CQC Board meeting 19th January 2022 - Wednesday, 19th January 2022 at 11:00am - Care Quality Commission

CQC Board meeting 19th January 2022
Wednesday, 19th January 2022 at 11:00am 









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Minutes of the Public Meeting held on the 15th December 2021
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Matters Arising and Action Log
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Researching the impact of CQC Regulation on Providers Led by GPs of an Ethnic Minority Background
Closed Cultures Summary Narrative of Progress
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Welcome to the National Guardian
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Any other business
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  1. Webcast Finished

Welcome everybody to the January 2022 Public Board Meeting for the CQC. We had one apology from Kirstie Shaw who is ill, otherwise we are all here. I would like to welcome as a guest to our Board meeting, Diane Horsley who is from our Gender
Equality Network – Diane, you are extremely welcome and please do stick your hand up if you want to contribute at any time. Can I just check there are no declarations of interest that anybody needs to raise? OK, thank you. I think that takes us

Minutes of the Public Meeting held on the 15th December 2021

straight into the minutes of our December meeting - are they a true and accurate record of everything we discussed? Yes, thank you. Excellent, good. We will take that as approved then, which takes us to the action log and I think there’s only one item

Matters Arising and Action Log

on the action log and that’s not due yet. Is there anything else arising anybody wants to raise? OK, so with all of that, let’s move straight on to the first item which, Rosie, is your report on the impact of our regulation on providers led

Researching the impact of CQC Regulation on Providers Led by GPs of an Ethnic Minority Background

by GPs of an ethnic minority background, and I think probably I need to welcome a couple of your colleagues as well for this. But Rosie… Yes, thank you very much Peter and good morning everyone. I would like to welcome Annabelle Stigwood and Ayisha Ashmore
who have been… have done a fantastic job on putting this work together and driving this work over the last year. I am just going to say a few words and then hand over to Annabelle just to take us through the report. So, the first
thing I want to say is thank you to the Royal College of General Practitioners for raising these concerns with us last year, and also for all of the organisations that have been involved in this work. We have worked across the system with all organisations
working in primary care and we have also worked with many experts in this field, to pull on lots of expertise. I’d like to express my thanks to all of those involved. The report highlights both some internal improvements for the CQC, but importantly I think
it outlines some really significant structural inequalities in general practice. My ambition with this work is to use this as a call to action for all organisations working in primary care to work together to address these going forward. I think they’re too big for any
organisation to address on their own. I think it is vital that the issues that have been outlined in this report, in terms of inequalities for both people experiencing care and people working within primary care, are addressed by all involved. So I am just going
to hand over to Annabelle just to say a few words now, thank you Annabelle. Thank you Rosie. So, throughout this work we have consulted with our colleagues within the CQC, including our working group and inspector reference group. We have consulted with an external advisory
group made of practising GPs, many of whom are from representative organisations such as BAPIO. We have regularly consulted with our round table of system partners including the RCGP and GMC. We have also consulted with academic experts and two of our non-executive directors, Ali Hassan
and Mark Chambers. So, turning now to key themes, we have seen a link between ethnicity and deprivation. Most ethnic minority-led practices that we spoke to served populations with high concentration of people from ethnic minority communities with high levels of deprivation. This was also identified
as one of the most challenging factors in meeting our regulatory requirements by both GPs and our CQC colleagues. CQC colleagues felt there was limited recognition within CQC’s approach of practices’ surrounding environments and this may disadvantage certain practices. These findings are reflected in our recommendations.
Then turning to single-handed GPs’ professional isolation and support. In our survey and in our literature review, we found that single-handed practices are often ethnic minority-led. Being single-handed sometimes means there is less time and resource that can be dedicated towards evidencing compliance and improvement and
often these practices can be professionally isolated. Many GPs in inspection teams told us that they would appreciate more support from the CQC and the wider system. They expressed a need for better engagement with CQC teams and simpler communication. Our recommendations highlight our need to
continue building on relationships with GP practices, but also the need to progress shared priorities with our partners in the wider system. Then turning to CQC factors, we identified factors relating to the CQC which could impact on the experience outcomes of all ratings of ethnic
minority-led GP providers. GPs and inspectors told us that CQC’s desire to be objective and consistent during the inspection process could potentially impact on a practice’s rating. They said that our methodology is not sufficiently tailored to reflect a provider’s circumstances, for example being single-handed or
located in an area of deprivation. We heard that CQC does not always consider innovation and improvement when assessing practices, particularly those who work in areas of deprivation. We now are completing a further project to help providers evidence their innovation, their innovative projects to address
health inequalities in our regulatory processes. Key things that we are asking to change - we know that there is still work for us to do to ensure that we achieve our strategic and quality objectives and deliver our core purpose to ensure that we are
encouraging practices that need support to improve. However, the research has identified that action is required beyond the CQC to address concerns relating to deprivation, single-handed GPs and the support available to those practices. Therefore, we have continued to work with our system partners including the
RCGP, GMC and NHS E & I and representative groups to ensure that the findings of the report are clearly understood to facilitate good collaborative working across the system to address the issues we have identified. The engagement teams have been working through a comprehensive media
and engagement plan to make sure that key messages are delivered. Dr Bola Olowabi, Director of Health Inequalities at NHS E&I, is chairing a meeting next month with key stakeholders to progress this work and coordinate a system response. We have worked with Bola to ensure
the agenda reflects the findings and directs a purposeful discussion. We look forward to progressing the findings of this work through this group. In relation to the recommendations which reflect how we regulate, many of these are already in hand, specifically around how we can focus
on reducing health inequalities through systems working as we develop the single assessment framework, as well as how we collect ethnicity data through our regulatory platform. The governance and oversight arrangements for the overall implementation for the recommendations has been identified. Today we are asking for
the Board to approve this report for publication, thank you. So Annabelle, I think it’s a great report and thank you and all your colleagues that were involved in producing it. I think we are going to have quite a few comments and questions. Robert, let’s
start with you. Well, thank you. Two things, firstly this is a great and informative report on an extremely important subject, so what I am about to ask isn’t intended to be a criticism, but suggestions of what we do now really. As I understand it,
this work was motivated by a perception on the part of ethnic minority doctors and other providers that they were in some way dealt with differently by CQC. What this report tells me, and correct me if I am wrong, is that a lot of the
issues that arise are because of the context in which we meet ethnic minority providers, namely many of them are single-handed practitioners, they work in socially deprived areas, and so on… Clearly to me, they are a highly important part of the provider community because of
the work they do, the areas in which they work and the understanding that they will bring of their own communities which will often share the ethnicity of themselves. What I am not entirely sure I see in this report, and wonder what work we can
do, is to be questioning ourselves about whether there is something about the impact we made on ethnic minority providers which is different to the impact we made on non-ethnic minority. By that I mean, if you take for instance a single-handed Practitioner GP who is
from an ethnic minority, whether somehow or another unconsciously or otherwise, we deal with them differently than we would have a single-handed white GP or whether that is what is his belief, which is probably more likely to be the case. We need, I think, to
be strictly conscious of the unconscious effect that we have on people in the bias as (unintelligible) providers we bring. I absolutely understand that the data you had was probably not sufficient to allow one to get into that in any depth, but it seems to
me that we owe it to our ethnic minority providers that we continue to do work about this and I would just like to know what proposals we have in that regard. So, Rosie and Annabelle, just hold on to that. Let me bring in Stephen
and then Sally, before we come back to you. Stephen. Thank you Peter and thank you very much to Rosie, to Annabelle and to colleagues. It’s a really interesting, really important report. One of the bits in it that struck me was the sense that many
of the GPs that you’ve been working with here, want help. They want support, they are looking for support, not just to understand CQC’s own systems, but actually more broadly, sort of how do I become a better provider of GP services. There’s a bit of
a flavour in the report of a different body saying “Well, it’s not us Guv”, I mean someone else should be providing that support. So, who should be providing that support? I guess specifically, do you see a role for ICSs as they get up and
running in making this part of an integrated support for providers in their areas? Thank you. Thanks Stephen. Sally. Thanks to Rosie and colleagues for a report. It is always good to highlight where we could do better. My comment, I think, follows on from Stephen’s
in that the report highlights support in a more general sense, and perhaps more that could be done. CQC are at the end of the line, aren’t they? After education, training, doctor representation through GMC, through the BMA. So because we can’t influence this ourselves, I
