader improvement conclusions or for that matter deterioration conclusions so in other words what is it that allows a trust or a care home to improve and what
is it that prevents that and what is it that leads to a deterioration after we’ve made a rating and in the Improvement Science that we’re trying to get to, we may have better data than more or less any anybody I would say so I’m
just keen that we we a use that I have a couple of points but I can

[Mr Peter Wyman - 0:09:06]

hold on to them unless you want to? Let’s just answer that, Ted you

[Professor Edward Baker - 0:09:12]

looked as if you are happy to? You can go first Ted. I’ll go first
then, I was going to highlight that actually when I came to reporting back on hospitals’performance because there is a continuing trend of our trust ratings improving as you say but it is mixed and some are getting worse but actually the majority are improving and
that is encouraging and I think first of all it’s a great tribute to hospitals working under enormous pressure that they are driving improvement and I think we need to recognise the amount of work is going on in these organisations to do that and especially
to the staff but also the management. I think the factors behind it were reflected in our report last July driving improvement and everything we’ve seen since has confirmed the conclusions of that report that this is about leadership it is about culture it is about
staff engagement and it’s about effective governance and I think that turns organisations around and increasingly we are seeing organisations learning from that and developing their own quality improvement cultures and I’ve been to several organisations recently where this is very much what’s driving it and
those are the organisation which are really changing and I highlight just this last week we published a report on Royal Berkshire hospital it was our I would be published last report two or three years ago it is now good and it is very high
good the Royal Berkshire hospital itself the site is currently an outstanding and that is a great tribute to an organisation working under pressure to the very real improvement if you talk to the staff they’ll say the cultural organisations for the change in the last
two years and that is a result of our report and I think is very

[ Andrea Sutcliffe - 0:10:45]

positive for them, Andrew Andrew to follow up on an that in adult social care we are following the lead and that hospitals gave is around the driving improvement report that
we published last year and doing a similar exercise in looking at 12 case studies of services that have improved from requires improvement or inadequate and requires improvement upwards and will be producing a report later this year hopefully in May demonstrating that and again I
think that very similar issues will come come out to what we saw in hospital trusts but it’ll be interesting to see if there are any variations or any kind of nuances from an Adult social Care perspective so we are doing that work to mine
into that data and also to do it on the basis of conversations with the organisations themselves so the registered managers their teams am and people using services to find out what’s happened there so we’ll be able to do something similar to what Ted’s team
did last year The second thing on deterioration I do think that two things 1 there probably is more work that we can do and I think we are sitting on an amazing evidence base of what are the factors that can cause that and there
are conversations that we are having with multiple team in terms of your how can we use the qualitative tools that we’ve now got that can actually look into the text of the reports and pull out some of those messages but I do think it
is reflecting what we have spoken about in the last two State of Care reports around the fragility and the precarious nature of the adult social care market and we are seeing concerns around staffing and particularly nursing in nursing homes and that impacting on safety
and on leadership and again I think that it’s those factors which if we did kind of get into a much more thorough analysis of it we would be seeing and I think it is important for us to use that information to highlight what people
need to be aware of but also ourselves and the rest of the system needs to be aware of in terms of the things that we need to do to

[Mr Peter Wyman - 0:13:03]

[Professor Steve Field - 0:13:05]

improve Steve thanks just to add to that that the figures for this has primary care
but it’s really general practice were talking about because they are the ones the majority of those that are rated doesn’t include the majority of our locations which actualy are industry if you look at by volume because they’re not rated of the GP ones this
data I think is as accurate as we can get it apart from the fact there are a number of surgeries which ceased to trade or merge or are taken over so these are based on going back to locations we’ve already been to what we
need to do is some more work to give you the figures on the takeovers mergers etc and it is quite fluid and we are finding some deterioration in some areas more than others so I think there’s a richness in the data the numbers are
still quite small but as the summer goes on we’ll have something quite

[Mr Peter Wyman - 0:14:02]

interesting to look at I think David and then Liz Again a really

[ David Behan - 0:14:07]

important pointless and I think you’ve chaired RGC for yesterday were paul had some slides in relation to deterioration in
return inspections in mental health and if you look at I think I’m right in my figures I think it’s 23 and 25 percent of those services we go back and we have inspected over the past 12 months or so are actually showing some deterioration
when we go back not improvement and I think this is something we need to keep vigilant because from those comprehensive inspections as Ted as outlined there was a really good performance on particularly inadequates improving but what we now face is some goods that have
deteriorated and declined and I think we need to understand not just why places that were required improvement have got better which was the subject of the publication but what is the challenge of holding that level of performance level rather than deteriorating and I think
this plays the Risk Register conversation we had earlier this morning and I think it’s behind Roberts question from me about what is the oversight of these services the challenge I think for us is because of the risk bares we’re going back to those services
where they are most worried about at the minute I am therefore it is almost a bit better this than I am by a long way it will be an inevitability that you’re going back to those who are most worried about you are going to
find something but I think it is something we need to continue to keep a under quite close scrutiny is trying to understand we did say in a quite a transparent way I thought on the stair report in October and I’m not sure it got
picked up I think it’s a particularly dominant narrative running at the minute about how a services the NHS in particular about money and actually it is something I think which is quite important that sits under that narrative about also are improving and a number
are as Ted has said but there are some declining and why is it that the declining and what is it and what do we understand and I for one wouldn’t like to actually give a definitive view about why things are deteriorate but I think
we do need to understand and that comes onto the predictive stuff that we were talking about earlier that you were you were raising and Peter has talked about as well so I think it’s a hugely important question so Liz yes thanks very much I

[Ms. Liz Sayce - 0:16:36]

wanted to ask about in the report at this comment that warning notices going down and criminal actions are increasing I suppose I wanted to understand is this a shift in our own policy in terms of how we are using the powers at our disposal
and or is it that there’s a change in the numbers of providers were meeting a threshold for criminal interventions and what the implications of whichever of those are for impact of use of these

[Mr Peter Wyman - 0:17:11]

powers in this way David did you want to answer that

[ David Behan - 0:17:15]

question I think Andrew might be better and I think its both I don’t

[ Andrea Sutcliffe - 0:17:19]

think it’s either or I think it’s and and so we are using the criminal power to prosecute a criminal investigations more I think we are reflecting on what is the impact
of a warning notice what’s the change we’re trying to get from issuing a warning notice and using those in a much more strategic and

