April 2018 Board Meeting (Wed, 18th Apr 2018 - 11:00 am) 

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Apologies and declaration of interest

Minutes of the meeting held on the 21st March

Right good morning everybody and welcome to our April board meeting. I don’t think we have any apologies for absence. Does anybody have any interest they need to declare? Excellent so that takes us to the minutes of our March meeting. Is everybody content they are

Matters arising and action log

a true and accurate record of what we discussed and agreed. Good thank you very much I take that as approved. Miraculously there is nothing outstanding on our action log which is a great achievement. Is there anything else that anybody wanted to raise as a

Chief executive's report

matter arising that’s not otherwise on our agenda? OK. So swiftly we move on David to your report. Thanks Peter. Good morning everybody I’ll do this in two bits if we do the performance report and then the pattern that we’ve had over the past few

Apologies and declaration of interest

Apologies and declaration of interest

Apologies and declaration of interest

Apologies and declaration of interest

Any other business

Any other business

Any other business

Any other business

meetings our colleagues around the table will pick up some of the key issues from the performance reports and then I’ll come back and I’ll whizz through the other items Peter. So on terms of performance again we’ve separated the introduction into those that are on
track and those aren’t performing to the plan that we’ve got. You can see on inspection frequencies good progress his being made, national customer Service Centre good performance that has been made. I’m not going to dwell on this but on money we’re underspending, on registration
we’ve got a strong performance particularly in the context of increased volumes, NCSC is performing above plan. Safeguarding alerts after a dip are back to where they need to be. In terms of volumes of inspection we’re performing strongly but there’s key issues related to recruitment
and recruitment pipeline has begun beginning to work. The perennial challenge around inspection reports and the time again you’ve got the up-to-date data as we continue and colleagues continue to work on that and whistle-blowing data is in here and we’ve tried to separate this out

[ David Behan - 0:02:38]

into priority one and two three and four to give you a sense of the priority that’s given to that information when it comes in. This is a monthly performance report so this is a reduced performance report given the one that he get quarterly but
the annex is attached to the report which has a more detailed analysis in that informs the covering report so if I pause here Peter and if colleagues have questions I’m sure that ET colleagues will endeavour to answer them. Mark Thank you chairman. David I

[Mr Mark Saxton - 0:03:18]

just wonder if I could ask a couple of questions around the sickness and turn over data that’s listed there. I mean looking at sickness we have a target of 5%, digital NHS tell me that the NHS averages 3.8% with quite a large percentage of
musculoskeletal injuries leading to absence which I am sure our staff wouldn’t have. And the UK average for absence according to ONS is 2%. So I’m asking whether we’ve actually got the bar at the right level based on our performance over the last 12 months
and perhaps more importantly for us as a Board whether there are areas where there are outliers and that would be a more interesting picture for us. That’s my first question. The second question if I may is about turnover. Again that’s an average and I
wonder where we have outliers and if that’s a cause of concern particularly in turnover. Usually there’s the challenge around turnover in the first year or second year of service so the churn. We have a big recruitment campaign on at the moment for inspectors so
whether that would be of more interest to us where the churn rather than the straight average. And then thirdly in terms of recruitment that I’ve preferred to it’s a key measure of organisational effectiveness and performance and I wonder whether we shouldn’t be recording average

[ David Behan - 0:05:13]

time to fill Okay Thank you So on the sickness and the 5&% we’d sat this, I’m not quite sure it a target, I’m not sure I want people to have an ambition to have 5% of our workforce being sick. If we were to set
a target I’d prefer we set it at zero but I think what we’ve got. Sorry It’s a line It’s a line yeah and but I think what we’ve got here is the record of our sickness average over a period of time which has been
pretty static over virtually all of my time in CQC to be honest Mark if you were look at our, going back to one of John’s early points trend analysis over last year and the year before that and the year before that I think it’s
going to come out at this 3 point something per cent. We can break that down and each directorate gets a much more broken down by directorate and then within directorates it’s broken down even further so I think it now goes down to each inspection
team and the inspection directorate so we keep this information in quite a granular fashion and that goes back to managers at different levels through the organisation. So if there are spikes long term illnesses we’ve got an older workforce, a predominantly female workforce that will
generate a particular kind of long term sickness issues that we’ve got. We do get musculoskeletal issues. You’ll see a lot of inspectors who were working away will now carry briefcases which are on wheels because of the amount of just the computers, the weight of
the computers people that have been doing the locals strategic reviews will have quite a bit of data with them that they’ll be carrying so musculoskeletal stuff is there. But if you wanted more information Mark I’m sure Ruth Bailey as Director of People would make
that available to you and get into that. Then the question on turnover. Turnover has been a tricky one because we’ve gone through a period where we have been expanding we have been taking on more people and but one of the issues we’ve had is
people that have been in the organisation for a long time it were felt that the changes we’ve made are not for them. So we’ve had a number of people leaving because they don’t feel comfortable with the changes we’ve introduced. These are people that have
been regulating for 10, 15 in some cases 20 years going back through our predecessor bodies who in terms of some of our new methodologies have felt this is not for them. One of the issues for instance would be about report writing. One of the
things inspectors would say is this job would be fine if I didn’t have to write the report and actually the report writing is an inherent and integral part of the job that we have to do so. So I think there have been people leaving
because they felt the job isn’t for them. Interestingly in your point about turnover in terms of the length of time people have worked for us and actually being alert to that as an Executive team we have had that report and monitored that through a
period of time. This is a high-level report that we’ve not been through and again it is something that we look out because that allows us to reflect on have we got the recruitment decisions right, are we inducting and supporting people prior to them beginning
to take up the heavy lifting of the job that they’ve come here to do is a key issue so we are alert to that. I can’t remember what the figure is off the top of me head in relation to this. And I think as
a consequence of that data we’ve spent quite a bit of time looking at how we receive people into the organisation, I hate this phrase but they use the phrase on boarding. But there’s a lot of effort gone into that about how we induct and
support people and I know there’s a lot of effort particularly for inspectors gone in by inspection managers to make sure that process is done well and people feel supported well. And again I’m sure Ruth would share with you the data and we take that
down. And then on recruitment I don’t know whether we do collect that if I’m being truthful the time to fill jobs. It’s certainly something that I think has informed the policy position we’ve now got to which is for inspection staff in particular to run
an always on recruitment. So instead of having recruitment campaigns which begin and end, we’ve adopted approach which is always on and I think has been informed by the position that we’ve had about recruitment. We’ve also got variation in recruitment so there’ve been some particularly
hot or cold spots depending on how you want to refer this so recruiting in adult social care inspectors I think in the south-east has been particularly challenging. A lot of effort has gone into that and I think those teams now in the south-east are
coming up pretty much up to full strength. But one of the reasons our performance on producing reports on time and doing the inspection programme that we’ve flagged in that south-east corner has been down to workforce. I’ve visited seems more recently where there should be
80 inspectors and they’ve been operating with 3. They’re now up to strength and so I think probably last month saw them start with 80 inspectors in a team that should have had 80 inspectors for the first time. So I think we are taking action
in relation to this but I’m just, do you know if we have ... So it’s one of the things I’ve asked them to look at because it helps us