am interested into what our response will be and how we are going to work with others to try and break this cycle of inequality, as one of my colleagues referred to before. It isn’t just about the support now on inspection, it’s about the whole
card of support that a number of different organisations provide to doctors from an ethnic minority. I have just another small comment really, about single-handed practices which clearly are more prevalent here. Because although we don’t look after the delivery model of how care is provided,
I think there have been attempts over many years actually to try to phase out single-handed practices and build them into a network, or build them into collaborations in some way shape or form. That strikes me as something that would be useful here. Thanks. Thanks Sally. So, Rosie
why don’t we just deal with those three points, and then a couple of other colleagues want to come in, but Rosie. Thank you Peter. These three points we could spend all day discussing, I think, actually, very, very good points. So, to Robert’s point, I
absolutely agree this is a very highly important part of workforce and particularly the reflection on the local communities and working with local communities that they serve. It is incredibly important. I think what you have outlined is exactly the reason we need to get our
data collection better in this area. I think we need to do that across the system. I think these issues that we raised in the report, I think this is the starting point of work we need to do in this area to really understand this
better. I don’t think we have got to the final point yet in our understanding as to whether these issues are just related to ethnic minority GPs, or whether they relate to a wider group of people. Some of the work that we have done in
the literature review does show that practices working in areas of deprivation do have a different set of problems and issues than areas where they are practising where there is less deprivation. But I think we do need to understand the role of ethnicity in that
in more detail. That is why it is imperative for us and other organisations to look at how we collect data to really understand this in more detail. In terms of Stephen’s point about help and support and whose role it is to support, I think
this needs to be everyone working across primary care, to be looking at what their role is in dealing with the issues that have raised. I think every organisation should take responsibility at looking at what their own processes and actions are, and how they can
improve those to support people working in areas of deprivation and people from an ethnic minority background. I think there is a key role here for integrated care systems. I think integrated care systems by their very nature need to be understanding their population needs, making
sure their workforce delivers good care for their populations. I think that all providers within an integrated care system need to be confident that when they need help and support, they get that from the integrated care system. We know from the work around the Inverse
Care law and much of the work that has happened previously that, actually, people who live in areas of deprivation often need more care and support, not less. So that needs to be absolutely factored in. In terms of Sally’s comments, I think we are fortunate
to be working with NHS England and very grateful of the support from Bola Owolabi in terms of her role in Inequalities lead. She has agreed to chair the round table in a couple of weeks’ time to look at the next steps. I think at
that stage we need to come up with a concrete series of actions that are going to…, and priorities across the primary care landscape to be able to move this forward. Finally, just to comment on single-handed practices, I think, as you say Sally, we are
not in a position as the CQC to say how care should be delivered, and the model of care. Having said that, I think that sometimes being a single-handed practice does bring challenges in terms of offering the range of services. It brings challenge in meeting
some of the regulatory requirements from providers. I think it is vital that if single-handed practices, whether they are led by ethnic minorities or non-ethnic minorities, get the support they need, and they work collaboratively within a Primary Care Network so that patients get good care,
whatever practice and wherever they are registered in the country. Thanks Rosie. Mark Saxton. Thank you Chairman and thanks Annabelle for a very good report and presentation. This is a question for both you and Rosie, Annabelle. I share my colleague’s comments so far in the points
they have raised but I wondered if I could focus on another area that came out of the report. That was particularly on the impact of the CQC inspection on individual providers. We talked about impact on mental health, that they saw the inspection as threatening,
that there was an impact on their family life and an impact on physical health. I mean clearly that is a narrative that we have to react to and I know that we have some actions to address that going forward. But a cornerstone of our
strategy is to reduce health inequalities and to do that through people and communities, through improvement, through safety, through learning and smarter regulation. So, my question is can we not find a way to reinforce our strategy and actions from us to ensure that the strategy
moves from a piece of paper to an operational initiative. Particularly, I am posing that question around that we do that alongside the actions we have said in the report that we are going to undertake. So, a greater focus on collaboration, on engagement, on understanding
context and on improved communications. But it seems to me that this is a broader issue that I am referring to which is about our strategy and people understanding it and then understanding actions in relation to that strategy, thank you. Mark, if I can start
with that and then Ayisha and Annabelle might want to add to the answer. So, firstly I believe regulation should be constructive, it should add value, it should be proportionate. We want to make sure that our regulatory approaches are done in a sensitive manner so
that, actually, the impact we have seen in this report is minimised on people who are practising. We know that demands are huge across the health and care sector and we know that people are delivering care under very, very difficult circumstances with huge challenges. We
want to make sure that our work absolutely delivers on its purpose of making sure that people get good care and high quality care, but does that in a way that is sensitive to the people that are working across the health and care system. I
think, as you rightly say, there is a huge opportunity for us to use our plans in the new strategy to address a lot of these issues and we are already making progress in those areas. So, for example, I think by our approach about monitoring,
our intelligence-driven approach where we can do things without actually visiting practices as much, that that will help by us looking at how we can streamline our methodologies and make sure that they identify risk and identify what is important to patients. By our focus on
improvement and making sure that, actually, what we do drives an improvement culture across practices. All of those things I think will very much help in this matter. We know that there is a very strong link between staff wellbeing and how they feel valued and
patient care and patient safety. So we absolutely want to see that really kind of good culture across all organisations where it is going to enable to deliver care, and we want to be part of the solution there in terms of helping organisations to drive
that improvement culture. So I think in answer to your question, we are…, there is work that we need to do, a lot of work in that area, but we are making good progress. And absolutely, the work, the recommendations from this report will very much
feed into the overall organisational work on things like the assessment framework, our new methodologies and our new processes. Great, thanks Rosie. Mark Chambers. Thank you. I have already mentioned this, but I want to emphasise the point that she raised about the underlying quality and breadth
of data that was available to the team here. You know, I would very, very strongly commend Annabelle, Ayisha and the team on their success in producing an insightful and actionable report when it would have been easy to conclude that we didn’t have access to
the data needed to get this this quality of insight. I think it’s a really important call-to-arms for constructive collaboration way beyond the CQC, to ensure that we all have access to better data to drive the improvement that I hope this report will help catalyse.
I think it’s a great piece of work. Great. Thanks Mark. Annabelle, you looked as if you wanted to wanted say something. I was just reflecting on Mark’s points about the impact of CQC inspectors on the physical and mental health, and the family life, of
ethnic minority-led GP providers and I think that was for me - personally throughout this work I drew on my experience both academically, but also as a as a CQC inspector - and it really did emphasise the need for excellent engagement between CQC and those
providers that we regulate. I feel confident that we have reflected those findings in our recommendations to make sure that there is better engagement with inspection teams to ensure that we are encouraging improvement across those providers. Thank you. Thanks Annabelle. Ted. Thanks. And just thank
you colleagues for this report. It has been really interesting following what you have done on this and I think it raises some really interesting challenges for us at CQC. We have made health inequalities one of the key things that we want to focus on
going forward in our strategy, absolutely. We can’t have high quality care without addressing health inequalities. But what this report makes absolutely clear, perhaps with great clarity, is the importance of actually looking at the inequalities within the workforce, as well as the inequalities within the
population served and the two are intrinsically linked. Because many of these minority ethnic GPs that have raised concerns are providing care to such deprived communities. So, I think bringing together that approach to our providers and approach to practitioners within the providers with our health
inequalities agenda, I think is a very important part of this. So, thank you colleagues. I think it really challenges us to think differently about how we approach health inequalities going forward. Thanks Ted. So I think this is a really good report and you have
heard everybody who has spoken say that. So what I would like to do is get the Board’s approval that we publish this report, and we do so immediately after this meeting. There are clearly some follow-up actions for us, but let’s get this report published.
OK, thank you. Ayisha, thank you. You have been silent behind the scenes, but you played a big part in this I know, and Annabelle, thank you very much as well. Right, and Rosie obviously. So, let’s now move on now colleagues to the Executive Team

