CQC Board Meeting 23rd February 2022 - Wednesday, 23rd February 2022 at 10:12am - Care Quality Commission

CQC Board Meeting 23rd February 2022
Wednesday, 23rd February 2022 at 10:12am 

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Start of webcast
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  1. Mr Peter Wyman
  2. Mr Peter Wyman
Apologies and Declaration of Interests
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Minutes of the Public Meeting held on 19 January 2022
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Matters Arising and Action Log
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  1. Mr Ian Trenholm
  2. Mrs Mary Cridge
  3. Mrs Mary Cridge
  4. Mr Mark Saxton
  5. Mrs Mary Cridge
  6. Chris Day
  7. Mrs Mary Cridge
  8. Ms. Rosie Benneyworth
  9. Ms. Sally Cheshire
  10. Mrs Mary Cridge
  11. Ms. Sally Cheshire
  12. Mr Ian Trenholm
  13. Mrs Mary Cridge
  14. Mr Peter Wyman
  15. Mrs Mary Cridge
  16. Mr Peter Wyman
  17. Professor Edward Baker
  18. Mr Peter Wyman
  19. Sir Robert Francis QC
  20. Professor Edward Baker
  21. Ms. Rosie Benneyworth
  22. Mr Peter Wyman
  23. Mr Peter Wyman
  24. Mr Mark Sutton
  25. Mr Peter Wyman
  26. Chris Day
  27. Chris Day
  28. Mr Peter Wyman
  29. Chris Usher
  30. Mrs Mary Cridge
  31. Chris Usher
  32. Ms. Kirsty Shaw
  33. Mr Mark Chambers
  34. Ms. Kirsty Shaw
  35. Chris Usher
  36. Chris Day
  37. Chris Usher
  38. Mr Peter Wyman
  39. Chris Usher
  40. Mr Peter Wyman
  41. Sir Robert Francis QC
  42. Chris Day
  43. Sir Robert Francis QC
  44. Chris Day
  45. Mr Peter Wyman
  46. Sir Robert Francis QC
  47. Mr Peter Wyman
  48. Chris Day
  49. Mr Peter Wyman
  50. Mr Mark Saxton
  51. Mr Peter Wyman
  52. Mr Ian Trenholm
  53. Chris Day
  54. Mr Jora Gill
  55. Ms. Kirsty Shaw
  56. Ms. Sally Cheshire
  57. Mr Ian Trenholm
  58. Professor Edward Baker
  59. Mr Peter Wyman
  60. Ms. Kirsty Shaw
Quarterly Change Report
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  1. Mr Mark Sutton
  2. Mr Peter Wyman
  3. Ms. Kirsty Shaw
  4. Mr Peter Wyman
People Survey
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  1. Mr Peter Wyman
  2. Mr Mark Chambers
  3. Mr Peter Wyman
  4. Ms. Sally Cheshire
  5. Mr Peter Wyman
  6. Mr Ian Trenholm
  7. Mr Mark Saxton
  8. Mr Ian Trenholm
  9. Mr Peter Wyman
  10. Chris Day
  11. Professor Edward Baker
Research into A+E Admissions at Barking, Havering & Redbridge University Trust & the Implications for CQC System Thinking
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Any other business
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Apologies and Declaration of Interests
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Apologies and Declaration of Interests
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Apologies and Declaration of Interests
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Apologies and Declaration of Interests
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Apologies and Declaration of Interests
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Apologies and Declaration of Interests
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Apologies and Declaration of Interests
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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Audit & Corporate Governance Committee Summary of 28 January Meeting
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  1. Mr Peter Wyman
  2. Mr Peter Wyman
  3. Professor Edward Baker
  4. Mr Peter Wyman
  5. Chris Day
  6. Mr Peter Wyman
  7. Mr Peter Wyman
Audit & Corporate Governance Committee Summary of 28 January Meeting
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  1. Ms. Sally Cheshire
  2. Mr Peter Wyman
  3. Sir Robert Francis QC
Welcome to the new National Director of Healthwatch England
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  1. Ms. Rosie Benneyworth
  2. Mr Peter Wyman
  3. Webcast Finished

Apologies and Declaration of Interests

Mr Peter Wyman - 0:00:00
Good morning everybody, and welcome to the February Public Board
Mr Peter Wyman - 0:00:13
Meeting of the CQC. We have an apology this morning from Kate Terroni who is ill, but Mary Cridge is stepping into the breach for Mary, for Kate. Mary, you’re really welcome, thank you very much
for coming at short notice. Stephen Marston is joining us remotely on screen. Stephen, it’s great that you could do that. We have Paul Kirby with us today as our network representative. Paul has been a fairly regular attender at our Board. You are very welcome
Paul, you know the rules. Stick your hand up if you want to speak. Paul is from the Disability Equality Network. Does anybody have any declaration of interest they wish to raise? Excellent. That takes us then straight to the minutes of our meeting of the

Minutes of the Public Meeting held on 19 January 2022

Matters Arising and Action Log

19th January, are they a true and accurate record of all we discussed? Good, so they are approved, thank you. We have one item on the action list which is going to be covered on the agenda, so that’s good. Is there anything anybody else wants
to raise as a matter arising? OK, in which case we can move quickly, Ian, into your Executive Team Report please. Thanks Peter. Just very briefly, just on partnership working. As we emerge from COVID, I just wanted to make the point that I am currently
Mr Ian Trenholm - 0:01:43
the Chair of the National CEOs Group which involves English Health and Social Care arms-length bodies. I have also just taken on the Chair of the UK and Republic of Ireland Health and Care Regulators Group and we have reinstated more regular meetings of the Safety
Regulators Group in England. The point I am making here is, taken together, I think it demonstrates that we are looking for opportunities to work collaboratively with other safety regulators and other arms-length bodies as we emerge from COVID. There have already been a number of
occasions where we have managed to look for a lot of opportunities to collaborate and share best practice. I would hope that that would continue. Thanks Peter. Good, thank you. Mary, straight to you. Thank
Mrs Mary Cridge - 0:02:36
you. So our priorities have remained responding to risk and inspecting
for improvement where that increases capacity. The numbers are in the paper and we are widening and ramping up our inspection for improvement as we go forward from March. On vaccination as a condition of employment, the Secretary of State announced the consultation on ending that
requirement. As we know the regulation applied to staff working in care homes from last November. While the consultation has been on going ongoing and ahead of any changes to that regulation, we are taking a proportionate approach. We are required to regulate of course as