[Ms. Kirsty Shaw - 0:11:21]

around both forecasting of our finances but also in terms of forecasting of our, you know
our resource profile so they are now on with that. Thank you David. I am actually meeting with Ruth so I’ll follow up a lot of those items.

[Professor Louis Appleby - 0:11:41]

Thank you. Anything else. Lewis Again on the issue of improvement which your talked about before but this
relates to the report data and it’s page 23 I think of the report information, yeah I think it’s 23. So it’s where we see the change in ratings on reinspection. Do you see what I mean. It looks like, it could be 24, it’s slightly

Chief executive's report

difficult to tell actually. We’ve got 2 reports one has 9 pages, the other has about 12 actually It’s slide 9 in the Oh right You’re looking at something we haven’t got? No, no, no No, because it’s the bottom right hand side if you do
the numbers of pages in the whole thing it gives you that but it’s slide 9 I think It comes up as page 24 for those who looking at my version of it. And, but the question is not what page we are on but the
issue of improvement. Because maybe the times that I’ve missed this before but it just looks like we are getting an increasing divergence between sectors on how much improvement is occurring on reinspection. And now obviously there’s a question of how many reinspections this is based
on and so on but if you look at the third slide, the third graph there that’s see ratings change for previous requires improvement, and say you compare the mental health trust with the acute trusts so the mental health trust look like they respond on
reinspection are quite likely to get a rating of good whereas the acute trusts that’s not true. I think that’s probably always been true in primary, in PNS but it just looks like the acute trusts are being slightly left behind so good for mental health
trusts they’re doing very well. It looks like they’re improving on reinspection. A question over acute trusts and when we look at these things we tend to say well that’s partly because of the complexity of acute trust overall ratings, their aggregates they’re based on a
number of locations and because there’s many locations in an acute trust that slightly counts against an upgrade in overall ratings but that’s not really true here because the locations figure which is on the same graph is more or less the same as the overall
grading figure. So it does, and if you then look at what impact that has on graph A you can see that we’ve now got quite a disparity between sectors on how likely you are to be served by a good or a requires improvement trust
locally and the acute sector is the only part of the system now where you’re more likely locally to have a trust with a rating which is below good. That’s the only sector and so mental health has improved, social care has improved but the acute
sector, I think it has improved but just quite obviously less so. And so, now is this real and are you, I suppose Ted in particular, are you getting the sort of confirmatory feedback on this. What’s your explanation for that. Yes. Well I think it’s

[Professor Edward Baker - 0:14:45]

real Lewis. I think we are seeing improvement in all sectors. We are seeing more rapid improvement in mental health trust then we are in acute trusts and I think that is real finding. I should say that we need to recognise the pressure the acute
sector is under at the moment and has been for a while it’s increased over winter and I think it’s 20 trusts in total moved from RI to good in the last year which I think is quite an achievement when you take into account the
pressure they’re under and I think we need to celebrate and congratulate them on that. I think there is a residual ... That pressure exists in mental health as well, I just... I think we need to, there is an issue with a significant number of
trusts that are stuck at RI and I think that is becoming an increasing evidence and I think there was a sense when RI was the most common rating for trusts that I think some trusts felt comfortable in that space. And it’s very clear that
some trusts have risen to the challenge of improving their services despite the pressures. Other trusts have, if you like, focused too much on the operational pressures and failed to see the necessity of improving services overall. And we will be challenging those trusts and increasingly
challenging those trusts that are stuck at RI to follow the example of those that have improved. So I think different sectors are moving at different speeds but they are all improving and I think the challenge to the acute sector is despite the pressures it’s
working under to keep driving improvement and I think you know many trusts have shown they can do that but some trusts still need to demonstrate it. Anything else for report anybody but he wants to raise? Okay David. Onwards Thanks. So I’ll do this next
bit quite quickly so. I just wanted to draw attention to the board in public session that we’d submitted evidence to the housing committees local government joint health and social care select committee where they were asking for evidence on the inquiry into the long term
funding of adult social care. We drafted a paper that’s been submitted as evidence that went up on the website and is now on CQC’s website and next week Andrea will go and present evidence to that committee and the published paper will shape and inform
the evidence and I’m sure there’ll be a healthy discussion at the committee that Andrea will be able to contribute to. We’ve also published a response to Health Education England’s consultation on the draft health and social care workforce which is a pretty important documents that