Executive Team's Report

Report. Ian. Good morning Peter, good morning colleagues. So I just wanted to just raise a couple of things before handing on to other Exec Team colleagues. First thing, I wanted to advise the board that as Accounting Officer, I have now sent our annual accounts to
the Comptroller and Auditor General and they will be laid before Parliament. We are hoping that the laying will actually take place tomorrow following the certification from the Comptroller and Auditor General. This is a process which, you will recall pre-pandemic, used to take place in
July time, but it has been a delayed for the last couple of years because of the linked pieces of work around audits of pension schemes that many of our colleagues are in. To be frank about it, I am expecting this sort of timetable to
continue for at least the next year, if not longer. I think the linking between our accounts and the pension scheme accounts remains problematic. It is a problem that is shared by many arms-length bodies, particularly those that have employees in the local government pension scheme
which is what is causing the delay in the process. But I would want just to take this opportunity to publicly thank Chris Usher and his Finance Team for the hard work that has gone on, and Sally and her group of non-exec directors as part
of ACGC. You know, this is a team effort to get what is a very complex piece of work across the lie, and I would just like to say thank you to them and, of course, colleagues from our Internal Auditors. So, I may want to
move on now and just talk about executive recruitment. We have been through a process to recruit a new National Director of Healthwatch England. Healthwatch England, as you know, is one of our companion organisations that we work very closely with and we are responsible for
recruiting the Director and, obviously, Robert represents Healthwatch on this board. So, I’m pleased to announce that we have recruited Louise Ansari as the National Director. Louise will be joining Healthwatch at the beginning of February. Louise joins Healthwatch from the Centre for Ageing Better where
she has been the Director of Communications for the last 5 years. So Peter, that is all I have got to say before I…, I am happy to hand on to Kate. Thank you. OK, thank you. Thank you. So, good morning all. I am going
to talk briefly about operational priorities and then I am going to focus my update on workforce and visiting. So, very briefly on operational priorities in Adult Social Care. I just wanted to remind Board where we are focusing our efforts through the early part of
this year. We have got three areas of focus. So, the first one is, as you would expect, it is responding to risk. The second is our new Infection Prevention Control Plus inspections. They are focused inspections that go out and look at whether we are
assured against 8 areas of requirements including visiting and good Infection Prevention Control. Then the third area focuses around activity to increase capacity, be that re-rating a provider where they are currently “requires improvement” and all the intelligence tells us if we went back out and
inspected, we would find a service delivering a good standard or care. So, those are the three priority areas in Adult Social Care, and Tyson will give you a little flavour about the volume of activity when he gives you his update. So, if it is
OK Peter, I am going to move on and talk about workforce which is a real hot topic, particularly in Adult Social Care, at the moment. At the back of your Chief Exec Update Pack, you will notice an Annex which provides an update on vacancies
within the care home sector. So through our Provider Information returns, over 8200 care homes have given us this data. What this data shows is that back in April 2021, there was a vacancy rate of 6% within care homes. Month-on-month we have seen that number
increasing to December where it has reached 11.5%. There is a kind of chart and a breakdown of how that looks regionally in your pack as well. But I want to really flag a growing picture around vacancy rates within care homes. I want to talk
a little bit about what does that tell us about the quality and the impact that has on people who receive services. So, we have developed a workforce tool which we are using on all of our Infection Prevention Control inspections. But also every time we
have a monitoring call with our provider, we are also using these couple of questions. These questions are asking our providers what impact, if any, is workforce having on your ability to deliver high quality person-centred care. So we launched this workforce tool back on the
1st of December. We have had these questions asked of 328 services so far, and 39% of those services are indicating to us that it is having a negative impact on the ability for them to provide high quality care. Now, in each one of those
instances, we will be following up with the provider and the Inspector will be using that, along with a wealth of other data and information they have, to make an informed decision about whether there is further regulatory work they need to do with that provider.
So a kind of picture of providers telling us that workforce is having an impact on their ability to deliver high quality care. In addition to that, we require providers to inform us of events that may stop a service. There is a requirement for providers
to do that. We have been keeping a really close eye on those notifications with a focus on are providers telling us that they are being prevented from delivering services as usual as a result of workforce. Now, we tend to get about 50 notifications a
month, that being steady and throughout the year. Through December up to mid-December, we saw an increase in those numbers, doubling, and again we see those numbers being higher than usual into early January, and starting to see them move back now towards the average. But
again, keeping a really close eye on that and what that is telling us about individual providers’ ability to deliver care, but also what that that kind of tells us about the national picture as well. Then finally on workforce, so we got a picture of
increasing vacancy rates, more providers than usual telling us it is having an impact on quality of care. We are also interested in what that tells us about that the market. So, we have seen a pretty steady number of providers de-registering throughout the year. The
numbers are relatively static. Again in December, we started to see an increase in providers changing their registrations and providers deciding to de-register and to exit the market. When I talk about changing in registration, this tends to be where providers are removing the nursing element
of the care they are delivering within a care home setting. So, moving from being a nursing home to being a residential care home. This data is pretty hot off the press, so again we need to understand what that is telling us. Providers rarely make
a rapid decision to exit the market or change your registration. So there is more work we need to do on that and we will be happy to update Board when we come back in February. So, that is workforce, Peter. I am happy to move
on to visiting and take questions at the end, or to pause now. What would work best for you? Why don’t you deal with visiting and then we will have questions. OK. So, on visiting, I wanted to start off by reflecting that visiting has been an incredibly difficult issue,
particularly for people in care homes and their families. As we have highlighted in some research we published today, on the day we launch our Because We All Care campaign with Healthwatch England, that nearly three quarters of carers report a deterioration in their cared fors’
mental health as a result of all the changes that has happened through lockdown. We have launched this campaign inviting people to tell us about the quality of their care because hearing about people’s experiences really drives our regulatory work, drives our activity. We are keen
to hear about families’ and people who live in care home’s experiences of visiting. What I would say on visiting is that most providers are trying to do the right thing. They have got an incredibly difficult juggling act of keeping their residents safe and well
while supporting their mental wellbeing and access to loved ones. In recent weeks, if we think about high transmission rates in the community, an increasing number of care homes with outbreaks have a very difficult juggling act to do. We have been really clear that care
homes need to follow government guidance, that any sort of blanket visiting bans would trigger an intervention, a kind of involvement from us. We continue to keep a really close eye on that. All of our IPC Plus inspections have an element where we are looking
at visiting. I just want to assure Board that when we talk about visiting, we are not just seeking assurance from the provider, we are going back to people have raised concerns with us, we are having conversations with residents, we are using our experts by
experience to make contact with families and with people who are in care, as and when needed. So, visiting is an issue we are watching very closely and we are taking action be it in any circumstance where people are concerned that a care home isn’t
following government guidance. That could be a call to the complainant, a call to the service and a conversation with those residents to seek assurances. In other instances it is us going out and inspecting, and in a small number it is us taking regulatory action
to ensure that that issue is addressed. Thanks Peter. Thank you Kate. Lot in there. Does anybody want to come in? Gosh, right, you have got off lightly there, Kate. I just want to emphasise what you have just said about the difficulty that providers have in trying
to balance safe care with visiting rights which are so incredibly important. So, that is a really difficult balance for people, I understand that. Robert. I gave you time to put your hand up Sorry, I was gathering a thought, it always takes a long time. Just about
the workforce issue within care homes which is so important. There have been some suggestions from the care home sector, albeit probably slightly tongue-in-cheek made - but I’m also entirely tongue-in-cheek - that because of the workforce issues, CQC are imposing a burden that shouldn’t be
imposed on care homes, and I just wondered what your comment was on that sort of approach. And the second question was the extent to which we could tell whether the rules about vaccination are having an effect on workforce in the care home sector. Thanks Robert. So,
as Board knows, the issues with workforce and social care is a very, very longstanding issue. 120,000 vacancies before the pandemic, turnover rates up to 37 - 38%, so I think it is hard to draw a link between any one change and workforce. We at