[ Andrea Sutcliffe - 0:17:42]

judicious way so it’s a bit of both to be honest Liz Do you want to add anything Andrew I think
that that’s right and also on the criminal side of things it’s not just the kind of prosecutions it’s also used to fixed penalty notices for failure to display ratings and a failure to have a registered Manager in post without kind of a sensible and
good explanation because as we know that’s absolutely critical in terms of the quality of care so there’s a variety of things that are covered in the criminal prosecution area and David is absolutely right what we’re wanting to do is to make sure that we
are using the most appropriate of our enforcement tool kit to enforce the improvement that we want to say or indeed to hold an providers to account for the poor practice that we have seen and I think that we’re also getting better to be perfectly
honest were also getting better at recording that information and presenting that back to the board and to the Executive Team as well

[Sir Robert Francis QC - 0:18:53]

Robert Just to follow on really from Steve’s point about figures concealed closures reconfigurations and so on and I wondered whether it will
be helpful not necessarily all the time but we probably have access to what the figures are for an area because if you one GP practice closes the patients will go somewhere else and actually what is the effect of our inspections and our general activity
on the general standards of an area as measured by the cumulative numbers of goods that are inadequate or requires improvement now it’s not as simple as I understand it cut counting up institutions because all organisations because it’s more a question of how many patients
are exposed to them but I just wonder whether it would be worthwhile considering how we do that sporadically in terms of systems reviews or whatever but whether it will be something we could look at on a more

[Professor Steve Field - 0:19:55]

regular basis We haven’t spoken that’s what
I’ve just asked my team to do for the next time that GPs are because I it is interesting when you look at London compared with some other areas and also in a general medical practice if you look at the press and there are some
areas of the country where other GPs are saying they’re stopping taking additional patients on because of the pressure because if we’ve got a practice in that area which is failing or we then have to balance our enforcement activity to close a practice or to
suspend a practice even if they are really really bad in an area where the system is so stretched and there aren’t any other providers we have to work very closely with the CCG’s and NHS England to try and ensure rapid action to improve the
quality of care whereas in other areas that might be different so we work in a very sensitive way and we’ve had to make some very difficult decisions over the last few years just because of that. Toulouse,

[Mr Peter Wyman - 0:21:00]

about half an hour ago you said you
had two or three questions, so that was the first. Well the others

[Professor Louis Appleby - 0:21:06]

ones are a comment in a way about the presentation of data, but it is on the same issue. It would be useful to see two refinements of the of the data. One
is it would be useful to see the mental health contribution separately from the hospitals as a whole, because some as we were hearing yesterday there is a mental health story reviewing that RGC yesterday, and that is that it would be useful see that mental
health trusts listed separately on improvement and ratings and so on. And the same then applies to special measures data. We used to say where this where special measures were being applied, which sectors, and of course there is a story there about the large number
of social care providers and to some extent primary care actually, where almost all the special measures locations were. We don’t have that any more, we have a kind of flow diagram now which tells us who was coming in and out of special measures but
it doesn’t tell us anymore where they are, in terms of their sector and I think that was quite a useful story. That’s one thing, I’ve got one other thing, which is about safeguarding data. This is on page 5 and it’s about safeguarding and I
think it’s the mandatory actions or notification to local authorities if I haveunderstood correctl, so it’s slide B. We are reporting as being below our KPI on this every month and our performance generally doesn’t look too bad because it is roundabout 90 percent but it
is consistently below our KPI. I just wondered whether that’s something we should be considering more, whether there’s a reason for that and could be doing more about that, given that we have the KPI.

[Mr Peter Wyman - 0:22:54]

[ David Behan - 0:22:59]

David, it’s you. There’s a bit of technical detail about this
Larissa, I can’t quite retrieve if I’m being truthful, but I think what you see here is some improvement, but I’d want to come back to you to be honest, I don’t feel I’m sufficiently up to date on, because if you look at the other
stuff that’s going on in NCSC they’ve made really good progress on their improvements and I don’t know the back story on why this one appeared to be stuck at 89 to 90 percent and it’s not really shifted over the past few months, when everything
else they’ve been doing up there, has had a pretty generous, do you

[Mrs Kate Harrison - 0:23:46]

know Kate? OK there is a story. Simply that it is a cumulative figure because they have difficulty when they were setting up the system earlier in the year, so it was quite
low, so they are constantly playing catch up but they are actually achieving the target at month by month basis now, and thats why. You need to plug yourself in The second thing that we’ve done, because we’ve as well as the NCSC data we’ve had
consistent performance issues making that last 8 to 10 percent, right across the organisation, so the Safeguarding Committee has done an end-to-end review of the process, trying to work out whether there are process improvements we can make. What we particularly discovered is at two or
three steps there was a huge amount of duplication with double-entry going on between those things, which were regenerating safeguarding alerts and those things that were also generating notifications and concerns and we agreed at the last Safeguarding Committee to strip that duplication out and create
a much more streamlined process. We believe that that will make a big difference because it will mean two things, one is that particularly in some of the high referral areas, particularly in adult social care it will make a difference to the numbers of alerts
and concerns that inspectors are needing to deal with on a daily basis but more importantly it will increase the sense and the confidence that if it comes through with a safeguarding alert or concern, there is something that needs to be done with it at
the moment it has generated quite a lot of false negatives any if we are quite honest on a priority day a sense from inspectors that they probably won’t be anything there and therefore they leave it so the change of this will be to it
to enable that focus we consulted staff about it and we’re just moving into the implementation and we are confident that that will be very important building block in this step change to be able to reach that

[Mr Peter Wyman - 0:25:56]

that KPI. Great, thank you. You may as
well stay where you are because eventually it will be your turn. You might like to turn your microphone off though. David, back to you. I think what should happen next is Ted and Steve will just give their

[ David Behan - 0:26:12]

update in relation to it and an
then Kate will do the money. Sorry did you want to raise something? I did, thank you Peter. I mean its a left-field question but it is

[Mr Jora Gill - 0:26:28]

something that is playing on my mind as I listen to the conversation. We are talking about the ratings
really a lot of the rating changes to say requires improvement or inadequate staff and staff numbers and resourcing and implying that adequate staff particularly in adult social care and potential interest. You also talked about sort of predictive and how to predict these things. The
left field question is really, one thing that we know that is about to happen is Brexit and that’s going to have a huge impact on potentially, depending on the type of Brexit we have, and we know it’s going to happen, my question was is
there any way of doing any form of impact analysis on what the the the effects on Adult Social Care in particular, but potentially trusts as well, what the impact of this actually could be or maybe looking at the different scenarios of what type of
Brexit we could have and doing different impacts for the different