[ David Behan - 0:17:51]

is being developed and drafted and again that response is appended to the report and I think one of the key issues signalled by the Secretary of State is he wants this to address social care as well as the NHS workforce and again we’ve made
a contribution to that given some of our inspection findings and the comments were made in the state of care report. Next paragraph updates you on the fee scheme and the introduction of the fee scheme the Secretary of State made a decision to support the
proposal that we put to him in relation to the fee scheme for 2017/18. Peter and Andrea met with some of the providers in community adult social care services and the trade body United Kingdom Homecare Association who had some concerns about the increase in fees
that were coming through to them. It was part of 4 year transition to full cost recovery on the fees for this sector. This is I think the third of those years going through but members of this sector were concerned about the significance of the
fee increase. We’ll continue to work with them and Andrea and Peter will meet further with UKCA later this year and we’ll need further discussions as we go through the year with them so I don’t think this is a one off. But we just wanted
to mark both the decision by the Secretary of State and the concerns that were voiced by UKCA. Just on updates they work on the thematic review or every event has begun and the teams here and led by Ted and I think Robert I think
you’re the non-executive sponsor for this so have begun this work anticipating an interim report in the summer and a final report in October. I just also wanted to acknowledge by NHS improvement and NHS England of the move towards making joint appointments particularly at regional
level and will continue to work with both organisations in relation to that work. On the 1st of April we saw 10 areas of the country designated as integrated care assistants and be part of the development of healthcare services working much more collaboratively in geographical
areas. And the issue this raises is what does that mean for the way that we regulate health and care services when they’re behave much more as a system rather than as separate organisations. And what this paragraph is attempting to do is just update the
board on some work that Malta’s been leading which is to get a connection with each of those 10 sites with a senior colleague from within CQC and the proposal that we work much more closely and in detail with two of the sites where we’re
having a much more in-depth conversation about what does the implications of the way that they’re working have for the way that we’re going to regulate in the future. We’ve got strong basis from the local systems reviews on which to build that does allow us
to work in real time to develop our thinking. The other advantage of linking people and working in 2 areas is that that becomes something that’s not just done at a senior level it’s actually done by managers and practitioners i.e. inspectors analysts etc. So we’ve
got some real time development. Following the Salesbury incidents and the issues around cybersecurity and I guess there’s been developments since this letter came from the Department of Health we’ve been asked to again review our security procedures in relation to cyber attacks etc. I think
there’ve been warnings as recently as this week as well in relation to this and I just wanted to provide some assurance to the board and that we again continued to pay attention to this area because of the importance of the security of our systems
and needing to attend to that. Because we have external providers of a lot of our systems this has largely consisted of actually seeking assurance and reassurance from the providers that they’ve taken the appropriate action to mitigate risks from cyber security. Now I’m not going
to dwell on these Peter we’re just flagging publications that we’ve made, approved mental health professionals, the states of independent healthcare, driving improvement in mental health trust and a shared view of mental health, sorry a shared view of quality in general practice and we’re due
to publish before our next board meeting a report on driving improvements in GP practices which play to this point about what contribution are we making to improvement not just at an organisational level but a system wide level which places the conversation we’ve just had
about the research paper I think which I personally think it’s a hugely important contribution that wasn’t really flagged about how we do these systemic reports. But that’s the report. Thanks Peter. So as always there’s a lot going on and you’ve gone over the ground
well but quite quickly. Do people want to come back on anything that’s

[Professor Louis Appleby - 0:23:43]

in there. Lewis. Thank you very much. Can I ask about the never events review. The never events I have to declare an interest here because there is only one never event in
mental health as I understand it and that comes from my research which I did about 15 years ago. So that tells a story here. We haven’t been very good in mental health at being able to develop a more up-to-date and practice relevant set of
never events and part of that may well be that the model was derived from acute care where there was something you could do and then the consequence would never happen. And in the complexity of people’s lives in mental health that’s quite a difficult thing
to say because is there something you can, an intervention you can apply and then a tragedy will never happen at all. Very difficult. And so I hope, and that’s played out in quite an important way recently because you may know that earlier this year
about two months ago there was an announcement by the Secretary of State about suicide on inpatient wards in which there is a drive now to, at the moment there is something like 85 to 90 deaths by suicide of mental health inpatients every year. That’s
quite a lot less than they were 20 years ago but it’s still 85 to 90 people and the question is whether we could drive that down to the point where it was zero and there’s quite in mental health called the zero suicide movement which
was behind that and one obvious route through which that might have happened in the existing system was the never event system. So take the zero suicide message turn it into the existing never event model in the NHS. And for various technical reasons to do
with the definition of a never event that wasn’t possible and so we got a separate announcement which stands outside the current system. And I think there is a question here whether that’s really serving people well and whether the model we’ve got for never events
is one which is helping improve safety. Certainly in my especially side I don’t know whether you’ll be in a position to comment on that wider issue but I think in trying to understand how well they’re working one of the questions is what’s not on
the list and that could be. Well it’s too early to draw any

[Professor Edward Baker - 0:26:00]

conclusions about what our recommendations are going to be but I think it’s important to emphasise that the reason we’re going this review is that never events have now been, I think five
years in action and the number of never events has not fallen. So there was a kind of assumption at the start that these events were preventable and if everyone did as they were told they wouldn’t happen. Well patient safety isn’t that simple. It’s much
more complex than that and we’re trying to understand what are the barriers that stop these apparently preventable events from being prevented. And that’s fundamentally what we’re trying to do and understand that if you like that dynamic and that is really fundamentally at the heart
of patient safety because it won’t just be about never events it would be about other safety guidance as well such as the issues you are talking about. So whether we should extend never events you know is certainly an open question but whether we’re going
to move in that direction or not I think it’s much too early to judge. I think we have to focus on what is it in safety guidance and in the practice and implication that safety guidance that makes it truly effective and prevent patients coming
to harm. And I think that is the fundamental question we’re trying to challenge here. And it is a fundamental question about safety and it relates back to the work we did it last year on learning from deaths for instance where there’s a similar question
asked. How can we learn from things going wrong to improve safety going forward. And I think that’s a fundamental challenge in the healthcare system across the board. Just very briefly Peter can I