CQC, for a long time, have been calling for a long-term plan for Adult Social Care, a plan around the workforce and funding. Obviously government has made additional money available to social care, particularly during this autumn which we welcome. Our comments have always been, we
want to see that money flow rapidly through to front line, through to care workers to recognise and value the work that they do every day. With regard to the burden that we are placing on providers, so I suppose my starting point is we are
here for the public, we are here for people who receive health and social care. We will seek assurances in a way that is as least demanding as possible, but we need to be assured on behalf of the public. So when, for example, families may
contact us about concerns about how a local care home is managing visiting, we will speak to those families, we will speak to residents, we will speak to the provider and we will go and have a look ourselves, in person if needed. We are not
looking to ask providers to do any more than is possibly required for us to have the assurance we need to give to the public that people are getting safe care. Thank you Kate. I’d just come back of that and I fully support what you
say and it strikes me that, actually in these current times when restrictions are, whether legitimately or not, but some often legitimately placed on people’s access, that is even more important that CQC is keeping a close eye on what is going on within institutions. Yes.
I have seen recent correspondence from a couple of families saying, you know, you are my eyes and ears at the moment. I’m not out there as often as I want to be, you are eyes and ears. But also Robert, to link it back to
our campaign, you know, people who receive health and care and their families are many, many, many numbers across the whole country and they will be seeing things. We can’t be everywhere all the time and we want to hear what people’s experiences are of health
and social care, be it good, bad or mixed. So, a little plug for a very simple online form to give us feedback about the quality of care that people are receiving out there. And just a reminder that over 55% of our inspection activity is
triggered and informed by what the public tells us. So, it doesn’t sit there, it is actively used and acted on. So, please to the public listening, get in touch and tell us about the quality of care you are experiencing out there. Thanks Kate. I
suspect you had an even greater audience than watches our board meetings when you were doing your radio and TV interviews this morning which were really good on this subject. Mark Saxton. Thank you Chairman. Kate, thanks a lot. Just to come back to workforce again,
I just wonder whether there is any vehicle whereby there is a national approach to recruitment into the sector, and if so, whether you can give us some insight into that. And secondly whether there is…, we could see some variance in the recruitment effectiveness across
the country, whether there is some opportunity to transfer best practice within the sector, and if you have some insight into that please. So, thank you Mark. The government earlier on in the pandemic, and recently, have led a national recruitment campaign for the social care
sector called Made with Care. So, that recruitment campaign is out there, it is raising the profile and it is inviting people to come and work in sector that makes a difference to people’s lives every day. So, the government would probably be better placed to
give an update on the impact that they are seeing that that is having on the numbers of people coming in to the social care workforce. Yes, as you say, in terms of workforce vacancies, there is a bit of a variation across the country, with
the south being above the average when it comes vacancy rates in care homes. When we go out and we look at the workforce, we look at things in the round. We look at how people up on boarded, how they are trained and the quality
of care they are delivering to people. So, in our inspection activity when we see examples of best practice, obviously we would be really keen to highlight that and share that so that other providers can take that on board as well. Thanks. Ian, you wanted
to come in? I think just to build on that point, we have talked before in Board meetings about a potential role, our potential role for looking at integrated care systems. That obviously, as you know, is going through Parliament as we speak, but I would
expect one of the key things on the agenda for an integrated care system is workforce in a whole area. I think there are some very practical problems between NHS services, that are publicly funded, versus social care services which are largely privately-funded and are private
enterprises. But I think there is…, you know, there is a useful place-based conversation for individual ICSs to look at workforce in the round, to look for local solutions to some of these problems and, indeed, do some of the sharing of knowledge between areas that
you were talking about there, Mark. So I think for me it feels like an important area for us to promote as part of our ICS work. Thank you. Thanks. Thanks and Kate, thanks very much for all you and your teams are doing as it
has been hugely stressful over the last couple of years, but it continues. So, thank you very much. Ted do we come to you next? Thank you Peter. Just to follow up on the discussion you have just been having, I think workforce remains one of
the key risk factors across the health services that we regulate. That has been compounded during this winter by absences brought about by COVID. So staff absences are running exceptionally high and that is creating enormous pressures in services that are already under a great deal
of pressure because of the pandemic and because of the normal winter effects. I just want to pay tribute to the workforce that is keeping services going. I think it is extraordinary the work that people are putting in to keep services as safe as possible
under, really, the most demanding circumstances. I think the one thing that COVID has taught us, more than anything, is the value of the workforce and the need to value the workforce. So not only that we have sufficient workforce, but they feel that they are
being fully supported to deliver safe care. So, it has become through this winter, I think that is one of the lessons we need to take forward. As we move forward as a regulator, I think we do need to focus on the support for the
workforce. Of course, that plays into the discussion we had earlier on about primary medical services as well. Colleagues will remember we postponed inspections of acute trusts and some community trusts in December to support the rollout of the booster programme. We still have not reinstated
those inspections, although we are keeping an eye on progress to decide when we should reinstate this inspections. We continue to monitor services very closely and we have continued to inspect mental health services and continue to do mental health care reviews, and many independent health
services as well unless they are involved in the booster programme. I remain particularly concerned about emergency service departments and ambulance trusts. They continue to be under intense pressure. This is not pressure because they are seeing more patients than a typical winter, in some ways
they are not. It is because they have such difficulty in the flow of patients through the system, through the urgent and emergency care pathway. This was reflected in the data published by NHS England last week where it demonstrated a record number of patients -
I think there was about nearly 13000 - were waiting more than 12 hours on trolleys in emergency departments in December, after a decision to admit before they are admitted into the beds. And some patients were waiting way longer than 12 hours, I should say.
I read that that 12 hours is from the decision to admit, it is not from the time they arrive at emergency department. There may have been a long delay before the decision to admit, there may have been a long delay in the ambulance before
they got into the emergency department. So I think, undoubtedly, some patients are suffering really very, very severe delays in this process. Talking to frontline clinicians in the last few days, it is clear that, while they are very committed to providing as safe care as
possible despite these delays, they are really being affected by seeing some of the patient experience that they are having to look after. Again, I have paid tribute to them to keep things going under the most difficult circumstances. It has really been a pressure on
staff and is really having an impact on patients, and this again stresses the importance of urgent and emergency care pathways being redesigned - new models of care for next winter. Again, that is something we need to focus on going forward in our regulatory work.
Again the pressures on emergency care is having knock-on consequences on planned and elective care. The waiting list for elective procedures has reached 6 million, and there is an increasing number of people waiting for extended periods, and two year waits for elective procedures are now
becoming more frequent. I think this is a great concern, and of course it is also affecting cancer services as well. Again, this reflects the need for models of care that can protect planned work and cancer work when there are surges in demand for emergency
services. I think again that is something we need to focus on. We need to work with people trying to resolve those issues and we have been working very closely with NHS England, both nationally and regionally, to give them support in managing the immediate problems
that I have been talking about, but also helping them work towards how they can plan services better in the future to deliver these priorities. That is all I wanted to say at the moment. I will take any questions. Thanks Ted. Any questions for Ted?
OK. Rosie, were you coming in next? Yes please Peter. Thank you very much. So, the first item in the report talks about the work that our Medicines team are doing in Adult Social Care. As the Board is aware, we have a Medicines team that
covers - although it sits in Primary Medical Services - it does cover all of the different sectors that we regulate across the CQC. They have been doing some great work to look at how we can improve the safety of medicines’ use, particularly in Adult
Social Care. The report outlines the work they have been doing there. The second thing I just want to talk about is around GP practices and access. As the Board is aware, we discussed at a previous Board meeting about the large increase we had had