the regulations currently stand. But the approach we are taking is that if that were to be the only breach, that it would not impact on the rating and we have a panel stood up to ensure our consistency of our approach in those cases. On
visiting into care homes, government guidance has been updated on 31st of January and a further update on the 2nd of February. We have obviously adjusted to take our approach and coverage to take account of that revised guidance. We published our own approach to this
on the 10th of February and what we are looking for from providers is to follow excellent IPC practice and to follow government guidance. We have since the 1st of December received 189 concerns about visiting to services, of which 82 concerned allegations of blanket bans.
We have reviewed them all, taken action where needed and followed up with providers. On workforce, there is a data update in the appendices that look to vacancy and turnover rates, bed occupancy and so on and some early findings from the workforce survey which I
hope will be helpful. On designated settings, our role in assuring those is unchanged. There are 50 designated settings currently approved which amounts to 639 beds. On care hotels, these have been set up in some areas to support short-term pressures on discharge. They are designed
where they exist to provide short-term accommodation for people. Our part in this comes in with the care they receive from domiciliary care agency. Should we be required…, should we receive concerns and need to inspect, we would do that as we do for other domiciliary
care agencies. Thank you. Thanks. Anyone want to come in? Belinda and then Mark. Hi, just a couple questions. So guidance from NHS England says that care hotels should only be used for days, rather than weeks. So, do we have a feel for, if that
is actually taking place? And secondly, clearly hotels are not set up for delivering personal care and accessible facilities etc., etc. So, are we looking at when we inspect and having inspections taking place of care hotels so far? Thank you. So, to answer your second
point first I don’t have the data to hand as to how many inspections
Mrs Mary Cridge - 0:06:39
we may have undertaken, but I will obtain that. If we looked at… the registration element would be for personal care and that would be the element that we inspected. If we
were on site to inspect and had concerns about environment, then those would be taken up. Our engagement has…, around this, has been with the commissioners of that care and influencing the sensible assessment of places for this. I don’t have a feel for whether people
are in those care settings for days or weeks. We do ask domiciliary care providers to notify us if they are taking on such contracts to cover a care hotel, but we wouldn’t have that data systematically. OK, thanks. Mark then Robert. Thank you Chairman, and
Mr Mark Saxton - 0:07:48
Mary thanks very much for a very full report. Could I just ask you a couple of questions? The first one is about the sector losing 134 locations and 1617 beds. I just wonder whether we have seen any increase in domiciliary care provision in this
period, and also whether you feel that perhaps secondary care beds are taking up the slack. We all know that that leads to an another set of problems. So that is one question. Could I just make the point about the people section which I found
very encouraging actually? But you know it is good to see that some providers are taking a more strategic approach to caring and recruiting and retaining their people. And it is good to see wellbeing strategies being implemented. But I did go into the Skills for
Care Report, that there was a link to your paper, and I thought there is some really interesting stuff in that Skills for Care Report that we should be very cognisant of. And the first one is to do, it is a more sort of structural
issue in the sector, and it is that 31% of Adult Social Care jobs in the independent sector were roles with less than 16 hours per week or 0hours contract. Prior to 2012 this was a significantly lower percentage and the Skills for Care report
makes the point that working with workers with fewer contractual hours are more likely to leave their role. So, a turnover rate of 50% of those with less than one year’s service. It seems to me that is a structural issue. I also thought the report
was very good in terms of the retention tools that are being used by those good employers I referred to earlier. So, values-based recruitment, the emphasis on training and learning, the emphasis on self-determination, quality of management and celebrating successes, all absolutely critical to try to
address this very big issue. Then, I think finally another structural issue for the sector is the median, independent sector, hourly care worker pay in adult social care compared to other low-paid jobs has narrowed. So there is greater pressure, greater ease to move because of
the pay rate. So I just think those points are worth acknowledging from that Skills for Care Report and, you know, should inform us as we move forward to, you know, understand and help and support the pressures in the sector. Thank you. There is a
great deal in what you have said there and I know that Chris will
Mrs Mary Cridge - 0:11:14
probably want to come in on elements of this. But we are very keen to support and promote the idea of Adult Social Care as an amazing career with the ability to
make a difference to people’s lives and experiences and to work with families and stay with them, sometimes for decades. So we are we are very keen to see that and the Skills for Care and the other data gives us the insights of both the
challenges and the opportunities for that. We are very keen to see parity of esteem for social care in terms of opportunities, in terms of career structure, in terms of pay and reward and recognition from the public for the part they play. So there is
a lot in that and challenges for us to address, and to pay a part in influencing others for their part in that too. In terms of the loss of locations and beds, some of that will be a positive, some of that will be our
direct hand in the closure of some unacceptable, unsafe environments, and for a look to increasing care at home and not being in residential care if that is not the most suitable environment. But generally, there is pressure all around. We see it in delayed discharges,
in the care hotels which has been part of the solution in some places. So, the roads lead back to staffing even where we have got evidence of capacity in currently registered services, it’s not always possible for providers to offer that service because of the
staffing challenges. So, it is a picture all round of challenge but with hope that in modernisation of approaches to both commissioning and provision that, you know, things can improve. In terms of the strategic approach to recruitment and retention, we work closely with the trade