[Professor Louis Appleby - 0:27:31]

just, thanks very much. The timescale looks quite as timescales always are
tight. So an interim report in the summer a final report in October that sounds like some big questions have to be addressed between now and then. Could I just ask you that would come back in some way to the board because it’s quite an
area that we should all take quite a strong interest in I think. I

[Professor Edward Baker - 0:27:55]

think it’s very important there. We’re on site at the moment inspecting hospitals as part of our routine inspections looking at how they’re implementing never events, learning from what works for them
and what doesn’t work for them. And we are consulting on a wide spectrum of experts from across safety field not just in healthcare but across many other industries as well to understand what’s worked in other industries. So at this stage I think it’s too
early to judge. It is a tight timescale but it’s an important issue and I think if we can really fundamentally changed our approach to safety events it can have an enormous impact. So I think it’s very important. I thought I’d done it sorry thank

[Mr Peter Sinden - 0:28:36]

you. So yes I think it will come back to the board. I think there will be an interesting set of learnings that will come out of it so I’m not quite sure which month, I haven’t got my mind around that yet. Well no I
think it comes back after the report rather than, that was what I was thinking. I think the interim report in the summer will just talk

[Professor Edward Baker - 0:28:57]

about progress not conclusions. It will be the autumn before we reach any conclusions. Yeah so it’ll come back at

[Sir Robert Francis QC - 0:29:10]

[ David Behan - 0:29:12]

some point. Yeah David Well I’d just like ...on the process all of our thematic reviews I think have been sent out to the board and allowed comment before it because we otherwise get into this, you’re either racing to get it for a board meeting
or you’re slowing it down. But I think the delegation say that I sign them off occasionally with Peter but I think on the last few the CAMHS report came to the board I’m looking at etc and you all got the opportunity to comment. Whether
it comes to a meeting where there’s a discussion or not is another issue but given your experience and what you’ve said and I’ve got huge sympathy with the point you’re making Lewis about suicides I’m absolutely with you on that. I think we should work
out how we’re going to get that in the way that we have done with the other thematics which is draft report letting you have some sight of it rather than we then trying to launch things based on the agenda. The October one will be
a lot easier to manage than the summer one I suspect suspect but we’ll

[Sir Robert Francis QC - 0:30:08]

make sure it happens. Robert I just wanted to say two things firstly a lot of very impressive work is going on, on this at speed. And secondly that it is a
very profound subject and I mean the observation I would’ve had before this review is that never events are a very peculiar. And certainly with the time of ##### staffs it was, the alert system was bureaucratically reacted to with the result that the alerts never
seemed to get through to the people who actually needed to do something. And if this review at least changes that that will be an

[Ms. Liz Sayce - 0:30:52]

encouraging thing. Good. Yes? Thank you, sorry. I was interesting to see our response to the Health Education England’s draft health
and care work force strategy and particularly drawing on our learning from new models of care and not having an overemphasis purely on hospitals and the role of social care etc. are very good stuff I thought. It mentions in there the potential of new pools
of labour and the importance of looking at new pools of labour and I just wondered whether we’ve done anything to sort of join up that thought with some of the work we do in another sense which in relation to some of our work we
do look at employment outcomes. For example looking at recovery focused practice in mental health, employment outcomes are one of the things that we do look for in inspections and are looking at mental health services. We’ve also got a work force disability equality standard coming
in throughout the whole of the health NHS this year and I just wondered whether there was a sort of, there’s a, I’m not suggesting for a moment that everybody who’s using health and care services wants to work in health and care but health and
care have a role in enabling people living with health conditions to work is my point. And there is a labour pool about which health and care have some influence and a lot of contact and I just wondered if we’d joined those two thoughts up.

[Mr Peter Sinden - 0:32:35]

Andrew do you want to ...hear that, no, no I mean just to respond,

[ Andrea Sutcliffe - 0:32:46]

just literally to hear what Liz was saying. I was going to make a different point on this which is, and I think our response almost, almost gets there but there’s,if you,

[Mr Peter Sinden - 0:32:58]

if you’re trying to work out what workforce needs you’re going to have over the next 10, 15, 20 years it’s impossible because we don’t understand and can’t understand at the moment the impact that technology is going to have and what skills therefore we will
need from our work force in the future. And it seems to me anyway that the very big part of what needs to be thought through is how do we equip the work force right from, you know right across the spectrum with skills that are
transferable so that as technology takes away some of the existing jobs and new jobs are needed in response we’ve got that flexible work force and I didn’t think that are, we almost get there we talk about, you know are we going to have a
need for more general physicians rather than specialists but I think it’s much wider than that I think it’s across the entire work force. And it’s not the same point you’re making Liz at all but it a point that I was going to make, and
it seems to me if I was trying to design a work force strategy, apart from panicking at the thought of it that would be the thing that would

[Sir Robert Francis QC - 0:34:22]