[ Andrea Sutcliffe - 0:27:32]

scenarios. Two, three things on that. One, you are absolutely right they at we are already seeing the impact of Brexit on staffing both in terms of the numbers of nursing staff from European countries
coming on to the register and those that are leaving and also and availability of staff in adult social care out of the grades and that it’s an issue for the health service and is a big issue for Adult social Care is actually twice as
many people working in adult social care from a European Union as there is in the health service. In terms of the analysis the National Audit Office is currently doing a study on workforce in Adult Social Care and that due to report later in the
next couple of months which I think will give a really good basis for consideration of these issues and I also know that and the Department of Health itself from an Adult Social Care point of view because that’s the system steward role sits with them
for that is looking at what the potential impact of Brexit might be and what the mitigating actions could be. I think my personal view on this is that we’ve not really bottomed all of that out but we do need to be thinking very seriously
about what the workforce strategy should be for Adult Social Care going forwards because I am personally very worried about what that

[Professor Edward Baker - 0:29:07]

impact is going to be. Thanks, Ted? Thank you. In terms of performance in hospitals you’ll see on slide 6 at the inspection activity
is high and remains high now where the well into the next phase of hospital inspections and that is generally progressing well it isn’t just about inspections to remind you it is also about building much stronger relationships with providers from ongoing relationship meetings and I
want to pay tribute to our staff who have adapted to the than use a scheme of inspection but also to working with trusts in a different way very effectively and I’ve had some very strong positive feedback from trusts about how much they value the
relationships they are developing with their local CQC staff that the next phase as I say is is well embedded but we are not complacent and I think we are endeavouring to learn and improve it and we would be building quality proven methodology into the
next phase going forward because we see this as something not just that we do once and get right but something we continuously improve and that is going to feed into our ability to approach data in a different way and drive efficiency improvements going forward
for the inspector. The reports are now being published we’ve been publishing our next phase reports and we’ve already discussed some of the changes that we’ve seen in the ratings and those changes have continued on the next phase report so demonstrating that we can set
demonstrate changes in quality on next phase as we were on the previous comprehensive inspections we mentioned earlier on about the number of trust going from RI to good which is is really encouraging but I should stress that there are a significant number of trusts
about an equal number who requires Improvement and are staying requires improvement on re-inspection now requires improvement to some extent was if you like the majority of trusts in the first round of inspections and we are worried that some trusts are seeing that as a
kind of comfortable place to be and trusts have demonstrated that even in the present environment they can significantly improve their services and that’s what we’re expecting to see in all trusts. So we are thinking through our approach to the Trust are at present stuck
at requires improvement which we don’t think is a satisfactory place for them to be. For those that that deteriorate to inadequate of course from the special measures regime and that is I think being very effective in turning trusts round it takes a while but
trusts are turning round and we took the latest trust out of special measures only a week ago there are now 15 trusts still in special measures and many of them are making progress and I hope during this next few months we will be able
to recommend further Trust coming out of special measures going forward. In terms of performance going back to the performance issues again it’s important to stress that we’re doing a lot of work on report timeliness that is still a concern for us in hospitals the
next phase has been designed around very tight timescales and I am very grateful to our staff who are working to those and we are delivering the next phase reports in a timely manner. We still have independent health provider reports that we are clearing a
backlog off so we haven’t quite hit the KPI’s yet and but a lot of work is going on and the average time to production reports is coming down so I hope we will be able to demonstrate that we are achieving the KPI’s in the
very near future. Thanks, can we go to Steve and then we will open it

[Professor Steve Field - 0:32:49]

up for comments and questions. Thank you I have got a couple of issues one of them was safeguarding but Ursula who is one of my deputies answered all of the,
she anticipates things really well so that’s excellent but there are systems issues both in safeguarding and in how we look at the forequarter breaches which our new Director of business Manager is taking as priority it may involve the whole system through a data input
as well. I want to, as Ted said very well for his staff congratulate our staff again for the continuing good progress towards publishing reports very quickly it’s something that’s come up over the last few years for the whole of CQC at National Audit Office
and the health select committees and a our performance is very good on that now and it’s pleasing to be able to say that at the same time as the staff survey for primary care is excellent although we can do even better but it is
a really really good response from our staff on that, we are going to talk about the pause of some inspections in another point later I think, I’ll keep it short. Thank you Steve, John? Thank you, a

[Mr John Oldham - 0:34:10]

question for Ted there’s lot of reports this
morning about a younger nurses leaving the system and I wondered if that was a correlated stall in the ratings and your inspections and secondly going back to the Brexit point and there was a 90 percent drop in application from EU nurses to come and
work here and those two things seem tricky, I wondered what your

[Professor Edward Baker - 0:34:46]

prediction might be going forward? The workforce is one of the key pressures facing the NHS at the moment its workforce across all groups but clearly nurses are the most common of the of
the largest part of the workforce and so there is a particular concern in that regard. I think when we started our comprehensive inspection regime several years ago there were real concerns about the the plans for staffing clinical areas and we have to challenge those
but trusts I think have stepped up to that on recognising the staffing they need but they still have problems in recruiting staffing and I think is a major challenge for trust going forward and there are very few trusts we go to who don’t tell
us that nurse recruitment is a real issue for them. A lot of the time they are filling gaps with agency and temporary staff who may be very good staff but inevitably because they are not permanent staff they don’t have that same continuity of care
that permanent staff provide. Occasionally we see Trust have difficulty filling shifts and those are trusts where we sometimes have to take action over their staffing numbers but they are working very hard to do that in terms of going forward I think one of my
chief concerns is and if you read some of the stories about the young nurses that you’re talking about this morning they talk about the pressures they work under and they talk about the difficulties they work under and I think it is very important that
we focus on the support and well-being of staff they are working under pressure and we need to recognise that actually the staff need support if they are going to provide excellent care to their patients. I am still worried about the NHS staff survey it
still remains and it’s been stuck in that way for many years with a high level of staff reporting bullying at work, you know and I think that is a real concern and in other services I think would be it would be questioned so I
think when we look at staffing some of it is about recruitment and the issues around Brexit and other staff recruitment I think this is a question but part of it is about retention and actually making staff enjoy and get satisfaction from their work it
is a great vocation working in the health service and the greatest satisfaction you get is from that one to one interaction with patients and feeling your make a different to individual people’s lives but if you find you working in an environment where it’s very
difficult to do that because of the pressures of the work you’re under then I think it is very difficult to draw that satisfaction and I think we need to recognise the staff need support. Robert. Can I just