associations that represent providers to encourage and support their efforts to take that strategic approach. Because it is quite hard, particularly for the smaller providers in the day-to-day pressure, to see beyond that. So, Chris, I don’t know if there is anything you want to add?
I think you have covered a lot of it, Mary. One of the interesting
Chris Day - 0:13:54
things that links the Skills for Care Report to our own report as now next to the Board is that we see a sharp rise in turnover rates, a moderate rise in bed occupancy in residential and nursing care and an
increase in events which cause a service to cease because of staffing. I think there is a piece which links what we see in residential care and what we also see in domiciliary care. To return to a question you asked earlier on, I think there
are signs that people are increasingly - when discharge to assess was brought in, it was brought in mainly around residential or nursing care. I think we are seeing signs of a lack of ability to get people out of a residential care home because of
paucity of domiciliary care. I think part of the challenge is how do you create, how do we nationally and in ICS areas create a better capacity for domiciliary care? Undoubtedly that is around funding and support for workforce so that organisations can make longer-term commitments
to bring people in, to bring the skills into the sector that are required. So, I think there is some work that we need to do nationally, and certainly with ICS partners, to help understand the relative tensions in different parts of the country, to bring
the skilled workforce, particularly around domiciliary care, into play. I think there are some ongoing concerns about the turnover rates and what that says about the relative security of Adult Social Care. We all know the implications of a of an Adult Social Care market and
system that is under pressure - the impact it has on other parts of the system. That is why I think, as we move into looking at not just organisations but places, we will begin to focus on that as a message to ICS leaders and
leaders nationally. OK, so Stephen you wanted to come in. Thank you Peter and thank you Mary for the report. Just to build on a couple of points that colleagues have already raised. The first was care hotels and kind of wondering from a positive point
of view whether this was an innovation that we should welcome, support and understand? You know, how might that be encouraged if we think it right to encourage it? Because the problem of people not being able to be discharged from hospitals because there was nowhere
suitable for them to go is longstanding and quite broad-ranging. If care hotels are or could be a good solution to that, a sort of specialist provision in a niche for that group of patients being discharged from hospital. Should we kind of not just view
this as a series of risks, but as something that positively we will want to understand, support, work out what good looks like and encourage it as an innovation? Just kind of interested in where you think that might go? Second point was to very strongly
welcome the emphasis on workforce development. And just to note that, if you kind of look at the precedent of what happened in nursing last time we needed to have a really significant upgrade of the profile, the recognition, the value in the professional skills base,
the registration of part our workforce, it took a long time. You know, this is a very significant, long-term initiative that we are now trying to promote and get involved in. I hope perhaps that might come back to the Board for broader discussion at some
point. Thank you. Thank you. So, the feedback on care hotels has not
Mrs Mary Cridge - 0:18:15
been universally bad. There have been places where it has been, for people leaving hospital who perhaps live on their own, a place to be for a week or so where their care
is provided, where meals are provided. I have had some positive feedback from at least one in the north where it was more – one might almost term it, more of an old-fashioned convalescence experience that help people on their stage to go home. But most
of them have been borne out of difficulty and crisis with delayed discharge. In the earlier days of recovery from the pandemic, when a lot of hotels were standing empty, there were some of the environmental concerns that you get when you reopen a property that
hasn’t been used for a while. Not least, for example, running the showers hot to avoid the issue of legionella, so there were some of those sorts of buildings being opened up sort of concerns that come with that. But the general point about being open
to the idea it might be used well and innovative, yes of course, we should stay with that. As I say, we are trying to influence the commissioning so that where these are being used, they are being done as well as possible and people are
not being left there. On the workforce development, absolutely. We recognise we are on a long-term task here and we also recognise that, for some areas, there are questions. So social care is a place of innovation, and we know that, and freedom, the two. We
know for example that personal assistance, there is some concern that we would not suddenly be regulating personal assistance and getting in the way of people who want to pay their neighbour to undertake some tasks for them, for example. But I think we can pull
that off. I think we can influence the long-term development of social work as a well-established and well-respected career path, without doing that stifling of innovation piece. Good, thank you. Rosie and then Sally. Thank you. I just wanted to
Ms. Rosie Benneyworth - 0:20:30
respond on the point about care hotels as well, because I think
we have to be very careful to ensure that longer-term solutions for people look at what is going to give people the best outcomes for their longer-term wellbeing and health. We know that often bed-based care and multiple moves, particularly when you are looking at elderly
people and elderly people’s care, doesn’t always deliver the best outcomes. And doesn’t always support people to get back to what they very often want which is an independent life and get back to living at home. I think we need to make sure that with
any solution, it is considered as part of the overall pathway for that person and that people get the appropriate rehabilitation support, the appropriate kind of care to enable them to get back to the best outcome for them. So I think that care hotels -
my view is that they are a stop gap and they have been needed given the pressures - but I think longer-term we need to be supporting systems and working with systems, so that systems provide solutions that are going to deliver the best possible outcomes.