[Mr Paul Corrigan - 0:34:25]

be most in my mind. And I’m just, on that the necessary flexibility is very very powerfully
cut across with the inflexibility of training so someone in this September will be going in and 12 years later will come out a #####. That is just very odd given the nature of the needs that will be there in 12 years’ time. So we
have an incredibly inflexible training system for what is, everybody intellectually knows, has got to be an incredibly flexible work force. And it seems like no one is doing anything about that so every year that continues and probably expands so when we talk about expanding
for the future work force we’ll primarily end up expanding inflexibility when everyone knows we need more flexibility but I think there’s another and really quite important point. This is one of the biggest industries in the country maybe the biggest industry in the country health
and social care, and everybody goes around saying there is a shortage of labour, and everybody by in large when they say there’s a shortage of labour is looking away from where labour is, and looking in directions where labour isn’t. And so actually there are
lots and lots of people engaged with health and social care who would love there to be a ladder of opportunity and the ladder exists has several rungs knotting it including where it reaches down into and so there needs to be something beyond exactly as
Liz was saying the way in which we are, we continue to re-plan and re-plan and re-plan as you said a mug’s game given we can never know what’s going to happen and actually start saying what have we got in our society. Where do people
want to work. How do we then reach those people because people would love to work in social care and the NHS and we construct barriers that stop them from working here. And then we say there’s a shortage of labour. Robert. Well why don’t we
just take from this conversation and capture that and then set out a supplementary letter back that captures the points in addition to I think some of the points about the difficulty of forecasting etc. I don’t think we made that point Liz but is it
connected intellectually. I think it is practically who’s doing what in relation to that I think it is a different question. I’m sure there’s examples where people are doing that but I don’t know that’s the norm and I think that’s what you and Paul are
both saying so why don’t we take from this conversation and get a supplementary letter to go in on the back of what we’ve sent in and make sure that the comments of the board are captured as part of the consultation. It’s just a practical

[Sir Robert Francis QC - 0:37:10]

way to do it. Thanks so Robert and then Steve One thing the strategy does deal with but our letter hasn’t but it’s a very particular criticism it is something I think we can do something about is workforce retention in so far as it is
influenced by the working conditions in which staff in the NHS in particular but also adult social care have to work. There was a recent survey done of trainees of the Royal College of Anaesthetists which indicated very high levels of concern about lack of really
basic facilities in which to work. Like places to eat, places to rest, all those sorts of things which if they persist particularly in an era of financial shortage and staff shortage will lead to people leaving and there is evidence of both doctors and nurses
leaving after pretty expensive training. And it seems to be that Work Health Education England undoubtedly has a role in this. We as the inspectorate also have a role in, when we’re looking at whether a place is well led and whether their staff are being
looked after. And I just wonder whether that’s something we could consider. I’m not saying we don’t consider it but whether we should

[Professor Steve Field - 0:38:28]

consider it more overtly. Steve. Thanks so the local system review summit meetings, the feedback meetings we have, it’s the single most common
question that I’m asked and the most common assertion is about work force issues in whichever area. And it’s usually about nursing and people working at the lowest levels financially in the health and social care system are those who are giving care in care homes,
nursing homes, domiciliary care are often paid or usually paid the worst of any careworker. And the problems for example in Oxford were around how do you recruit people when you’ve got London prices without London waiting with inadequate supply of housing through to Trafford where
we were where you got a massive retail park and as soon as a supermarket opens or a new shop opens, who pay more, for less responsibility why wouldn’t you move or about attraction. And so we talk a lot about that and I think if
you read our reports, in most of the reports those who are not doing very well from delayed transfers of care and care of the over 65’s there is a lack of a work force strategy locally to look at the whole work force. The headlines
are about lack of GPs and doctors often are but in reality it’s at the bottom of the pyramid of work force where the greater care happens for the least money and it’s that comprehensive work force strategy which is necessary. One little bit of good
news to finish on because I know you want me to shut up, is in Dudley where I come from which is a poor area in parts of the West Midlands where we went to congratulate an outstanding surgery in a very difficult area. And what
they said, I went into the room with the management staff and talked to them and I just asked why they wanted to work in this sort of surgery and they said well it’s rated outstanding and that’s really important and we looked for the rating.
And I said well what was your background and the first person said well I was at hairdressing college. And I said to her, the person next to what was your background, I was at hairdressing college and I turned round to the third person who
was much older and said oh well you’re not a hairdresser as well are you, and she said well actually I was. And it’s an important thing because the aspirations of some people in this country at school are for those sort of careers because they
have more contact with them and they’re perceived to be stable and the income is often better than the care workers where they have no access to and they don’t know what the careers are. And so to the sort of thing I was feeding back
into places like Hartlepool was if you’re going to do a work force strategy you need to look at the whole thing from junior school onwards and see health and social care as a career to aspire to. And I think we have a responsibility of
a regulator to do that but the good news was the rating of outstanding in the practice helped the lower end of the work force look to aspire to work there. And we have other examples where they have succeeded in recruiting doctors and nurses when
before they were rated outstanding they couldn’t. So that is a positive impact given the theme of today is what’s the impact of CQC. Thanks Steve. Andrea. Thank you Peter and it’s just to respond to

[ Andrea Sutcliffe - 0:42:17]

Robert’s point about the questions that we ask on inspection
about well led and how staff are supported and that absolutely is one of the key lines of inquiry both in terms of whether staff are safely recruited. Do we have enough of them, are they recruited properly, do they have the training and development to
allow them to have the capability and confidence to do the job that they need to do in the circumstances that they’re working in. And secondly what is the culture. Is it inclusive, is open, is it supportive to members of staff so that they feel
engaged in the development of the service and feel aligned to it in a way that actually makes them want to kind of give more of themselves to it and it helps to support retention as well. So they are key questions and they are some
of the areas that we find difficulties when we go into services and you know it is something that we have highlighted both in response to the questions is the service safe and is the service well led. So I think it may be one of
those things that as we go forward we could be, we’ve talked today about some of the thematic publications that we’ve done. I’m sure there’s probably quite a lot of evidence within the depth of our report that identifies some of the good things that providers
have been doing and some other things that providers should avoid and maybe one of the things that we can think about is whether using our independent voice that’s something that we might want to exemplify more in a more thematic way. And just to support