from people using services, and particular concerns around access to general practice. As the Board knows, we then started a series of inspections looking at access specifically. We undertook 40 of these inspections in November and December and we have currently paused them due to the
vaccination rollout, the booster programme that had happened due to the Omicron variant. We are looking at how we can restart them and align them with the urgent and emergency care work given the vital role of general practice in the urgent and emergency care pathway.
Just to give you a few headlines of the things that we found within those inspections. None of the reviews of the locations identified any current issues with patient access. The practices we visited had recognised some previous problems, but had taken action to manage them
and improve their systems. We saw a lot of good practice in the practices we visited. We saw practices had a variety of ways in which they had ensured patients, who are vulnerable or digitally excluded, were supported to access the treatment or support they needed.
We saw a rapid increase in the use of e-consultations with a response time between 78 minutes - which, I think, is very impressive - up to 48 hours, which even given the pressures on primary care at the moment, I think, is impressive. Practices had
really structured their workload and appointed extra staff to be able to deal with e-consultations. We found a small number of should recommendations to address, for example updating practice websites to look at appointment availabilities and practice opening times, and some issues around telephony systems and
reporting in telephony systems. I think one of the key things we found are that practices are under sustained pressure. We found staff working regularly over their contracted hours. We saw staff sickness having an impact and we all saw the impact of the isolation and
self-isolation on practices. So I think, just to reiterate Ted’s point there, I think it is imperative that we do think about how we arrange services and work cross system to look at new models of care, particularly in advance of next winter. But I know
that the pressure is still very sustained and very high on all of our sectors at the moment. I think the final point I just want to make about primary care is that there is a significant backlog in primary care services as well. Now, that
is not quite as easy to quantify as with the waiting lists in hospitals or some of the other services. But, I think, it is going to be imperative over the next few weeks and months that systems really understand what that backlog looks like in
their primary care services and consider how they address those going forward. Thank you Peter. Thank you Rosie. I mean, this sort of next stage of recovery is just so important, isn’t it? And, as you rightly say, it is looking cross the system as a
whole to be able to do that. Right, nobody else wants to come in? Tyson, over to you. Thank you Peter. Kate highlighted the work we have been doing since the last Board on our plan for accelerating Adult Social Care inspections over the course of
December and January. So, as promised in my written report, this is a bit of an update. Before I give the update, can I thank many of our colleagues, so many of our colleagues for mobilising behind this priority, not just from Adult Social Care but
also from Primary Medical Services and the Hospitals Directorate. It has been a great cross-CQC effort. First on designated settings, they are currently 48 services who are operating as designated settings. We have now inspected all of those and those will provide 617, 6-1-7 approved beds
to the sector. On inspection more generally, across Adult Social Care we have undertaken 639 inspections from the 1st of December last year. Of these, 352 included a review of Infection Protection Control at the service and Kate talked about the importance of these types of
inspections at a time like this. We have a further 241 IPC assurance inspection scheduled for the rest of January. I mean, one of our priorities has also been, as Kate said, has been to inspect social care services where we believe there is a chance
that, in doing so, additional beds would be added to the sector - what we call improvement inspections. To date, we have undertaken 18 of those improvement inspections and we have more scheduled for the rest of the month. More generally, across all of our inspection
directorates in December and so far in January - despite the decisions we took before Christmas to change our operational tempo, which Ted has talked about - we have inspected over all 867 services, of which 442, 4-4-2 were in relation to new and emerging risk.
So, although there has been the Christmas and New Year period and we have changed our operational tempo over that period to provide support to the vaccination programme, there has been a lot of activity underway amongst our teams, particularly in support of Adult Social Care
and particularly in response to risk. I think the plan is for Chris Usher to update the Board more generally on performance, Peter, but that is it from me for now. It is perhaps, Tyson, the appropriate moment for the Board just to acknowledge the huge
amount of work that our colleagues have been doing right the way through the pandemic, but particularly over last few months. It has been exceptional and terrific. Absolutely. So, thank you everybody. Right, so I think that takes us on to you Chris Usher. Thanks Peter. Yes,
so in terms of performance for November, there is a few area I am going to pull out and talk to. I thought the main one to pull out would be regulatory activities. We have had a few conversations on this in recent months. So as
our business plan, as per business plan, we have been tracking the regulatory activities we have undertaken through our direct monitoring approach and inspections. For the year to date, that activity is 16.5% of regulated services. However, I recognise the wording of this measure is broader
referring to regulatory contact. So alongside the inspection and direct monitoring activities, we have also published a public statement for services where the information we hold does not find evidence that we need to reassess the rating or quality of service. Also where we receive information
of concern through safeguard and whistle-blowing concerns and complaints, we have regulatory contact with those services. If we factor in those different regulatory approaches in, it means we have actually had contact with 67 percent of services this year. As well as the regulatory contact and
service level, we also have oversight provider level and these are some of the areas that I think you are asking around at the last Board, Peter. So, for example in hospitals, inspectors have interactions with NHS Trusts on a regular basis. Our Market Oversight and
Corporate Provider teams also regularly meet with providers and have done on 482 separate occasions so far this year. So, as we plan for 22-23 and refresh our business plan, we are just considering how we reflect this wide range or regulatory activity with providers into
our KPIs. I plan to bring that up to Board next month. If I hadn’t just thanked our staff in response to Tyson, this would be the other appropriate moment to do it. I mean that is a huge amount of activity, and really important activities, so thanks Chris. Indeed.
And I think, as I said, I mean this reflects that for our…, going forward from April we just need to really reflect the breadth of work we are doing in that (unintelligible) Thank you. Do you want me to …? Carry on… Oh, sorry Sally. I didn’t
see that. Sorry Sally, yes, why don’t you come in? Oh, that’s fine. Thank you Peter and thank you Chris. Given that I was the one who raised that point at the last Board meeting - because it was 14% then - so it has already
increased. But it is really helpful for you to give a sense of how much work we do behind the scenes and the fact that two thirds of the people we regulate have had contact with us, even during a pandemic. So thank you for all
of that detail. I just thought it might be helpful for you, or Tyson or somebody, just to set out for the public what happens. Because there is another detail inside the report which talks about our overall interaction with providers, but our specific interaction where
issues of concern have been raised, where quite a significant amount of those people who we go to see are then rated “requires improvement” or “inadequate”. Just so people don’t think that we leave it there. I think it would be good just to give a
sense of what happens next in the inspection cycle, once someone has been given a “requires improvement” or worse rating, and the fact that clearly we don’t just leave that. That is probably not one for you Chris, but I thought it might just be helpful
to give that broader sense of not only how many people we have contact with, but what we then do proactively. So, Rosie looks as if she is willing to respond, and Ted as well, but Rosie, you go first. Thank you very much Sally, and a
really important point because, as you rightly say, when we have been into a provider that is struggling and gets a “requires improvement” or an “inadequate” rating, the work doesn’t stop there. Firstly, all of the recommendations and all of the kind of concerns we have
about those practices are followed up. Those providers are followed up. Depending on the level of concern will depend on the time scale that that is, but certainly, particularly any enforcement action is followed up to make sure that the improvements have occurred. There is also
a wide range of conversations, usually with the other stakeholders, so for example in general practice, we would be working closely with Clinical Commissioning groups and other parties to make sure that they are aware of the issues and that support is given into those providers
as well. Then all of these providers that are…, particularly the “inadequate” providers, will be re-inspected. Well, all of the “requires improvement” ones will be as well, but as well as the ongoing monitoring there will be a further inspection to make sure that improvements had
happened. So there is a huge amount of work once we have identified our concerns in a provider. Just to give you the assurance that those are followed up and we continue to follow them up until we are confident that improvements have happened. Thanks Rosie.
Ted. Well, Rosie has really covered it all, but I mean Sally, the rating is not the end of the story. It is the beginning of the story in many ways of because it triggers enforcement action, it triggers monitoring and follow-up, it triggers working with other parts of the system to