From work that was done pre-pandemic, often that doesn’t necessarily mean a bed-based care, it means looking at actually wrapping round multi-disciplinary teams around people to support them to meet their goals and to meet the things that are going to enable them to get back
to a really good standard of living. Thanks. Sally. Yes, thank you. I think that was a really helpful discussion, Mary, and we have touched
Ms. Sally Cheshire - 0:22:13
on a lot of points, haven’t we? I suppose I am interested in the next 6 to 12 months really. How we
encourage the sector to be able to live through that and continue to provide good care? So Kate came to the last Board and talked about extra funding that was going into the sector, which is very welcome. But we can see from your report that
vacancy rates and turnover rates are continuing to go up and as bed occupancy also goes up - either because of lack of domiciliary care, or not enough care hotels as a stop gap, or overwhelmed GPs who can’t provide that oversight to patients - the
system backs up, doesn’t it? So then you end up with - and your report talks about the loss of beds being in nursing care rather than residential care - so you can see the acuity of patients back in, back up into hospitals and ending
up with worse delayed discharges. So, despite the fact that workforce money is going in, it will take time to have an effect, won’t it? So what’s your view on what is going to happen over the next 6 to 12 months, and how CQC support
providers, perhaps in a slightly different way to what we are doing now or more of the same? I think I would struggle to give you a
Mrs Mary Cridge - 0:23:42
prediction for the next six or more months. I think we have to see what happens over the next
couple of months data. This data, the last data we have got before us today, suggests continuing increases. We may see some stabilisation over the next couple of months, but I think it will be a case of wait and see. In terms of what we
can do to support providers in the sector, I haven’t got anything beyond keeping on what we are doing which is having that dialogue, providing the sorts of data through our survey work to give that wider broader insight, and working with the trade associations and
with the larger providers to listen and support their own innovation. There is no magic bullet here. We need to see how this is going to pan out. Ian. There’s not been a magic bullet for decades, has there? But I think it is just worth
Ms. Sally Cheshire - 0:24:49
outlining to people who might be listening to this, that it isn’t a new problem, that it has perhaps been worse by the pandemic. And that, although there is that willingness to put extra money into the sector, it will need solutions in the longer term,
thanks.
Mr Ian Trenholm - 0:25:08
Yes. I think just to add to that, I think Mary made the point very well at the beginning that the aim of the game here is not to necessarily to solve the problem in the next few months. It is about how to really excite an 18-year old that social care is a great place to work and there is career pathways that go in and out of both health and social
care. There are some examples nationally where places are doing exactly that, and having skills passports and this sort of thing. I think our role is to keep having this conversation in a very clear way. In the last three State of Cares that I can
think of, we have been raising this issue about very high staff turnovers, we have been raising this issue about this migration from nursing to care homes. So, these issues are, as you rightly said, not new issues. I think my worry would be, if this
is seen as a cash problem to be solved by a short cash injection, it is kind of missing the point. So, for me, I think there is something about what are the innovative solutions and using that cash to prime the pump, but this has
got to be a long-term play, as you know, as you rightly said. OK. I think that we will be returning to this quite a lot. Mary, can I just congratulate you on the appendix? It is really good and a number of colleagues outside the
Mrs Mary Cridge - 0:26:23
meeting said that to me. So the data in there, which I am sure you
Mr Peter Wyman - 0:26:27
prepared and Kate had nothing to do with it. Really good, thank you.