[Mr Peter Sinden - 0:44:00]

that I mean just in my casual visits to providers right across the spectrum I’ve seen some fantastic examples of how staff are being supported in lots of different ways and I’ve seen some examples where there’s little evidence they’re being supported at all. So you
know it’s a really big point. John you wanted to say something. A very quick point what hasn’t been brought out here is that the sustainability of health and care systems will struggle unless we embrace the users of the system as part of it. They
have the maximum amount of time they have to look after their own conditions and for that you need the workforce to be systematically trained in how to do co-production and co-management which currently they aren’t and I wonder if you’d consider adding that to the

[Mr Peter Sinden - 0:44:50]

supplementary letter. Perfect. Good. Are we happy to move on. Mary welcome. Sorry we’ve kept you waiting. We’ve denied you the opportunity to speak up for a little while but now is your opportunity

[Mrs Mary Cridge - 0:45:01]

so very nice to see you. Thank you. Well thank you. Thank

CQC Freedom to Speak Up Guardian Annual report

you and thank you for the opportunity to provide a verbal report ahead of my presentation of the Annual Report which will happen in June. I am the CQC freedom to speak up guardian and also the day job as a head of hospital inspection currently
covering south-west and south central on the acute side. I’d like to cover three areas and then I’m very happy to take questions. I’d like to give you a brief update on our arrangements. I’d like to tell you about the recruitment and training of speak
up ambassadors and also touch on my membership of a cooperative inquiry group. A group of folk I happened upon via Asheridge and involving tutors from Asheridge and the NHS leadership academy. So the arrangements. I was appointed after open competition within the leadership group at
CQC and I’ve had great support and encouragement from the hospital’s directorate to fulfil the role and also HR and in the engagement team have been great support too. I’ve worked very closely with Henrietta Hughes as National Guardian and her office and they are a
supporter of advice and guidance and also I’m part of the network of guardians from arms-length bodies. We take into account Henrietta’s recommendations on the back of her annual reports and surveys and so on and we check out a lot of the work that we’re
doing with them. In the day job as I head of hospital inspection I encounter guardians on inspection and it’s always my pleasure to interview them and we’re also seeing guardians’as part of our regular 12 month engagement with trusts and that’s a great source of
support and inspiration meeting people doing the same thing in a different environment. We have revised our policy in line with the national guidance that came out from NHS improvement in England and we’ve also taken account of the best practice in trusts and were pointed
by the guardian’s office towards a mental health trust in London as having what they regarded as the best of the policies. It’s been a key thrust to get those policies out of the HR space if I might describe it as such and much more
as a sort of open way of being as opposed to set prescribed procedures. Our revised policy awaiting sign-off. I’ve set up a reference group. I didn’t like to fly completely solo on this so I have a group of people from across CQC to support
and challenge me. We devise a work programme together they hold me to account and I’m pleased to say all the equality networks are represented on that group and we have a spread across the organisation. The National guardian’s office has presented their report to you
in the past and described the series of recommendations they’ve made for guardians. We’ve undertaken a gap analysis against that. I’m pleased report we’re in a good place and there’ll be more detail in my annual report about it. We have as you would expect internet
pages and a communications plan and we run a number of campaigns to raise awareness of speaking up. It is not my ambition that everyone comes to Mary Cridge to speak up it is my ambition that we are a place where speaking up is a
way of life where staff are encouraged and supported to speak up well and when they do that managers and colleagues respond well. And therein lie some of the challenge. I’ve mentioned campaigns. We worked around the national anti-bullying campaign that’s been a feature of our
public life for a number of years now and focuses on education and we took the opportunity to run a week-long campaign involving our dignity at work advisers as well who are specifically tasked to support staff who feel they are subject to bullying and harassment.
I’ve had a number of cases and contacts with staff and ahead of providing you with the figures and themes in the annual report I’ll say that they broadly reflect the experience of guardian’s in NHS trusts. Although there are safety issues that do come forward
and things that you know are surprising, the vast majority are around behaviour and how atmosphere in teams and groups. We have had a couple of cases that have gone all the way by which I mean to formal investigation but that those are a rarity
as they are in the NHS too and success for me is when on the back of a conversation someone goes away and speaks up themselves and gets a good response and when you see the detail in June there’ve been some quite inspiring examples of
that. I’ve referred to ambassadors I couldn’t possibly do this alone and we have them at all levels in the organisation including one round this table. So we have inspectors, inspectors managers. We have personal assistants and executive as I say. We have ambassadors from everywhere,
strategy intelligence all the inspecting directorates and the corporate functions and I’ll come on to say a bit about that training in more detail. The whole purpose of them is to provide confidential advice and support, to be approachable, to listen well and to role model.
Our dignity at work advisers have all signed up to be ambassadors and in the longer term we will be considering whether we merge those roles as well. The training, we trained 38 staff last week in London and Leeds. This was delivered in partnership with
the academy and the national guardian’s office. We reflected on some of the sayings of Michael West around civility, warmth, positivity and kindness having a place in our culture and in how we deal with each other every day. We reflected on what a great fit
this always with our CQC values. We also reflected on it’s hard to do. If it was easy we wouldn’t be even bothering would we but it isn’t. We looked at the barriers there are to speaking up. We understood the background. We had a very
moving film featuring Helena Donnelly and Dr Nick Harper who I think you will all have met at one stage. We considered our role and activities. We tested ourselves on our listening skills and we’ve looked at the support arrangements because it’s quite hard to provide
support at times and keep oneself safe and positive in this space. I’m