give support to the provider and it will trigger follow-up inspections against a very, very clear timetable during which we expect improvement to take place. So, I think inspection triggers the regulatory activity. It is not the end of the regulatory actively. Thanks Ted, and Kate,
you were nodding so I think, you know, exactly the same in Adult Social Care. Yes, nothing to add, thanks Peter. Great, thank you. Right, Chris back to you. Yes. I mean just playing exactly to Sally’s point, we monitor the outcome of inspections where we
have inspected due to risk. Over the last few months we have noticed this is starting to increase in some regions. So, for example, this financial year 56% of risk inspections are “inadequate” or “requires improvement”, but in certain regions we are seeing that as high
as 66%, so 2 out of 3 inspections are “requires improvement” or “inadequate”, but that is kind of something that we have just recently started to see as a trend. So, we will explore that further and bring that to Board next month and provide further
information on. In registration, we have got a continuing good trend, so simple and normal registration applications have been processed in 13.2 and 11.4% reduction respectively which is tracking well for 15% reduction target this year. Also, just in terms of sheer work we have got
through this year, registration colleagues have completed and processed nearly 23000 registration applications. So another example of, kind of the work load that we managed to get through as an organisation. Then, the last bit for me, just in terms of finances, underspent year to date
with a 9.5 billion on revenue. Its forecast is unchanged from last month, we are predicting that will be 11.3 by the end of the year. On our capital budget with 2.9 million underspent and this is forecast to reduce to 0.1 million by the end
of year, so nearly on budget. Good, thank you Chris. Pause there, it’s me again… OK, I’ll go again. A couple of bits that Kirstie would normally have updated on. So, in terms of our mental health and wellbeing strategy, the July Pulse Survey evidenced a high awareness of mental
health and wellbeing resources, but lower usage than when we would expect, and brought out inconsistencies in people feeling supported. We are now reviewing our pathway to our resources and how to embed more effective use. We will review the outcomes with the aim of agreeing
some actions for implementation early in the financial year, next financial year. On talent, we have 32 colleagues enrolled to start their Level 3 or Level 5 Management apprenticeships. We have recently had three candidates join us s part of a first digital graduate programme. Lastly,
our People Pulse Survey closed on the 7th of December. The survey received 2211 responses which is 73% participation. Those results are just being analysed and working their way through internally. We will provide an update to Board in February and KPIs will be updated accordingly.
That’s it from me. No, not quite, because Mark has a question for you. Mark. Thanks Chairman. Thanks Chris for that report. Just looking at the people plan, I mean, certainly very good news about the digital graduate recruitment and management apprenticeships, so well done to
the organisation in moving that forward. Just in terms of the wellbeing pathway that you refer to and the inconsistencies, I just wonder whether we are considering that with the new HR system that we are shortly to conclude, I think, in terms of the procurement
of that. And whether effective reporting of wellbeing is an element that we have been looking at for that system. So, I think that is planned for later in the year with regard to the HR systems. It is not something that we are actively looking
to procure just yet. We will revisit that later in the year, but I am sure this would form part of the plans for that system when it comes. We are picking that up later in the financial year for the HR system. Sorry Chris, I
thought we were further along than that, but certainly then my point is I hope that we are looking at a system whereby we can track those pathways effectively and efficiently without having to dig through loads of piles of paperwork. I will speak on behalf
of Gill, but I am sure that is the case. I am sure that would certainly be the aim. Thank you. If it wasn’t the case before, Mark, it is now. I’m sure it was anyway. OK, thanks Chris very much, and thanks for stepping into
the breach with Kirstie’s absence. Mark Sutton. I’m hoping we get a at nil cybersecurity risk report from you. Yes, absolutely, Peter. Just a short update on this from me. So, no significant information or cyber security issues to report in the last month. But I
did just want to close the loop on the global security vulnerability that was raised in the last month. This is known as Apache Log4J. Just to let you know that we have completed all about our activity review and remediation work was needed to make
sure that CQC were protected. But I think probably worth noting, as we know, the work on cybersecurity never ends and our ongoing programme of continuous improvement is continuing and progressing well. That includes recently reviewing our information security policies, our capability of our security operations
centre and we are also reviewing and updating our training offering for the organisation as a whole. Perfect, Mark. Thank you. Right, Chris Day. Yes, three quick points for me. The first in the report you will see this this week links something that was said
in the Mental Health Act Report. We have been concerned about the quality of ethnicity coding for mental health services and we found substantial and very important patients whose ethnicity is not recorded or not known or not stated. It varies across ICSs from 5% to
around about one in three in some areas. Obviously, we have talked earlier on about the importance of recording this information. It is part of local demography, it is part of us understanding how services need to respond to people are well. Poor recording of this
data and an overreliance on general categorisations we think is a real problem that we have raised, - to assure the Board- we have raised this concern with providers and with other organisations responsible for both the completion of their exam and use of this data
elsewhere and will continue to reflect what we said in State of Care, in the Mental Health Act Report and in future pieces of work. The second are - again it has already been mentioned today - the Because We All Care campaign. So, today sees
the return, the launch of this year’s Because We All Care campaign encouraging people to speak up and give their feedback about their loved ones in care. Obviously, people have different experiences of care and we want to make sure we capture all those to support
our regulation of services. I will refer back to what we said earlier, and what Kate said in her interviews this morning, this information is used well to describe and to inform how we see services operating. The campaign itself tries to target groups where very
often we might receive fewer bits of feedback from, so the audiences are particularly targeted around carers, people with long-term conditions, people aged over 55, people from a BME background and we have spikes of campaign that run over the course of the year. Just to
give you a few stats on this year’s campaign, we have seen a remarkable uplift in the volume of information received, a 60% increase on information. We have reached over - just for those interested in the web stats on this - we have had 10.8
million reaches with the Because We All Care hashtag. We have had a an organic growth in social media a 50.4 million as a result of this. We have had over half a million elements of social media engagement on this. And, in addition to that,
we have had about just over 750 media mentions of the campaign in the last year. The other thing to mention as well is that this is…, it is a good campaign, there are so many people across the organisation who I want to thank who
are responsible for this. It was also, it is also shortlisted for PR Week award in the Best Use of Social Media and it is up against private sector organisations who use this. It is not a public sector campaign, it is a national award. So,
I am really proud of the team and what we have achieved with that. There is much more to do in the next campaign. We have got a number of areas of focus for this next year starting with the campaign launch today. We have got
a focus on carers, we have got a focus on people with long-term conditions, we have got a focus on the over 55s, we have got a focus on people with learning disabilities. I am hoping that we can continue to build on the success of
the campaign last year. Finally just on the maternity. We have got a maternity service survey coming out shortly. Just to give the Board an early bit of insight, thanks to the work in Mark’s team and others we have managed to move the campaign…, the
survey online as well as offline. And we have seen a substantial increase in the response rate generally, and particularly from women who describe themselves as Asian, Asian British or Muslim. Those response rates have, in some cases, almost doubled which I think suggests that the
new methodology, encouraging women from different demographies to give their feedback in different ways is having an impact. The actual report itself will come at the next Board meeting, but I wanted to give colleagues assurance we have made some improvements in the way that we
target people from different groups in that survey work. That is it for me Peter. Great. Thanks Chris, and again huge volume of work going on. Robert Francis. Thank you. I just wanted to add a comment from a Healthwatch point (unintelligible) about the Because We
All Care campaign. It has been a really productive partnership and I just want to emphasise how vital is the information that has been coming in through that. It informs not just CQC’s work, but also ours as well, and I think the two-pronged approach is
quite useful here and a good example of how probably Healthwatch and CQC can complement each other. A great piece of work. I agree Robert, sorry I should have mentioned that. This part has seen a really strong partnership between Healthwatch and CQC there has been
a number of organisations that provided real support. But I think the partnership that we have had together to deliver this work has been fantastic. So, the praise goes equally to your team as it does mine in terms of what this will have managed to
achieve. Great. Thanks Robert. Thanks Chris. Ian, I think that is the end of the ET Report, so can thank all ET colleagues? Can I now welcome Mary Cridge who has joined us and, Kate, I expect you want to introduce the Closed Cultures Report? Fabulous.