Mrs Mary Cridge - 0:26:31
All my own work, Peter. Thank you I’ll pass on to the team. Thanks,
Mr Peter Wyman - 0:26:34
Mary. Ted. Thank you,
Professor Edward Baker - 0:26:38
Peter. So, reporting back from hospitals this month. We have continued our approach to inspections focusing on areas of risk. That is continued through and we have increased our focus on urgent and emergency care, taking the collaborative integrated approach which Rosie is going to talk
about in a few minutes, so I will say no more about it. We have got a session later on about urgent and emergency care which I think will be an interesting opportunity to discuss that. What I wanted to focus on today was to follow
up the report I gave to the Board in October about a trust that it improved quite significantly, despite the pandemic. That was the Isle of Wight Trust. I think because we are focusing on services where we perceive there to be risk, it is easy
to conclude from our reports that things are getting worse across the board. That is just not true. Before the pandemic we saw NHS Trusts, who had had the right approach to leadership and culture and governance, were driving forward real improvements in their services. I
think the news from what I am presenting today is this, that is continued during the pandemic. The Isle of Wight was one example of that which I reported in October. When new leadership take a new approach to engaging staff, to driving forward the right
culture in the organisation and the right approach to leadership made a real difference to that organisation and changed an organisation, which really caused great concern for a long time, into a really good organisation, going forward. Now, we published two weeks ago our report on
United Hospitals in Lincolnshire which, again, is an organisation that has caused us great worries in the past. It was in special measures, it came out again, we put it back in special measures because it didn’t sustain improvement. It has been recently in the recovery
support programme which is the success of special measures announced. Our recent inspection showed again a new approach to leadership had changed the culture of the organisation. These are hospitals in Lincolnshire that have been under particular pressure from the pandemic in terms of urgent and
emergency care. But having said that, despite that, they have actually driven forward major improvements in the quality of the care. The staff experience that we observed at our recent inspection was very different and that was having a real impact on the quality of care.
So we published that two weeks ago and today we publishing a further report on Queen Elizabeth King’s Lynn NHS Foundation Trust. Again, new leadership in that organisation has changed an organisation which, a few years ago, we were very worried about in terms of the
quality of care and the culture in the organisation. Now it has been transformed by that approach to leadership. There some articles about it in the HSJ today which I recommend to you. There is a particular one written by the chief executive there, Caroline Shaw,
where she emphasises the cultural change that she and the leadership team has brought about. I think what I would want to say is all credit to the leaders of these organisations, but all credit to the staff who have risen to the challenge at a
difficult time. I think it is really an exemplar of how you can drive improvements, even under difficult circumstances, in NHS trusts. I think there is a lot of learning there for other organisations. The principles they followed were the principles that we laid out in
our improvement publications a few years ago. They are laid out very clearly in our Well-led Assessment Framework which we published in 2017. We are now refreshing the Well-led Assessment framework and we need to build into that the characteristics of the good leadership that we have observed over
the last few years. I do think that one of the biggest leadership challenges in the NHS is are organisations such as these three, that were in real difficulty with real problems with the quality and safety of their care, taking forward organisations where the culture
was really very damaged and changing that. I think that is a is a formidable leadership challenge and I am really grateful to the leaders in all three instances that have taken it on and made a real difference to the quality of care for those
patients. I have to say that one of my concerns is that actually leaders are not attracted to these posts because they feel that they are posts where they can be so easily criticised because these are not easy jobs. But actually what the best NHS
leaders need is to take on the most difficult challenges and that is something that that we have made very clear to the Messenger Review that is going on at the moment. I am really hopeful that they are going to reflect that back in their
report at the end of March. So, I think the message is really a strongly positive one about the improvement that can be driven forward in NHS trusts despite the pressures. I think that is a lesson for all other NHS trusts. I have to say
we still finding problems in NHS trusts and there are still some trusts that are not making progress. I hope they take the lessons from these organisations. It is a very encouraging a story you have got
Mr Peter Wyman - 0:31:35
there, Ted, and I echo your congratulations to the
people that have transformed in this way. Very good. Robert. Thank
Sir Robert Francis QC - 0:31:48
you. Very encouraging indeed and it’s good to hear. I just wonder if you have a reflection, in terms of the challenges facing leaders who are seeking to change the culture of their organisations, which,
as you know, is central in some places. How that is challenged in itself by the understandable demand - it is an understandable demand - to reduce waiting lists and that sort of thing, as in terms of the pressure that puts on Chief Executives to
fulfil targets based on numbers really, as opposed to patient experience? And how actually the Executive is meant in this day and age to meet both those requirements at the same time? I think one of
Professor Edward Baker - 0:32:34
the things that Chief Executives of NHS Trusts have said
to me, on many occasions, is that they don’t feel they have as much autonomy as the title Chief Executive sometimes implies to others. They often feel they have to work…, they are directed by the centre to follow targets around waiting lists or other access
targets. Now, those targets are an important aspect of quality, but they do not define quality in themselves. The view we have taken in our inspections is to look at quality in the round, not just in terms of access targets but also the safety and
effectiveness of care. I think it’s really important that when anyone looks at quality, they look at it in the round and don’t look at it as a simple target, a numerical target that reflect something important but does not define quality in its right. I
think Chief Executives and leadership teams and Boards of these organisations need some courage to be able to stand up to the external pressures and to focus on the needs of the patients they are looking after, and look at those in the round. I think
that is a real challenge. I do hope that with the new approach and with the improvement that these organisations are given more autonomy. They need accountability, but they also need autonomy to prioritise the quality of care around the patients they are looking after. Thanks.