[Sir Robert Francis QC - 0:37:14]

say how much I agree with what
Ted has just said and add that my understanding is that senior nurses are leaving as well so there’s a shortage in retention at that level which of course is part of the knock-on effect of the quality and experience that junior nurses have because they
ate not getting the right support. My question is a fair amount of frankly not entirely co-ordinated work is going on around the system about how we should improve recruitment, retention, the quality of life for staff but I’m wondering what contribution the Care Quality Commission
can make to that work in particular by way of identifying the good practice that undoubtedly exists in some trusts who don’t have quite as much of a problem as other places, to do those things which actually make life tolerable and possibly even valuable for
staff, I’m not talk about pay increases now I am talking about the conditions in which many staff now have to work in which they have no place to rest, no place to eat, students I learn who have to pay for car-parking spaces when they
go too remote sites and don’t actually get any reimbursement in relation to that. All these little things, they sound little in terms of money but they actually extremely important for people who work in the system and unless something is done about this I’m persuaded
that things are only going to get worse leaving aside the huge challenges of Brexit, immigration, control policies and so on. Well I

[Professor Edward Baker - 0:38:59]

would support everything you said there Francis. It is making staff feel valued but also giving them support in actually doing their job,
recognising the difficulties of their job. So some of it is some of those if you like peripheral things that actually make their working lives easier but it’s also the culture in which they work and we’ve seen many trusts where there is still a blame
culture if things go wrong, the front line staff get blamed, well clearly that is a difficult environment in which to work and staff need to be if you like drawn into into a culture where they feel positive and supported and encouraged to do good
work if you look at our outstanding hospitals those with really embedded quality improvement cultures, you’ll find the staff there the staff recruitment issues there are much less. I’m not saying they don’t face challenges because the whole system faces challenges but there is one of
those hospitals I was talking to a few days ago and they were saying they had set themselves the goal of having no agency nurses whatsoever, which is a great achievement for hospital in the NHS at the moment and yet but that is very real
for them and achievable and I think there’s an awful lot more that hospitals can do in terms of culture and staff engagement and effective leadership that will make a real difference to their recruitment and retention of staff it will not solve the problem because
there is a genuine shortage but it will make the best of where we are and I think at the moment we are not making the best of where we are because we are not creating a working environment in a working culture that people feel

[ David Behan - 0:40:28]

supported in. David can we come back to the rest of your report please? Right thank you, I am now going to go on to paragraph 2 of my report and this is a brief update in relation to digital intelligence is pointing out two things,
we continue to work on IMS3 that’s the platform we’re on that we share with NHS England the Department of Health and we updated you on this in December and this is just to say that those conversations continue to go forward and following the board
meeting in December the focus of activity has really been about developing the business plan which was an item that we considered earlier today particularly in relation to digital. And then the second issue was the commercial activity to secure some of the skills that we
need to introduce into the organisation to make sure that we’re well placed to take that forward. So that work continues I meet with the patron Andrew and Helen on a weekly basis on a Monday just for half an hour to check where we’re up
to so I can give the board some reassurance that there is a huge amount of focus on that activity. Paragraph 3 is the decision that we took within the organisation to pause routine inspections I think there is a question from Mr. Ward in relation
to this that has been placed as well so anticipating this. What I’ve tried to do in this paragraph is just to explain the decision that we made and it was to pause routine inspections in hospitals and some inspections in primary medical services these were
for those services that we’d rated good or outstanding previously and if they were scheduled to have a routine inspection during January that we wouldn’t go ahead with that routine inspection in light of the pressure that hospitals were under in respect of norovirus and a
influenza if a trust had been rated requires improvement or inadequate or there had been are concerned that had been referred to us that we were equally concerned about and we were intending to bring forward an inspection those inspections would continue so this wasn’t a
moratorium or a pause on inspections it was an attempt to apply a risk stratification to the activity that we were going to undertake. That was a conversation, to go to Mr. Ward’s first question who made the decision, that was a conversation that we began
on Monday a couple of weeks ago and we worked at that through the Executive Team on Monday and Tuesday we checked the data we look at how many inspections, it is less than a handful of Trusts inspections, Ted will give you a number I
think but I think it’s less than five. And that we published that decision in a letter that I signed on the Thursday of that week so over a four-day period we actually had the discussion and we looked at the pros and the cons we
looked at how many inspections this would affect on the inspection programme and took the decision. Effectively it was an Executive Team decision I take responsibility for a that it was my name that went on the letter and I stand by the judgement that we
made in relation to this. In relation to PMS one of the interesting phenomena that I think we’ve had an and Steve might comment on this as well Peter it was, you know we have specialist advisers on our inspections these are GP’s, these are serving
GP’s and a number of GP’s said they couldn’t do the inspection which was programmed during January because of the level of flu and they couldn’t afford to be away from their surgery and get the cover in because of the pressure that they’ve got back
in their practices that they needed to be. So in a sense we were trying to balance the impact that inspections have on the places we go to so but we are also cognisant of and sensitive to the fact that some of the people we
needed wouldn’t be released from their inspections to do some of this stuff so we were trying to ease that pressure as well because we did need specialist advisers on those inspections we were going to go back to do because they were requires improvement or
inadequate we were not stepping back from doing those inspections so it is a balance between impact on the services we were regulating and also the supply of particularly specialist inspectors that we’ve got, our sickness rates havn’t gone inordinately high within CQC. We do have
some sickness rate but we’re not inordinately high so they influence the decision. In terms of external influences on that decision I think is why your questions Mr. Ward, there were no external decisions whatsoever I got up on Saturday morning looked at a press thought
about this which is sadly what I do on Saturday mornings thank about the week that we’ve had in the week that is coming up and so is there a contribution we can make to ease some of the pressure that people feel they are under
at the present time, without stepping back from doing our core responsibility which is to provide public assurance about the quality of health and care. I can honestly say that nobody outside of CQC at any conversation with me nor have they had any conversation with
me in the lead-up to that so if this was were we pressured by anybody they answer is categorically No. And as I say we then had a conversation within the organisation Ted had the Heads of inspection coming in to see him on the Monday
it was an opportunity to take an absolutely bang up-to-date position from the Heads of inspection, Steve spoke to the DCI’s and Heads of inspection during Monday and Tuesday, Andrea went away and talked to her people her management so this was an informed position that
we we we took Peter. And I thank you for your third question Mr. Ward which was why was the decision made, the decision was made to balacne the impact on people providing services where they are dealing with norovirus and influenza as well as the
surge in winter but also to accommodate how we could ensure that those inspections that we needed specialist advisors we got those specialist advisors available to us. We’ve got to remember a significant number of our hospital and GP inspections in particular specialist Advisors a crucial
part of that team that goes into a hospital and if they are serving practitioners which is the position we’ve been trying to move to not time expired retired practitioners and that is an issue about credibility then there is going to be a pull on
the time about are they present in the delivery of service or are they present on inspections. So as I say we weren’t stepping back from doing inspections but we were trying to get some accommodation but if the Board remembers Naomi helped me with this
but when the junior doctors’dispute was on we also took a similar kind of approach on the Junior doctors because of the pressure that hospitals were under providing cover and if you remember it was consultants that we’re doing the frontline cover during the junior doctor
strikes to ensure that was on and we did have some conversation again then about what the intensity of our inspection programme should be where we did do some scaling back in light of that and again they were marginal, they were very small numbers but
we did try and make some accommodation to it. I don’t know what the non Executive colleagues are going to say in relation to this but one of the learning points from this is should we adjust our inspection programmes over the winter period to allow
for the workforce supply issue the skills supply issue that we need in acknowledgement because as Ted has said to us on many occasions winter comes round every year and it comes for us as well so there is an issue about how we provide accommodation
to this whilst continuing to provide assurance. So I’ve gone a bit more Peter just to answer Mr. Ward’s question because he asked three questions about who made the decision, was there any influence on it and why did we do it so I hope that’s
done that as well and I think there might have been non Exec Members that wanted raise some similar points aswell. So just before we open it up can I just say David I mean you rightly said this was a decision taken by the executive
team but I reassure the Board that I was fully aware of it so as you always do keep me fully informed and I fully support it. Ted just