[Mr Malte Gerhold - 0:51:44]

going to pause and invite Malta to just comment on the training. Thank you very much. The one thing you haven’t said that we did during the training and as you said there
was really colleagues from all parts of the organisation and all levels which was very exciting. First of all how much interest and enthusiasm there is from our staff to take on this role and to role models the support to everyone else to speak up
where people find it difficult to have less confidence as a result. And secondly the idea that ultimately what you are trying to achieve and what I hope I can help you with as one of the ambassadors alongside the others is that this becomes a
social movement in the organisation that changes the way that we challenge, that we speak up and then we talk about how we can improve. This isn’t just all about something that we’re doing wrong as an organisation that we speak up about and have concerns
about. This is also about speaking much more openly where we things can be done better and as you say if that turns into a social movement then there might be a future where actually as ambassadors and as guardians we don’t have a lot to
do but that is because everything else is working in the way we want. And that’s where we support so I’m really proud to be part of it and you’re doing a great role in supporting that. Thank you. Finally let me mention the co-operative inquiry

[Mrs Mary Cridge - 0:52:59]

group. So a co-operative inquiry is a group of people who come together with a shared interest and questions and explore that together and it will probably lead to a piece of published research. But at the moment we are talking about speaking up about the
barriers to it and about the examples of where it’s being done really well. I was signposted to Professor Megan Rhys who is one of the tutors at Ashridge and she has a group there about 6 of us. We meet every quarter and explore this.
Megan published some research last March being silenced and silencing others developing the capacity to speak truth to power, the key finding of which, and this was research based, international research in both the public and private sectors. The key barrier is how leaders vastly overestimated
how approachable they are. The workplace is very different now from when I started my first job. People on first-name terms. People communicate very well with each other. Dress code doesn’t usually distinguish either and it can be really difficult to tell from watching an interaction
just who’s got the power but the people in that reaction understand who has it and who doesn’t. And being more aware of situational and positional power is really important. Another aspect and Michael West research also touches on this is the energy and courage it
takes to speak up is usually a build up to a point where the person when doing that speaking up maybe doesn’t reflect themselves at their best or the values of the organisation and as leaders and managers there is a danger of falling into the
classic trap of dealing with the behavior and not with the message that’s been presented. So my longer term plans include training for all members at CQC and particularly managers and first line managers in terms of encouraging people to speak up and then how to
react, how to react well when they do. As I say that sort of brief cancer through what I’ve been up to and there’ll be a formal and

[Mr Peter Sinden - 0:55:17]

fuller report in June. So Mary we look forward to the fuller report but can I just say
thank you not just for the presentation just now but her what you’ve been doing as I know you put in a huge amount of energy. I dare say a huge amount of your personal time as well and I think the whole organisation is the
better for it so thank you very much for what you’ve been doing. Thank you. Anybody want to raise anything with Mary. Could I just say thank

[Sir Robert Francis QC - 0:55:45]

you very much for what you do do and sounds for what you’re saying that you’ve incorporated everything and
more of what has been learnt from the freedom of speak up review and it’s only right and proper that we should try to position ourselves as a role model for the system generally. But thank you. Thank you. Thank

[Mr Peter Sinden - 0:56:05]

you Mary. Oh sorry, you nearly

[Mr Paul Rew - 0:56:09]

got aware there. Paul. Just one, Mary that’s a really good presentation it’s really good to hear what’s happening there. Is there

[Mrs Mary Cridge - 0:56:20]

anything else you need by way of help from this Board or from others. As you might imagine I’m not slow to speak up
when there are things I need but so that’s a good challenge. I haven’t got anything at the moment but I will certainly give that some thought

[Mr Peter Sinden - 0:56:36]

and maybe talk to you in June. Ok. Mary thank you very much again that’s really great. So from
the Board is there any other business that anybody needs to raise. So we’ve got about 4 minutes for questions from public who are here. I know Robin you’ve given notice of a question. Can I just ask has anybody else got a burning question that
they ...Mr Hogarth how surprising. How nice to see you. Anybody else. So we just have the 2. Do you want to go first Robin since you gave us notice of your question. Thank you chairman. Robin Pike Health Watch Hertfordshire. This is a question relating
to hospital inspections and to ask really how certain types of patient experiences which cross over all core services are noted in the course of an inspection. I have in mind particularly the pharmacy services most of which are outsourced many which are outsourced in hospitals
and this can involve quite a task really for the patient who is generally handed a blue copy and a pink copy of the prescription, the Doctor having held the white copy. The patient then queues at a desk at the pharmacy in order to hand
in the 2 copies and takes a ticket. The ticket is numbered so that the patient then waits for a period frequently an hour in order to obtain the medication. I understand that in #### medical services many prescriptions are electronic. There are other experiences relating
to the reception in a clinic when in some hospitals the patient can register electronically on a pad. In other hospitals the patient will queue in a corridor in order to see a harassed receptionist who is looking for their file and that can be sometimes
a lengthy wait. And finally I mention of secretarial services to doctors in a hospital where in some cases the secretary doesn’t have their own desk or their own telephone because the secretarial services are hot desks and consequently it’s very difficult for a patient to
contact a doctor’s secretary. Ted I think he was looking at you as he

[Mr Peter Sinden - 0:59:58]

was asking the question so Absolutely and I think you must’ve been

[Professor Edward Baker - 1:00:02]

following me Robin because you described my last experience when I picked up a prescription in a hospital exactly, almost
exactly and I think we’re very well aware that some of these interactions at the front desk are very important for patients in terms of their experience of care. We certainly do look at these areas when we inspect. I think it’s a real challenge from
you that are we giving them enough priority and I think that’s something I accept and take away. We have pharmacists who go where and with us in inspections. They look at medicine management but they also look at the process and one area you haven’t