Closed Cultures Summary Narrative of Progress

Thank you Peter. Welcome Mary. So, this is the last in a series of updates that Board have had on our work on closed cultures. This is a comprehensive programme that has been going on for a couple of years now. So, the programme is formally
drawing to a close. There are some outstanding actions that will get locked into other programmes like our single assessment framework, our (unintelligible) Reg model, etc. and we will continue to talk with Board about the ongoing work around the Out of Sight-Who Cares Report that
we published maybe 18 months ago. So Board will continue to hear our activity as a result of closed cultures, but the programme is formally drawing to a close now and this is a kind of a task to kind of reflect on what has been
achieved while noting there is a few outstanding things that will be taken forward. So, before I hand over to Mary, if I could just say there has been a huge amount of colleagues involved in this work from across the organisation, but it’s under kind
of Mary’s leadership. Mary managed to wrestle a huge number of recommendations from David Noble and from Glynis Murphy into something with a really concrete plan and timeframes. I hope Board would agree that a lot has been delivered while recognising that we will not let
this go, because this is one of the most important things we need to do to be an effective regulator. So it is not over, but it is a chance to hopefully catch our breath and say thanks and well done to the team. So without
further ado Peter, if I can hand over to Mary please. Thank you very much, Kate and good afternoon everyone. So the paper that I have prepared for today is really, as Kate says, a sort of summary of our ambitions, our achievements, thank you for
your kind words Kate, but this has been a team effort. There has been a lot of individual and collective effort right across the organisation that has inspired me along the way. So, it is a great thing to be part of. There is a more
detailed update on a Glynis Murphy’s recommendation in the appendix so I won’t go into too much detail on that. But I did just want to acknowledge that this work was kicked off by our late and much missed colleague, Ursula Gallagher. She passed it onto
me in about Spring 2020 with some very wise words which have stayed with me. So, I just wanted to say Urusla’s name in this meeting to acknowledge that she kicked it off. So, underway since 2019 and just a reminder that we are talking about
cultures where there is a higher risk of poor care and abuse. We have consistently looked at this work through the frame of services for people with a learning disability and autistic people. So, everything I say, should be seen in that context. But we know
that what we have learned through this and the advances we have made, are applicable right across all the services that we regulate. We know there are other places that are particularly vulnerable to the development of a closed culture, services for people with dementia and
maternity services would be two that I would name. So, our ambition was to be more aware, to improve our ability to detect, to be able to prevent and then to be able to improve. And where improvement couldn’t happen and couldn’t be sustained, then to
help those providers off the pitch. Because that is what we are about, isn’t it? The second page of my paper is something of a chronology that just shows that, way back in 2014, a programme of inspection of services for people with a learning disability
started. In 2018 there was an appalling and shocking scandal of a young woman who was, for the best part of two years, kept entirely segregated from human contact. On the back of that, the Secretary of State asked us to undertake some particular work, which
led to the Out of Sight work. Coincidentally, just as the interim report on that published, we had the Panorama programme focusing on Walton Hall. So, on the back of that swift action to get two independent reviews, and so David Noble and Professor Glynis Murphy
working with them and their recommendations have really formed the basis of our whole project. But the key part of the whole thing, taking those recommendations as the framework and all that had gone before, has really the been the work that we have done with
our internal and external advisory groups. The external group, being combined of providers, commissioners, other regulators, but chiefly majority made up of people with direct experience and their families and carers. It has been their input that has entirely shaped our view on priorities, the ordering
of our actions and so on. We also had the pandemic hit during all this as well, and we know there is a reference in the paper to the other report about the evidence of how that has disproportionately affected people with a learning disability, as
indeed has so much else. So we focused our attention for improvement on four key areas we listed here. We wanted better data on people’s experiences, and Chris has touched on some of the work in that area. We wanted to have a look at our
observation – what were we doing to look at culture? We wanted to look at training - all the reports looking at this had referenced better support for inspectors. So, you know, we didn’t just want inspectors to sit there and a whole load of data
pour over their heads. We needed to get this handled in a way that would help identify risk, that would help us predict that risk and put early warning flags up. As Professor Murphy noted, we were seriously lacking in research in this area. I would
like to think - and hope I have conveyed in this report – that our understanding, our approach, our readiness is transformed through the work of this project. The impact that we are having is improving, but it is never going to be done, so that
is still a work in progress. We have so much better on our intelligence and collection and analysis, and the at the end of last year we launched the new dashboard with a set of indicators so inspectors can see which services are triggering the factors
that we learned through Walton Hall and other work, that we need to be concerned about. Also the absence of information. So that that is much…, inspectors are much better equipped with that information and how to make sense of it, and obviously we will be
evaluating that as we go forward. But, just to note, the 20% increase in whistle-blowing on services for people with a learning disability and a 25% increase in enforcement action around those services. So this is leading to better detection, prevention and improvements. Glynis Murphy talked
about enhanced inspections and our interpretation of that, in our new world as we move towards our mew regulatory model, has been very much about increasing observation. There is no substitute for being in a place to observe how care is given, how people are experiencing
that care and living their lives. And important factors like observing how staff talk to each other. Lack of courtesy between colleagues in a service is one of those indicators, and hard to see that from a set of minutes. So, the combination of this enhanced
intelligence and onsite presence, talking to people receiving the service, talking to their visitors, talking to staff working in that service, all very important. Our training has been transformed and is now part of the mandatory offer. Over 2000 colleagues have gone through that training, a
further 1400 have gone through additional training about how to how to be a great regulator in a service where people…, autistic people are receiving a service. Over 70% of our staff are telling us of their increased understanding and awareness of closed cultures. So overall,
we are confident that we have improved our ability on all areas of our ambition. The fact that we now have a Director level post that focuses on the services means there is…, we will continue to have oversight of the agenda and its mission embedded
and keep learning and extend it further. We are clear the work doesn’t stop here. It is always going to be a priority for us, but as we reach the end of this stage of the project, I think we can be pleased with where we
have got to, but there is no resting on laurels. There is so much more to do to make sure it lands really well, and survives and thrives in the next stage of our history. Thank you. Thank you, Mary. So does anybody want to come
in? Stephen. Thank you Peter and first, huge, huge congratulations to Mary, to Kate and the team. This has been such important work and I think you should be really proud of this report demonstrating what you have achieved through the work you have done. The
one bit I wanted to pick up, it is Recommendation 6, which is page 90 of the pack. It is the one about registration, because I was very struck by what you were saying, Mary, that, kind of, a lot of this is about things you
can only pick up through observation, through being there, through getting the feel of the place. And, kind of by definition, you can’t do that at the point of registration. So I am interested in, kind of, are you confident that you can head off at
the pass people seeking new provider registration who might become closed cultures, but you don’t yet know that. Just interested in those comments about what you think you might be able to do at the registration stage because that feels a lot harder, to spot people
who might become closed cultures. Yes, indeed. But through the particular lens of learning disability services, there are established principles around models of care that we have ourselves set out. So, we are talking about places where people are going to live, home, their home. So,
any provider coming forward with what looks like a traditional hospital model - you know, high numbers of beds, people shoved together - that isn’t what we want. So, there is conversations and education at that stage, but we have gone to the wire with some
services and we have refused, and we have had other providers where it hasn’t got to that final stage. But they backed down, reassessed, changed their plans, but it is an area that we always need to watch. There is…, we are noticing a trend of
some providers getting registered not appearing to be a service for people with learning disabilities, then seeking to add it later. So that is a trickier area legally for us, but Debbie Ivanova, my colleague who is focused entirely on services for people with a learning
disability, is onto that and working with registrations to try and call, well what I call sneaking round the back. We would much rather that people were absolutely clear and open about what services they are intending to provide, so we can help them to get
the best registration to provide the best service they can. But it is always going to be an area we need to keep vigilant around. Thanks. Mark Sutton. Thank you. I just wanted to come and reinforce a bit of what you said there, Mary, about the closed
culture report which is the dashboard which was delivered recently. It is not a static delivery. That is something that we will continue to enhance and develop through feedback, to improve and enhance that over time, so it isn’t something that remains static and it becomes
part of our ongoing data insight improvement plan. Great, thanks. Belinda. I have got a couple of questions. So the first one is really what risks do you think there is to the project, as it winds down? And the second question is the bespoke dashboard
more than displaces an artisan. We have already mentioned, you know, that closed cultures can exist in dementia care and maternity services, and whether a similar dashboard - bespoke dashboard - could be created for those services as well. Did you hear that okay, Mary? I
did, thank you. I was just - Mark can’t see, but I am looking at him for the second question. But anyway, so the risks, well as with all closure of projects, there is a risk of that loss of attention and focus. But we do
have the project disciplines which require owners and safe landings, the things still in progress. But, I think, going forward the keeper of the keys in my head is definitely the regulatory leadership function. There is the Director Post in there, focused on services for people
with a learning disability. So, I think, that will be the place and I think there is some work to do to think about how best to continue to roll this out, widen it across sectors and so on. But the lessons from closed cultures are
very well understood in the development of the regulatory model. People from those teams have been sat on the closed cultures board and it has been working, going along hand in hand as it were really, rather than a separate piece of work, which is good.
I think the concept of silent services is something we increasingly understand. We need to build that in as well. We know we are progressing our preparations for surveillance, so there are still some big, meaty pieces of work. The research that we have commissioned -
this is Glynis Murphy saying there is not a lot of research. I have reported before that our research and evaluation committee proposed research to the Department of Health, which has been commissioned. There is a unit underway working on that as we speak, made up
of a collaboration of the universities of Oxford, Kent and the London School of Tropical Medicine. So they will continue to engage with us, and as that research commences, that will keep it in the forefront of CQC’s mind and attention. I have mentioned already the
aspiration to expand it. There is also, I think - what we haven’t given particular focus to but recognising who is after me on the agenda - is the connection with Freedom to Speak Up. So a strong Speak Up culture is one of the best
preventative measures against the risk of a closed culture developing, so as we continue to look at that in our assessment framework going forward. There is a synergy to some of this which will help it. I would also say we need to stress test everything
we do, designing our organisation, our own policies and procedures and the way we go about our regulatory role. We need to stress test it against the lessons we have learnt through Glynis Murphy and David Noble to make sure that we are as much guarding
it, you know we are leading by example as we always aspire to do so. So, that is a long answer to your question but I hope that covers the points. In terms as to when we might further the dashboard to other services, I think
that would require a new work up of an ask and we would have to get in the queue with other things on the development of the Reg platform. But just what I know of that work so far, is going to make it so much
easier to avoid rabbit holes down which information can disappear. So, I think, just all the things that we are advancing will collectively help us to keep closed cultures with a focus. But I would really like to see somebody with it in their job description
in the new team, but that’s for another day. Thanks Mary. Sally. Thanks Peter and thanks Mary to you and your team for such an extensive piece of work over a long time. We have seen it two or three times at audit as well, reporting
back, so I know how much hard work has gone into the recommendations. I think you and Belinda may well have covered the point I wanted to make, which is about not necessarily winding this project down, but thinking about what we have learnt and how
we can apply elsewhere in CQC. Because there will be other areas of practice, won’t there? Belinda mentioned dementia and maternity services, but our review of Mental Health Act compliance is going to be published in January, and there are lots of places in the areas
that CQC regulates where we could learn some lessons. I think I have just put a marker down that I would be really keen, as you have explained, to try and expand that and not simply close this down and say we have done the work.
So I think that is quite a good to point to end on, Sally. Thank… oh, I thought somebody else was trying to come in. Yes, I was right, Mark Chambers . Just quickly… wind it up, yes… Sorry to come in right at the end,
but it was just to reinforce those messages about the importance of Speak Up, and to emphasise, and perhaps a quick call-out for the National Guardian on this who recognises that there are best practices and learnings way beyond our sector that are worth drawing on.
Lots of…, you know, there is a vast amount of work out there on culture and what influences culture. There are many sophisticated corporates that are using a behavioural psychologist to help nudge and influence their culture work. I think the National Guardian does a great
job of tapping into this through their pan-sector network, but we similarly need to have the same desire to learn from the widest possible group of sectors that we can serve. Quick corner… … for the National Guardian who is in the meeting and will have
heard all of that and will respond, or not as she wishes. But I was just going to say, Mary, I think where Sally got us was to say that there is a lot of work that needs to go on, and we need to make
sure - and you were saying this yourself - we need to make sure the various actions get properly embedded in work streams that continue and the Board will want to see those coming back at some point. You said the work is never done, that
may be true, but we want to definitely see lots of progress as we go along. One thing which I think is done, and I would like the Board to agree, I think we can say that we have actioned all the actions that come out
of both David Noble’s initial report and then the two reports from Glynis. That is not to say that that there isn’t more work to be done, but the actual specific recommendations have been actioned. So we can sort of say that positively, close down the
reports, but then there’s lots of work activity, work streams that are embedded in ongoing work streams that this Board will want to keep an eye on. Excuse me. Just at this moment, Mary, your job is not done but Mary, thank you very much for
the work you have been doing. I’m very glad you mentioned Ursula’s name in this Board at the start because, as you say, she kicked this off. Excuse me. But Mary, thank you very much indeed. Thank you. Bye. Excuse me. So Jayne, you have been