Good. Rosie, onto you. Thank you very much. Three areas to cover
Ms. Rosie Benneyworth - 0:33:57
today. The first is the urgent and emergency care inspections that Ted mentioned. These are going very well. As people know, we did a couple before Christmas. We paused it due to the Omicron
variant, but we have now restarted these inspections. They are a great collaborative effort across all parts of the organisation and all of the inspection teams. We look at all of the different pieces of the jigsaw that fit to make the urgent and emergency care
system in a local area. The aim of these inspections is very much to look at how can we support systems to improve, how can we support systems to identify areas that might need some more focus, and also how do we pick out best practice
so that we can share it. We are aware that the urgent and emergency care systems across the country are under huge pressure and continue to be under huge pressure. So we need to look, as a regulator, to what we can do to help that.
We are continuing to evaluate this programme and we are learning as we go as well, and iterating our methodology as we go based on feedback from both inspection teams and providers. So, that is all going very well and the next four systems that we
are in at the moment are listed in the report. With regards to GP access, I mentioned last time and gave a verbal update on the findings of our programme. This is just to build on that. So, I won’t go into that in more detail
other than to say when we are doing the urgent and emergency care inspections, we are, when we are looking at GP and primary care provision in local areas, we are having a focus on access during that time as well. The final piece I wanted
to mention was some work we have been doing collaboratively with NHS England and Health Education England, looking at Primary Care first-contact practitioners. So, the Board is aware that there has been a great expansion in Primary Care staff over the last couple of years and
this is going to grow. There was an expectation that there will be 26,000 new Primary Care practitioners from a whole range of backgrounds – pharmacists, paramedics, mental health workers. We really welcome this multi-disciplinary approach in Primary Care. I think it will add and enhance
the experience that people get and outcomes that people can get. However, we want to make sure that people working in these roles feel supported, they are supervised adequately, they are working within their competency areas and they are very much kind of part of the
wider Primary Care team. Because they are often working across the Primary Care network, so sometimes working across multiple practices within a local area. So we have been working to put out some guidance as to what we feel the safe and appropriate use of people
in these roles are. That is available for you to see there. So thank
Mr Peter Wyman - 0:37:12
you, Peter. Good, thank you. OK, Tyson on to you. Thank you, Peter. Let me just add briefly to my written report. In terms of operational delivery over February, which of course
we are only part of the way through, in Adult Social Care we continued the strong performance we saw over Christmas and the New Year period, even though low needs from Primary Medical Services and hospitals have now returned to their home directorates. Because of the
decision to pause some of our activity over December to allow NHS colleagues to focus on the booster campaign, I think it was always going to take a bit of time to get our operational tempo fully up to speed across the other sectors, because of
the need to re-plan the inspections that we had postponed, and also to book specialist advisers who are crucial to our work. That is now up and running and we are starting to see our performance pick up and we are now much more moving towards
our normal operational posture. I see us being on an upward trajectory going into March, and I think that will hold us in good stead for the next performance year that starts in April. Two other points briefly. Firstly, we have now agreed with the with
the teams their objectives, their operational objectives for March to June, which will give them a longer timeframe to plan to and I think that is going to be welcomed. And also that the national Direct Monitoring Approach Team which had been set up to pilot
a new approach to monitoring what we call our Band 2 providers is now up and running. It is starting to perform well and it is being fully evaluated as it is being piloted for the six-month period, and very happy to return to the Board
with an update on that work as we go along. But that is all I was planning to say, thank you. Good, thank you. Nobody wants to come in?
Mr Peter Wyman - 0:38:59
Mr Mark Sutton - 0:39:08
That is great, well done. Mark. Thank you Peter. Sorry, one second. Obviously taken by surprise that
the long dialogue after… I had made a note I was after Kirsty, apologies. So, in terms of a cyber update, there are no significant information or cybersecurity issues to report this month. I think it is worth noting, given heightened tensions in Ukraine, we are
aware of the elevated risk of cybersecurity threats. Our security teams continue to monitor cybersecurity threats, as we do normally, and we regularly monitor the advice and guidance from the National Cybersecurity Centre. It is an ongoing activity and we will respond to recommendations from the
NCSC as they come through, as well as our ongoing continuous improvement activities which includes things like… This month we are launching a new programme of cybersecurity awareness and training throughout the organization and this has been a great collaborative effort across the organisation, including digital,
our information and governance colleagues and our academy. Good, thank
Mr Peter Wyman - 0:40:25
you. OK on Chris. Just two things to update on. In terms of the
Chris Day - 0:40:31
passage of the Health and Social Care Bill, that comes back to the Lords on the 1st of March where there will
be…, the detailed examination proposals will continue. I wanted to touch on the Integration White paper which was published recently. This paper isn’t expected to change aspects of the Health and Care Bill, but I think it does offer a view as to how the Department’s
expectations on the delivery work of ICSs will happen. There are some things that are important to note in there. Firstly, the idea of designated shared outcomes for organisations around a place, person-centred in their approach, I think is really important and critical. I think it
strengthens the approach of Small Neighbourhood place as a function of how health and care is delivered well and introduces the expectation of a single point of responsibility at a place level. I think these…, it sets out some of the key enablers of integration, some
of which we have spoken about this morning, workforce, digital, data, financial pooling and alignment, all of which I think are potentially supportive in how ICSs will operate. And obviously it references the role of robust regulation. I think particularly significant is this issue of neighbourhood
place system and region, so to have in those four sort of tiers, if you like, of responsibility. I think when it comes to our role, understanding what the outcomes look like at a place level and working with ICSs and organisations to understand improvements at
a place level, I think will be important. Obviously, this is an important starting position for both the ICB and the local authority, which will form part of the ICS, and it will hopefully guide our work with them in the regulatory framework that we oversee.