Any other business

mentioned which I think is particularly of concerned to us is the delay in getting medicines for patients being discharged from hospital. Because not only is that a wait but often it delays their discharge. Sometimes it delays their discharge overnight and I think there are
it’s sometimes enormous delays in getting descriptions for patients to take home and that’s something we’ve focused on and we have challenged trusts about. But the outpatient experience a little difficult to follow up because we do sit in outpatients. We do watch what’s going on.
We watch from the interactions between receptionists and patients and of course we talk to patients about it. And we talk to staff about it and staff sometimes express great frustrations about those interactions. And we do reflect that when necessary in our reports both under
the key question of caring and also the key question of responsiveness. But do we capture it as well as we could and I think that’s a challenge you’re giving us and I think it’s a challenge I am quite happy to take away. I think
secretarial services are very important and anyone who’s worked in hospital knows how important they are in terms of the patient experience and I think sometimes we have challenged hospitals that if you like have downgraded the secretarial services and don’t understand how important they are
to patients in terms of their contact with the system. And sometimes it’s the doctors who raise that with us and point out that actually the patients experiences are downgraded because of secretarial services. Of course the patient often doesn’t understand why their experiences is less
than satisfactory because they don’t understand the internal hospital systems. And again we have challenged that on occasion. Have we focused on it enough. I’ll take that away as a challenge. Good. Thank

[Mr Peter Sinden - 1:02:15]

you David. Can I ask you to be ...no come please and ask
the question but as I say could I ask you to be as brief as possible in asking the question which would just help us meet our timetable. I’m David Hogart #### St John’s Wood #####. My question goes back to what Lewis was saying under
the performance when we were talking about performance and about how it’s more likely that a mental health institution will go up from requires improvement to good than an acute trust. Of course these sort of comparisons are important or only as important as the validity
of the judgments that the CQC has made. And I really wanted to ask Lewis how satisfied he is that the judgments in mental health area that the CQC are making are really valid. So we have a convention

[Mr Peter Sinden - 1:03:14]

David that this is not an opportunity
to quiz individual members of the Board of their views or anything else so I think, can I answer the question by saying that we put in a lot of time and effort in reviewing and understanding the judgments that we’re making the there’s a whole
quality assurance process because the central point is not whether the services are improving or not but absolutely the point you are making is can we have confidence in that the judgments and findings that we make so across all of the directorates this is an
important area. I don’t think we’ve got perfection in this area yet. I think, strange enough, I think some of the technology that we will be adopting in the future will help us further. So it’s a really important issue. We’re on the case. I don’t
know whether any of my colleagues want to ... I’m looking at the Chief Inspector’s wants to add anything or whether that’s a brief summary of where we’re at. Ted you look as if you want to come in Just to

[Professor Edward Baker - 1:04:27]

reassure you there is a
very rigorous process to make sure the ratings are consistent between one inspection and another. So I think when we demonstrate that a trust has changed a rating I think that is actually quite a significant finding so, and we have a framework to make sure
that we’re making similar judgments in different sectors. So we have, we’re very aware of those issues and we have a process in place to control, I’m sure Peter’s right that we’re not perfect in this regard but that these judgments are not made lightly without

[ David Behan - 1:05:08]

a lot of detailed study of the evidence should’ve said this when Lewis spoke and I’m just trying to not speak on every item. I think Lewis’s challenge this morning and your question is absolutely legitimate it’s a question I ask and ask of myself continually
about how far is the performance report we present and the data in it a reflection of what we’re finding or a reflection of how we’re behaving and how do we begin to understand that in a different way. So I don’t think this is something
we can give a ready made answer to but I hope as well as the answer Ted has given about the quality assurance how confident are we when we say this is good. It actually is good based on our methodologies. I think we’ve got stronger
and better and more effective at doing that over the years but I think the question that Lewis asked earlier today that you’re repeating just on Peter’s lead let me take it away from individuals I think it’s a question we need to continue to return
to and continue to ask because it’s a hugely important question. Earlier today and we had a conversation in private session about how we evaluate the work that we do and how confident we can be of what we found and what I’d like to do
is not give any kind of conclusions from that work but actually say it’s a hugely important parts of our work going forward to make sure that we are able to answer those questions because it’s not just you David that are raising them with Lewis
I think these are questions that our stakeholders ask as well about consistency etc. So it goes, it’s a question that goes right to the heart of our credibility as a regulator I think do we understand what’s behind our numbers and what we reflection by
it so I hope it provides some reassurance Peter that it’s a hugely important issue. I wouldn’t like to answer the question you just ask Lewis about you know, but I think it’s right that that question needs asked and we continue to work at understanding
it. So thank you David for the question. I think that is the end Board you’ve got, according to my clock 22 minutes before we start again. So short break. Thank you very much. Thanks everybody.
  • Professor Louis Appleby

    Position Board Member

  • Professor Edward Baker

  •  David Behan

    David Behan

    Position Chief Executive

  • Mr Paul Corrigan

    Position Board Member

  • Mrs Mary Cridge

  • Professor Steve Field

    Professor Steve Field

    Position Chief Inspector of General Practice

  • Sir Robert Francis QC

    Position Board Member

  • Mr Malte Gerhold

    Position Interim Director of Strategy and Intelligence

  • Mr Paul Rew

    Position Board Member

  • Mr Mark Saxton

    Position Non-Executive Board Member

  • Ms. Liz Sayce

  • Ms. Kirsty Shaw

    Position Chief Operating Officer

  • Mr Peter Sinden

  •  Andrea Sutcliffe

    Andrea Sutcliffe

    Position Chief Inspector of Adult Social Care