[Professor Edward Baker - 0:49:49]

again before we open it up it would be quite helpful if you just talk about the
role of the the relationship managers I mean you were talking about earlier but I think in this context it’s really important. This has been reported in some sectors as we’re stepping back from risk and that’s absolutely not what we’re doing and I think it’s
very important to stress that’s designed to be flexible and agile and respond to events rather than be planned six months in advance and this is the first opportunity for us to demonstrate that and I’ve been impressed by the way that our staff have actually
focused on that we are not standing back from inspecting services under pressure if we believe there is risk to safety and quality for patients indeed we will probably be inspecting in January just as much as we are going to, we may be inspecting in
different areas focusing on different things depending on the risks we identify and we have been inspecting emergency departments under pressure over the last 10 days or so, we’ve issued enforcement action against at least two services in the last week or so because of concerns
and we will go on focused on services under pressure we want to be supportive and I think it’s very important to recognise that the staff in the front line are doing a great job in delivering care. They are working under pressure they have been
put in a position where they have, a lot of work can begin with the extra flu and norovirus etc as David has mentioned and they have great difficulty in finding beds for patients and so they are working under enormous pressure we want to support
them we don’t want to do anything to undermine them but equally we want to ensure that patients are kept safe and we will be going forward with a plan to inspect any emergency departments where we find this evidence either from intelligence or from data
that suggests that patients are being put at risk in those Departments but I think I should pay tribute to the staff working in emergency departments at the moment and in acute medical services they are working under pressure and I think the planning that has
gone into winter has been highly effective in making sure they are maintaining as good quality care as they could. You will remember that we wrote to chief executives in September to tell them what we thought were the essential elements of safety built on what
we learned from the good and outstanding A&E departments in the country and I think those those factors are being taken into account on the ground and we will ensure where they’re not being taken into account we take action. Stephen and the Lewis. Thank you

[Professor Steve Field - 0:52:14]

Chair, just to build on on David and Ted’s point I mean we were having a debate within our team at the same time David was having his Saturday morning coffee and read of the papers so actually we came in on Monday morning we came
wanting to have this discussion as a team as well and I just wanted to slightly redress the balance of reporting in that when you read the papers it’s all about hospitals it’s all about A&E, actually most care in the NHS is provided by GPs
and nurses in primary care and actually most of the pressure for winter is on general medical practice you read about A&E departments but actually where you’ve got GPs working harder many GPs are doing longer hours seeing more patients to keep the pressure off A&E
departments but you only see the reporting from hospitals and I’d like to on record a pay tribute and add to Ted’s tribute to the staff in A&E to the GPs and the staff who are going the extra mile to try and keep the pressure
off and keep people where they should be which is at home. We were having some issues around SPAs having to cancel inspections on short notice because of either illness or as David quite rightly said were wanting to provide care for for their patients and
so we were reviewing what was happening and for us it was an important decision in order to focus the resource we had on those practices we were worried about and this affects now One Hundred and One practices we have postponed the inspections of, none
of those were acutely worried about from a risk point of view but we’ve reallocated SPAs to focus on those we are Thirty of those practices have been rescheduled already and we’re pushing seventy one of the good outstanding practice reviews back to next year to
quarter 1 because we’re not worried, it was just part of our ongoing programme and the feedback has been really supportive but again with Ted and David saying as well we are not doing this at risk to patients it is reallocation of resources and because
of the heterogeneity of primary medical services it does mean we can use different SPAs and our inspections teams to look at independent providers and others are therefore we can reallocate and keep the

[Professor Louis Appleby - 0:55:03]

productivity up as well. Lewis. Thanks, I should say first of all
that I think on balance it was the right decision but it is on balance because I think there are some other considerations as well it obviously runs the risk when we’re talking about our relationship with the providers that we are focused on that to
a degree which, where patient experience at a particularly difficult time for the NHS is outweighed by our concern to do the right thing by the providers and that’s the way in which it could be interpreted and I think to some extent is the way
it might have come across in some places. So in other words you could argue that this is the time when we should have, our scrutiny should have increased this is the time when the system is under greater pressure when patient experience might have deteriorated
as it wasn’t a one off this was a predictable and potentially a period of several weeks not just a period of a couple of weeks even in the trusts that were rated as good, it may be that those are trusts we should be most
interested in because they are the ones where the deterioration might be greatest, we don’t know. So although I support the decision I think it’s very important that we now do the right thing in understanding patient experience during this difficult time for the NHS and
so I think we should be looking for a greater scrutiny through other means so how we use data, how we relate to the trusts and expect to comment on the specific issue that we should be proud to tell patients and the public how patient
experience was affected where possible so a piece of work which would correct any false impression that we’ve got the balance wrong and that might include some of the specific incidents, I mean we hear it almost everyday there is a particular incident that’s happened somewhere
which is said to reflect the pressure that particularly A&E departments are under although I accept that it’s not just A&E departments and in my field thre was one particular incident, a patient who it was reported died, fatal overdose in an A&E department I think
that was in Worcestershire. So the question for us I think is have we followed that up are we looking at what was actually happening in thatA&E department when that incident occurred and so on. So I think there’s a requirement on us now to provide
sort of compensatory increase in scrutiny even though it might not be by inspection I just want some reassurance that will be doing. Ted I