The other thing it clearly sets out is a need for partnership working. I think it is important we maintain that as we go. It doesn’t become an NHS thing or indeed just a trust thing, it is a genuine partnership between all aspects of the
health and care system. So I just wanted to note that that has happened and I think it will influence - albeit not in a in a legal way - the shape of the Bill as it enters its final stage. Just the last thing to
say, as a sort of teaser for next month, the next development in our Out of Sight Report looking at access to community mental health services and how support for autistic people or people with a learning disability is being delivered. I wanted to do…, it
is an important report. We are already beginning to speak to stakeholders about the implications of it and we will look forward to position it for the March Board. That’s it from me. Great. Thank you, Chris. Anything from anybody else on the Executive Team Report?
Could I? Sorry Stephen. I’m going to blame Naomi because she’s sitting in front of the bit of the screen where your hand goes up, so I can’t see it. Sorry, Naomi. Stephen. Just a question for Chris if I may? Which is whether you feel…,
whether you’re hearing anything from others about the implications of the Levelling Up White Paper that came out recently, either for the wider Health and Care sector or for CQC directly? Health is one of the stated missions within the Levelling Up White Paper and it
must be true that if you are serious about levelling up, then levelling up in health must be one aspect of that. I wasn’t seeing a lot of kind of new announcements though about what levelling up would mean for the Health and Care sector. Have
I missed…? Yes, I think the conversations that we have had so far, we
Chris Day - 0:44:28
have had a conversation which Rosie has talked about many times, around the relative inequalities in different areas. And there is something for me about how ICS areas places understand where they
start from, in terms of their relative inequality, and what they need to do to improve. I think there is a strong link between that and the levelling up agenda. So, last year we did a piece of work which looked at what investment in Adult
Social Care would mean economically to see the impact it would have, both in terms of the improvement in Adult Social Care but also in terms of the local area. I think there is some serious thought being given now as to how we can use
Health and Care as part of the stimulus for an environment locally and I think that will be part of the consideration of the of Integration White Paper that we just talked about there. So, I think the challenge is how do you make sure that
the economic stimulus that goes into an area deals with the relative inequalities that an organisation or groups of various have. The first bit for me though is making sure that we have adequately describe where an organisation or an area sits and that is the
work we are on with now. Great, thank you, Chris. OK let’s move on in
Mr Peter Wyman - 0:45:48
that case to the other Chris, over to you. Thank you, Peter. So this
Chris Usher - 0:45:56
is the second performance update we have done of the new business plan, so I will walk
through the headlines of that, and we can take questions as we go if you like. So, this is the quarterly update on performance. I think what we have said we will try and do is do a quarterly update in between that on change and
another quarterly update on people. So we will get into a rhythm, in a cycle of performance, change and people updates so we will be able to see more in-depth data in some of those areas which probably will help some of the conversations. In terms
of analysing data we capture and interpret to identify risk, I mentioned in our last quarterly update our KPI focuses on inspection and monitoring activity. This translates to a coverage of 18.2% of providers have had that activity to the end of December, as shown in
Slide 4. Factoring in a range of activities that we have, in addition to inspection and direct monitoring activity, means that probably a more accurate reflection is that we have had…, 74% of services had some level of regulated activity to the end of…, to date
which is, as I say, provides a better representation. Slide 4 also provides information detailing…, on the volume of inquiries we get on a monthly basis and you can see, in excess of 85000 regular inquiries. We published a short statement on a website where the
information does not evidence that we need to reassess the quality of a rating of a service. We undertake these Quality Assurance inspections to test our approach and findings. Slide 5 shows that we have undertaken 236 of these QA inspection so far which will keep
helping our learning going forward. It also shows that we have undertaken just over 4,200 inspections in response to risk. 57% of these were rated as “requires improvement” or “inadequate”. We have observed an increase in risk inspections resulting in an “inadequate” or “requires improvement” ratings
over recent months. For example in the SC North region where we inspect due to risk, for inspections between the end of November and the end of January 63% were rated as “requires improvement” or “inadequate”. Mary, I don’t know if you want to comment further
on what we found in Adult Social Care. Thank you. I think there are
Mrs Mary Cridge - 0:48:35
two things I would like to say. One is that it shows we are getting the decision to inspect right. Of course there are more reasons to inspect than just a change
of rating, but that is quite powerful, the outcomes where we are seeing that to be RI or Inadequate. That also speaks to the quality of the information that is coming into us, whether that is our assessment of our own intelligence or the quality of
information that is being passed to us by other stakeholders, commissioners or members of the public. The other thing it does of course - it is nothing to celebrate that we find so many services as RI or Inadequate - but it would be incredible wouldn’t
it, if all the pressures that we have already touched on today affecting the sector, if in fact there had not been an impact on the safety and quality of care in those services. So, I think that is what we are seeing. It is telling
something to us about our own decisions and information, and also about the very significant pressures in the sector. Thank you, Mary.