Welcome to the National Guardian

mentioned, your reputation precedes you, but as a result I particularly want to welcome Dr Jayne Chidgey-Clark who is the new National Guardian. I am sorry Jayne we are having to do this remotely, and we will find an opportunity in the not-too-distant future for you
to be able to come to the Board in person when the Board is able to meet in person. But just welcome, and the floor is yours. Thank you very much Chair, and thank you colleagues. It is an absolute privilege to appointed as the National
Guardian. I am following in footsteps which I hope I can live up to. For those of you who don’t know me, know my background, I am a nurse by background. In fact hearing Ursula’s name mentioned, Ursula was two years ahead of me at university,
so I knew her well, and you know, we’ve kept in contact over the years and so to hear that today was very heart-warming and she did so much good. I think as well, just hearing that discussion absolutely. Mark, as you said, the pan-sector network
is really key and absolutely one of my commitments will be to continue to engage with the pan-sector network to bring that learning back into what we do within the NHS, and obviously as we go into social care, but more of that in a moment.
I have been given out about a 10-minute slot with you, but I won’t take it up, just in case you have some questions today. But I will be coming regularly to Board, so this is not the only opportunity. I shall look forward very much
to engaging with you on this important agenda because I know how supportive the CQC is of this agenda. So, as a registered nurse and a senior leader in healthcare and as a Freedom to Speak Up Guardian myself in a previous existence, this agenda is
obviously absolutely key to what I do and why I wanted to become the next National Guardian. What I am going to do is just speak very briefly about a bit of background, in case there is anybody on the call today, either members of the
public or anyone who wants a very short reminder of what the National Guardian and the National Guardian Office does. Then talk a bit about our current priorities and then a bit of a further future look, so in three short parts. So, many of you
will be aware that the National Guardian’s Office was set up as a key recommendation following Sir Robert Francis’ review into Speak Up back in 2O15. And five years on from the publication, substantial progress has been made to embed Freedom to Speak Up into a
range of our systems and processes across the health sector. The Freedom to Speak Up Guardian network has grown in both number and diversity in a way maybe we couldn’t have originally predicted. Since the last update that Dr Henrietta Hughes brought to the Board back
in June last year, there are now over 800 guardians in over 500 different organisations and they have handled more than 50,000 cases, amplifying the voices of those who might not otherwise be heard. Around half of the network still supports NHS trusts, but you may
be interested to know that over 40% support other providers than NHS trusts and 10% supporting organisations such as arms-length bodies like yourselves as the CQC, NHS England Health Education England, etc. We have training support and guidance and this thriving network of peer-to-peer support for
offering to speak up guardians and workers have spoken up about a range of issues including patient safety, worker safety bullying and harassment, as well as improvements to services as well. Workers are utilising the support of their guardians and providing really positive feedback. Over 55,000
cases that have been handled and over 80% of people, who come and bring an issue to a guardian, say they would use that service again. So that is a great position to be landing in this role in. However there is still - as Mary
said previously with the work that she has been doing, - this will never be complete. There is so much more to do. I just want to do a quick shout-out regarding Speak Up month. Back in October, every year, we have a Freedom to Speak
Up month and I just want to call out to the support from CQC leaders to that. We had a big awareness-raising process which included workshops. Mark, you hosted a live event, thank you very much indeed. Many of you as leaders took Speak Up pledges,
which is a really key part of the campaign. We actually had over 6000 people completing the training during that month, and many, many pledges that were made, including from many of our senior leaders. So, thank you for that and I will be looking again
to that this coming year. But for the immediate future, we are working very closely with NHS England on improvement and revising the Freedom to Speak Up guidance that is out in the NHS at the moment. There is going to be a new policy and
there is going to be universal guidance and that is important for one of our challenges for ourselves. At the moment there is relatively little uptake offering Speak Up guidance in primary care and as such, when this new universal guidance comes out - the current
guidance is aimed at trusts – this is likely to raise awareness of the issues. Because, despite it being in the contract, much of primary care - and I know from my discussions with Rosie Benneyworth - much is not being implemented there at present. But
this new guidance may cause quite a big draw on our resources as people want to look at how they can implement this important role. As such, we are looking at how we can strengthen and make our training less face-to-face and more virtual, so that
we can increase what we can offer up to people who want to come forward within those sectors. But alongside that, I have met with our three Chief inspectors in CQC - and thank for your warm welcome - and we are looking at how we
can ensure that Speak Up cultural behaviour is embedded in the new regulatory platforms. So, that is a key point of work at the moment. Also we continue to support Freedom to Speak Up guardians as a key part of our officer’s function because we know
that not all guardians are supported well by their individual leadership teams, and that is an issue of great importance for us. It is a complex role in order for workers to be heard and for that message to get back to those who have got
the power and the authority to change things that need changing. It is really key that they are listened and acted on. We are also currently looking at how we change our case review mechanism - I won’t go into the detail today, maybe when I
come back next time, I will give you a bit more information. But we are moving to a system, rather than doing Speak Up reviews where people feel that the systems they gone through for the matters they have raised have not worked well. Moving from
that that way of working to a new way of working. We will be looking more at case reviews rather than…, sorry, moving from speaker reviews to case reviews which will give a broader look. And excuse me, my tongue is not around all these matters
after the first couple of weeks of being here, so forgive me. Also, really excitingly, we are working with Health Education England for our training and we are about to launch the third and final module which will be Speak Up for leaders. And I will
be encouraging, when it’s launched in March, the Board, the CQC Board to undertake that training as role-modelling - as well as for your own information, - but role-modelling for other arms-length bodies. Then, looking at the longer term, we have a strategic framework which you
may well be aware of, that was published at the end of last year, setting out our vision for how we are going to go about our work. It is in four pillars. We are going to be looking at workers - how we champion and
support our workers to speak up. We are going to be looking more at how we support and enhance the Guardian role. We are going to be looking at leadership, very much looking at what supports and encourages leadership in those culture changes that have to
happen, if we are going to see good Speak Up culture. And also the wider healthcare system and how we support healthcare system alignment and accountability and that is key in my introductory meetings with senior leaders. My commitment is to lead the implementation of that
framework that is going to underpin all our work as an office. We have a commitment, a very strong commitment, to reducing the current variability that we see in both the implementation of the Guardian role and in how leaders listen up and follow up on
matters, so that is something that you will hear me talk about in the future. We have also got high ambitions for the national bodies to do more to deliver a consistent and high-quality response to workers who speak up to them. So, we have workers
that speak up to yourselves, to NHS England, to the regulatory professional bodies. And we have, a sort of, a very firm commitment through those organisations in a Speak Up partnership group. I want to thank CQC for being a key partner in that work, and
that is something that I very much will progress forward in the next few months. Finally, I am going to close on the fantastic news that the government has committed to working with our office to explore, not if but how Freedom to Speak Up guardians
can be implemented in social care. And, very much, this will be a programme of work that we will be undertaking with social care, not to social care. I am very aware of having worked alongside social care as a health professional, that actually it is
about taking - yes we got our learning experience but how can that be translated into practice? Kate Terroni and her team have already been very, very helpful in initial discussions. We are looking currently with the Department of Health and Social Care - how that
funding will be given to us and then our programme of work that hopefully will start in the new financial year. So that is all I wanted to say today by way of introduction. Happy to take any questions if you have time, if not you
will see me very shortly on a regular slot. Thank you Chair. Jayne, thank you. That was a terrific tour de force for a couple of weeks in the role. I mean that is very impressive, thank you very much. We will definitely be seeing you,
as I said earlier I hope actually in person rather than on a screen at a future meeting – we will obviously discuss with you the timetabling for that. Is there anything anybody wants to quickly say, or shall we let Jayne go for the moment?
I think, Jayne, don’t take silences as a lack of enthusiasm. With Robert on our Board, you know that we will always be hugely enthusiastic and supportive for you and your office. So, but for now, thank you very much indeed, and as I said a

Any other business

minute ago, we will see you in person at a future Board meeting fairly soon. OK. Yes, thanks very much indeed. So that takes us to Any Other Business and for once I have a piece of any other business. Just as the meeting was starting,
the secretary of State announced his preferred candidate to succeed me as CQC chair and that person is Ian Dilks. Many of us know Ian, he was the Chair of NHS Resolution until last year and worked very closely with us in that role. I have
to say, personally I am absolutely thrilled with the appointment. I think he will be really, really good for CQC. It is still subject to confirmation by Select Committee hearing, which I don’t think we have actually got a date for yet, but hopefully it will
be in in early February. Then he will take over when my term finishes at the end of March. So, really exciting and a good development. So, that was my bit of any other business. Does anybody else have any other business they want to raise?
OK, so that is the end of the formal meeting. I had 2 questions from Robin Pike, a member of the public. The first, Robin, was about visiting rights in care homes and I think Kate really has fully discussed that earlier in the meeting. So,
I think we will take your question as if it were already answered. The second question was how is CQC improving accessibility to its data via the website, and I think Chris, this has to be one for you. Yes, thank you Peter. Thanks for the
question. So, we are currently developing an upgrade to our website which is expected to launch the first phase of it in April this year. We have put accessibility at the heart of that work and we are working with colleagues from Mark’s team in a
digital team, and also colleagues who use about the website and the Internet and people who use services, particularly user-assisted technology, to try and make sure that the information we placed there is effective or meets our needs. There are 10 standards that we are trying
to put in place for web publications around reading age, around tone of voice, around length structure, image, use of colour, linking styles, the style guide generally used for tables and design. All of which are designed to make sure that our information is accessible to
people who use services, accessible to providers and accessible to a wider people responsible for improvements in health and care. Prior to the launch, the site will be subject to a full accessibility audit by an external organisation. But I want to make sure we do
more than just meet the requirements of that audit. There will also be some improvements over time, so later in the year, linked to our new regulatory model. We will no longer use PDS as our primary source of publishing inspector reports. We will still enable
people to print and use that information, but we want to make sure that our information to inspectors, and to people who use services and to others, is accessible, no matter whether you are using…, whether you have got a sensory or physical impairment or whether
you want to use a mobile or desktop, or indeed an Alexa device. I think some of the ways in which we are developing that with the help of Mark’s team have been fantastic and I am really hopeful by April and beyond, we will get
into a really good place with the website content. Great thank you Chris. That is the end of today’s proceedings. Thank you all very much indeed.