[Professor Edward Baker - 0:57:48]

don’t know if you want to quickly respond to any of that. Paul just repeat what I said a few minutes
ago, we have increased our focus on A&E’s under pressure and will continue to do so and that particular case you highlighted we are

[Mr Peter Wyman - 0:58:03]

following up. So I mean my own perspective is very briefly two things. One, our whole strategy is to be a risk
based and intelligence led and I think this is exactly what we’ve been doing and secondly just to slightly change the impression Lewis that you might have left there that that we need a compensatory activity because I think the compensatory activity as Ted and Steve
both said is actually we’ve been moving our resource to where we have the greatest concern so it’s not that we haven’t been doing anything it’s just that we’ve been doing it in different places and I think that’s a really important message to get across,
that is what I was going to say but Robert go on you were going to say

[Sir Robert Francis QC - 0:58:40]

something. Well agreeing with a lot of what Lewis has said and indeed what Ted has said I understand the reasons behind this decision but it prompts for me
a number of questions. The first is if it be the case that at a time of maximum pressure the way we undertake an inspection if we did it would actually make the situation worse rather than better then are we considering, Lewis I think has
made this point but I am putting it a different way, are we are considering how we can visit places to see what’s actually going on in a way which doesn’t produce that pressure but at the same time protect patients. For example we hear of
reports of 20 plus ambulances outside some hospitals, we hear reports of elderly people in corridors sometimes on the floor or not even on trolleys it seems to me that our staff inspectors, our representatives should be in such places in order to see what is
going on and the public really require that. That’s the first point, the second point is that the premise behind this decision is that our assessment of risk is sufficiently good to enable us to identify the places we need to go to do just what
I have described and at what basis do we know that our intelligence, the information we gather in real time is good enough to enable that to happen and my third point is that if we don’t apply the same criteria to the good and outstanding
places some whom will have been given that rating now some time ago and actually their rating may or may not have related to any observation about how they deal with this sort of pressure should we be not going to visit them for two reasons
one is they may not be as good as we think they are but actually perhaps just as importantly they may be as good as we thought they were they may be showing exactly, we know there are some hospitals was despite all of these pressures
have not cancelled elective operations, have not been having huge waiting times in A&E and so on, so why aren’t we actually not wasting their time going there to trumpet their achievements. I mean I think

[Mr Peter Wyman - 1:01:05]

you make a really good point Robert in that inspection
is by far and away not the only contact we have with a hospital visit I mean Ted you and colleagues and even I am in hospitals quite

[Professor Edward Baker - 1:01:19]

regularly. I think that’s right and just to reassure Robert there are lots of informal visits that go
on that are not inspections and clearly we want to build relationships with organisations and for them to be honest with us about their problems and we visit them regularly and this last week our teams have been doing informal visits to A&E’s just to see
what’s going on without trying to inspect them. So in a sense we are doing what you ask and we are also in touch with ambulance trusts about any particular delays so they can identify where they feel particular pressures are in the system as well
and that will inform our approach to individual services so I think we are trying to do that I mean we can’t be everywhere all the time and the situation in an emergency department can change hour by hour so inevitably we cannot see everything that
goes on but what I would stress and I think it’s important that we get this message across if you read our reports from emergency departments over the whole year you will see elements of this the system is under pressure at the moment and that’s
particularly so, but we’ve been reporting our concerns about emergency departments throughout the year and you’ll see reports from the summer where supposedly emergency departments aren’t under winter pressures where we found unsatisfactory and unsafe care and taken action as well. So it’s important that we
don’t just we don’t just accept that winter is the problem and the rest of the year everything is well. So Jane very quickly then I think

[Ms. Jane Mordue - 1:02:47]

we need to move on. Healthwatch end and review that’s what we do we are there when the inspectors
go home and I’m just tapping a note to my staff saying what actually did happen with that hospital there. So that’s a very light way of

[ David Behan - 1:03:06]

going in and can be very effective. David. Thank you, I think the conversation just captures exactly what the
Exec team went through on the pros and cons and you’ve just rehearsed what we did over the four days that we were having the conversation if it’s any consolation and on balance that’s where we got to and so I am grateful for the conversation.
If I could just go very briefly Peter to paragraph 4 in my report which I think I’m telling the board what you already know in relation to the powers to the rate independent healthcare providers and the work we’ve done over the summer and they
publication in January the Department of Health’s outcomes of their consultation on this proposal but I want to take the opportunity just to clarify something which I think has been a bit muddied and a bit opaque which is we do have new powers but those
new powers do not give us the ability for CQC to rate Health applications apps or websites and it’s quite important because I think there’s a narrative out there at the minute that we do do that, we do not do what, we do is we
rate the services that people might access through an app not the app itself and what we’re trying to say in this very final paragraph of this is that we are doing and we have begun to do some work with other arms length bodies who
have oversight to some of those services to make sure that there is absolute clarity between the organisations about what the respective responsibilities are and then just going back to partly the conversation we’ve had Peter that the public can’t takle an assurance that we are
looking at these things when we’re not it is the importance of the assurance we give I think which is the point that Lewis was I think getting at behind his question and that’s what you want to do. I’m not going to do the publications
you can read those and we’ve covered the appointments so if I conclude the report there Peter thank you. Great so we’re running horribly late but I really do want to spend the time that we’ve allocated Ursula to the Health and Justice report, is Nigel

Children’s Health and Justice Report to the Board

outside? Oh Nigel is there sorry I beg your pardon. Nigel join us. So I don’t know who’s going to kick off, put your microphone on please. So the first thing is just to thank the Board for this opportunity to come and talk to you
about the work that the team the Childrens Health and justice team have been doing for many years and aswell I think just raising the profile perhaps of some of those areas that CQC is responsible for in some of our ways of working that perhaps
haven’t had as much attention while we’ve been focusing on some of the core comprehensive inspection programme over recent years but also because I think they highlight some of the work that we do in support of some of the most vulnerable populations whether that’s vulnerable
children, those looked after, people detained in a secure estate for a whole range of reasons, those in immigration detention centres as well as those in prisons and secure facilities for young people. I hope the report demonstrates some of the work that we do in
partnership with other bodies and again as we look forward in some of the other presentations I know you’ve had around the local system reviews about CQC with others modelling Partnership in regulation and assessment in the same way as we hope to see that sort
of partnership in terms of how those systems are working together and this team in relation to their work whether it’s with Ofsted or Her Majesty’s Inspector of prisons and Constabulary and probation have been doing this work for some time and have been over the
last year or so particularly sharing internally with the local systems review team and others, some are learning in those areas. I hope what the report also does is highlight some of our successes and particularly our impacts which aren’t only through the individual work that
we do within local areas, the feedback that we get from sending inspections from individual prisons about the impact that our work has through our reporting and regulatory action but some of our highly impactful thematic reviews again often done in partners with other agencies on
areas like domestic violence, child sexual exploitation, and misuse of substances in in the secure estate and being asked to contribute through things like the independent inquiry into child sexual abuse we were asked to present evidence and go back subsequently to some informal sessions offering
advice on the recommendations much to the credibility of my friend Nigel here. I think there are a couple of things that are really important to that success, I think one thing that we do in our methodology which isn’t routinely shared by some of the
other methodologies in CQC is the use of case tracking and people find the powerful messages that we get out of tracking a child’s right the way through the system gives a real granularity and really helps both local systems and us in our thematic review
to identify where were those real pinch points and critical moments sometimes what opportunities were maximised for improvement and sometimes what opportunities were lost and I certainly know we’re having a conversation with some of the other teams who do some of this work although it’s
a little bit labour intensive I think there is a real benefit cost-benefit equation to have for when judiciously applied in those areas where you’re really trying to get underneath what is going on and what is the impact in terms of a fact that is
happening and I know that Nigel would want to say that in areas for example a SEND inspection programme has been really powerful thinking capturing some of that stuff and has been reflected back to us on occasions where it’s the first time sometimes local stakeholders
have got together to prepare for the evil inspection and actually has carried on having conversations afterwards because they recognised how useful it was to join up some of those relationships across the system. In line with other parts of CQC we share some common challenges
I think the Board will not be unsurprised to know that in terms of what’s going on within local authorities in systems, children’s services are under immense pressure currently and we certainly know that the prison estates are real opportunities to be working in partnership with
Her Majesty’s Inspector of prisons although sometimes bringing together a lead inspectorate with a statutory regulator has its challenges in terms of how the powers sit and how we maximise some of those opportunities but I think if our colleagues were here they would say that
those relationships again have really strengthened over the last couple of years and we will shortly be meeting again with Peter Clarke, Steve’s opposite numbers as as Chief Inspector to discuss how we continue to take forward those relationships particularly where we’ve got those complex situations
of NHS trusts and other providers working into the secure estate with not all of the leavers then to be able to deliver services in a way that they would like to end the big example at the moment is shortage of prison officer and other
staff able to escort patients to the services and appointments that they need to go to, really complex about where you hold that to account through the provider who on the one hand is failing to deliver services but it’s another partner that is not enabling
that to happen and how again do we speak that truth to power in terms of what it is that’s really causing that pressure in the system, what should our expectations be of providers in those circumstances about how they are responding and flagging some of
those risks while not getting into situations of blaming them and holding them to account for that for which it is very difficult for them to be accountable. I propose to stop there, Nigel is there anything you wanted to add? No I think I would
have covered, I think just to emphasise I think that the team that carry out these inspections they’re a national team, very specialist in nature and they are quite intensive inspections and I think if you looked at the staff survey results you’ll see that both
teams will maximise positive results in the Commission and I think that reflects I think the value that they see they get from these inspections, they see that the inspections we do and the nature of these inspections have great value and as a consequence of
that I think that’s why we saw such quite spectacular results in the staff survey. I think the other comment I would make merely is that I think it’s taken us a long time to have our foot really in the door chip in relation to
the joint inspection work, we’re working with inspectors have got quite different cultures to ourselves but I think by doing the hard work and some of those inspectors are here today of the work that they’ve done in engaging with other inspectorates we have a very
credible relationship with other inspectorates and you’ll notice I think we’ve certainly for example do a lot of work with Ministry of Justice Home Office, DFE, DH we are always called the table as equal partners and certainly Minister of Justice talked to us last year
about raising the profile of health within prisons we were critical partners in that discussion we were called alongside HMIP and they wanted to talk to us separately as well. So what we have seen is very important in that dialogue. And finally just another comment
to make is that one of the consequences of our inspections is that we do, agencies in a local area are required to come together to talk to us and when we go away without doubt we’ve had numerous examples of where agencies will recognise the
value of talking to each other and they continue those conversations after we’ve left and I have no doubt that has a significant impact on the way in which services are provided. Just before, can I just say that it seems to me that the areas
you’re working in are in many respects some of the most challenging

[Mr Peter Wyman - 1:14:25]

that we work in the environment the fact that the providers as you say are in control of a lot of the factors that gets in the way of delivery. My sense Steve relates
to what Nigel and Ursula both said the partnerships that are now involved are working really well we’re not seen as trying to gatecrash or we’re not in competition with each other it’s now beginning to work extremely well is that how you see it? I

[Professor Steve Field - 1:14:57]

see that, absolutely and I mean it is a great tribute to the team that the environment that they work in often particularly if you look at say prisons, it’s very very challenging and I think the team have been the word spectacular I think they
have been spectacular and it was really good when we got the staff survey results back because some of the inspections, I mean just like in hospitals actually people away from home for substantial periods of time working in the night as well as during the
day and I am really pleased that we’re giving a report to the Board now and you’ve put them in the open board because I think we should share that sort of work because these are very vulnerable people that we are shining a spotlight on

[Professor Louis Appleby - 1:15:50]

their care and the team are doing a great job. Lewis. It’s really good that this has come to the Board I do I really think this is up there with the most important work that we do the reasons Steve has just said they are
some of the most vulnerable people in the system, people with previous neglect and high rates of most of the problems health and social problems that we should be concerned about so it’s really good that you’re here. And to see the progress that’s been made.
Would it be useful to get a couple of comments from you though on one or two issues that you’ve touched on and they do, my questions do reflect the collaborative work that your inspections have to be involved in. So if you take prisons for
example, very unhealthy environment and psychologically a very unhealthy environment and yet very psychologically vulnerable group of people and what’s your impression of the kind of impact that we can have not just on the direct healthcare where people are receiving you know sort of clinic
appointment and treatment and the issue of escorting is the problem but on this wider issue of the ethos of institutions as you know I went to a prison recently and it is just a reminder of the environment and the way that the environment can
have an impact on people’s health and we just would not accept in health the environment in which vulnerable psychologically damaged people are looked after in prisons and although these aren’t necessarily healthcare facilities, although they are not great either, these are vulnerable people in institutional
care looked after essentially by the state and I just wonder whether we are able as the healthcare inspector to have that influence on the wider system and just before we go I’ve got a second point to this if that’s OK and it’s the point
you made about case descriptions I think it’s a really good point about young people, say young people in care for example, people who spend time in secure settings and then emerge into the outside world because those people move between a host of different services
carrying their vulnerability with them and all the potential for things to go wrong and I just wonder whether there is any way in which we can highlight what happens to those people they seem to be a really good example of what we’re trying to
do now which is understand the the pathway that people are on the movement of people between services not just look at the individual service, you know those are the people you might start with if you were taking that approach and I just wonder whether
we should be doing more about what you’re finding for those young people. So I think in terms of the wider system issues particularly in relation to prisons but also into Children’s Services I think we have had and will have more impact on two or
three different levels. So the first one and I hope Jan will nod, our inspection Manager for the health and justice team. The HMIP has recently introduced a new framework for their own assessment where health services fit within the respect domain but also under the
healthy prisons policy and I think we had a lot of input in how the HMIP themselves thought about that domain and the issues in relation to that healthy prison environment as well as the issues about specific health services and I think we are continuing
to push on that open door of how it is that we get how we might have a greater role in assisting with the assessment and evaluation of some of those wider health particularly some of the public Health and Health and wellbeing aspects within the
prison service and that’s certainly what we will be discussing with Her Majesty’s inspectors of prisons in are in our Annual review meeting and it’s one of the reasons why we think it’s so important that our inspectors continue to have free rein across the prison
estate and we’ve had conversations about the risk of that in terms of our inspectors being key carrying through the estate but on balance we think that is absolutely the right thing to do because it gives us the ability to comment and working with dedicated
health inspectors from from HMIP into those assessments. I think the second thing is the work that we’ve done within some of their thematic reviews which again pulls that together and seeks to create a bigger narrative and put that narrative up into policy, and secondary
I think we’re particularly pleased that two or three really important strategic issues have now been picked up so in 2007 there was a report from the Health Select committee that advised that the prison needs to do particular work on the prospect of older people
within the prison estate which at that point was completely rejected. I went two weeks ago now to the first MOJ steering group on how we are going to care and support older people in the prison estate and that includes the physical environment but is
allowing us to discuss dementia care and a wide range of health and wellbeing issues around older prisons and we are doing a thematic review of social care within prison on the operation of the care act and I am also part of work with NHS
England where we’ve got some dedicated people working together on the care and support of people with learning disabilities and difficulties, who are another vulnerable population and I had exactly that conversation at steering group last week, where I thought that case tracking methodology will be
particularly powerful looking at how those perhaps some of those individual’s the opportunities that were missed early in their life when they were children and young people that meant that they got into the prison estate and certainly we’ve had that conversation in the context of
the Child and adolescent mental Health Services thematic review which you also know that we’re doing about what is it, particularly in terms of the equalities and inequalities agenda that mean that some people will end up in the justice system and some people will end
up in a tier 4 secure bed and sometimes it’s the issues of background and a range of other things around opportunities that distinguish what happens to a distressed 14 or 15 year old that is beginning to exhibit difficulties about whether that’s regarded as illness

[Mr Peter Wyman - 1:22:39]

or delinquency. Great, thank you I’m going to bring this to an end not because it’s not really interesting but I just, we are so late but I think he will have picked up from what Lewis said and certainly what I think this is such
an important area and a very difficult environment for our people and I just like to echo I think the whole boards thanks to your staff collectively for all that they do so thank you very much indeed everybody. And yes I was going to say,
I know he is sitting there and so thank you. Lewis, a challenge for you, I don’t know if you ever listen to just a minute but you have 1

[Professor Louis Appleby - 1:23:16]

minute without hesitation, repetition or deviation to brief the Board on last night’s RGC committee. OK,

Health and Justice Report to the Board

two topics, one was mental health we heard about the inspection programme where a third of mental health trusts have been rated requires improvement or inadequate mostly requires improvement two thirds have been rated good or outstanding mostly good and subsequently on re-inspection to pick up
the point we discussed briefly earlier there’s a reasonable improvement story where of the requires improvement trusts about three quarters have improved on re-inspection so a positive, sort of positive anyway, overall message about where mental health inspection is going and the improvement that it might
be triggering there are some other concerns there are some thematic reviews at the moment on CAMHS there’s another one on the mental Health Act and the rising use of mental Health Act powers and Paul Elliott who is the deputy Chief Inspector who oversees our
mental health inspections had some other themes for future work very sensitive areas which is planning to explore, sexual safety, physical restraint, long term a rehabilitation wards and so on. So some very forward looking positive account of where mental health has got to. Second theme
of the meeting was actually a report, an interim report really of an internal investigation an incident that was raising questions about some of CQC’s approach particularly on the issue of fit and proper person regulations so there was a discussion about that and I think
it’s fair to say its incomplete and so we will come back to it at a later time but it was raising questions for us about how we apply the fit and proper person regulation, whether it’s doing exactly what we want it to do and
therefore whether we might have a view on its future but also on our own investigative process do we when something happens and incident happens and we’re concerned about the implications for how we work do we have a proper process for initiating an instant for
reporting it for the governance of the learning and so on and what came out of that incident review was in particular that we ourselves need an instant investigative process which is a little bit more formal, little bit clearer for people and although the meeting

Any other business

didn’t conclude on that we are expecting to receive a further report on how that might go. Thank you Lewis, it was a very good meeting

[Mr Peter Wyman - 1:25:52]

yesterday. Is there any other business the Board wanted to raise? Great, so I think that is that. Mr. Ward
I hope you think you’ve had a pretty thorough answer to your question, I hope you also got a copy of the letter that I sent you in answer to your question from the previous Board meeting. I have not got any other questions from members
of the public or actually here so with that, running very late, we finish the meeting. Thank you very much indeed.
  • Professor Louis Appleby

    Position Board Member

  • Professor Edward Baker

  •  David Behan

    David Behan

    Position Chief Executive

  • Professor Steve Field

    Professor Steve Field

    Position Chief Inspector of General Practice

  • Sir Robert Francis QC

    Position Board Member

  • Mr Jora Gill

  • Mrs Kate Harrison

    Position Director of Finance, Commercial & Infrastructure

  • Ms. Jane Mordue

    Ms. Jane Mordue

  • Mr John Oldham

  • Ms. Liz Sayce

  •  Andrea Sutcliffe

    Andrea Sutcliffe

    Position Chief Inspector of Adult Social Care

  • Mr Peter Wyman

    Mr Peter Wyman

    Position Chairman