Chris Usher - 0:49:45
In registration, as you know, we are aiming to reduce the average number of days to complete registration by 15%. We have seen great
strides in this and in previous months. Slide 6 shows where we are currently shows we are close with regard to normal applications. However, our simple applications is reduced. It is now a 1.5% reduction, so moving away from the 15% reduction. Kirsty, I don’t know
if you want to add more to what I said on registration. Thanks, Chris. So, I think we have made some really good progress in registration in terms of building our performance culture over the last year or so. I
Ms. Kirsty Shaw - 0:50:24
think we have really struggled recently
with recruitment. So, we have had a number of people exit the business. That is one end and then we have been bringing trainees in at the lower end which has slowed our progress down. What we are hoping to do is try and get a
stable approach to our resources which then enables us to really drive that performance. I think if you look at…, if you get under the skin of this and look at some of the detail, there are some really outstanding performances in individual teams which are
driving, which are really showing massive increases in productivity. It is just that overall (unintelligible) of getting a stable resourcing platform to really be able to drive that performance. But I am hoping that the underlying improvements that we have made will start to continue and
show again once we get the latest batch up and running and working at full productivity. Mark. Yes, if I could just come in on that. I mean I was encouraged to see the trend in relation to complex. I guess I was quite surprised to see the
Mr Mark Chambers - 0:51:20
trend in relation to simple. I kind of thought that would be were some low-hanging fruit would be. You mentioned resourcing and recruitment, but is that the story for simple or is there some challenges about how we make what we do simpler? So, there’s a
combination. So, in terms of registration in the simple areas and to some degree some of the normal applications, a lot of those processes will be automated through the technological advances we are making
Ms. Kirsty Shaw - 0:51:53
with REG Platform. So, at the moment we are…, it is people,
and we have had quite a lot of churn in that team which are doing the simple applications as our NCSC-based team. So, that purely is to do with churn rather than anything else. But once the technology comes in, we will start to see these
numbers absolutely plummeting down in terms of productivity because a lot of the activity will just disappear. It will be automated fully.
Chris Usher - 0:52:27
OK, good. Chris. Thank you. So we have talked a lot previously about Give Feedback on Care and we are still seeing a 56%
increase compared to the previous year as shown on Slide 7. We have noticed that rate slowed down a bit since November, so it seems to have peaked and then tailed off since November. All directorates received an increase, however it is still PMS directorate where
the most significant increase can be seen. But again, even in that area, smaller volumes in December and January. I think Chris was going to want to add to that as well. Just to say that I remain pleased that we are 15% up on last
Chris Day - 0:53:06
year’s Give Feedback on Care rating, and I think 9% up the quarter. Just to give you what that means in reality, we are receiving some form of Give Feedback on Care every three or four minutes from a member of the public for a working
day, which I think is good. The campaigns I think will help. The next campaign is aimed at carers and I know we have got strong support from colleagues in Healthwatch for that, alongside other organisations that represent people who use services. Just to play back
into what Mary talked about earlier, the really important thing with this information is that it directly goes into our responsive inspection activity and we use the feedback to guide our understanding of risk and guide our inspectors in terms of where they go to assess
the quality of services. So not only are we gathering more, we are using it better. Thank you. OK. Slide 10, so we continued testing our
Chris Usher - 0:53:58
new approach to inspect services for people with learning disabilities and autism. To date, we have undertaken 35 inspections with
this new approach and 39% include some form of out-of-hours inspection activity. Yes. Slide 7 shows the major report publications we have issued to date. All have been delivered on time, collectively they have had view of 42,000 to date. In terms of our transformation activity,
Slide 13 - all current milestones are on track for delivery of our change programme with two slight exceptions. Fees calculator is scheduled to complete in February due to some final amendments, and the new data insight unit is due for completion in March rather than
January as initially planned. In terms of managing our people and resources, a lot of metrics will be refreshed as part of the People survey that we have recently had. So we will be able to update a lot of the survey-led questions there. Sickness is
tracking at 3.8% with a sharp reduction towards the end of the quarter as you can see on Slide 15. 1.4% of sickness is triggered by stress or mental health conditions as well. In terms of diversity we continue to ensure we are examining our conversion
data and we have got the right attraction strategy. We have also ensured that all Grade A in executive recruitment has an independent Panel Member in 100% of instances. Then, final bit for me, in terms of our money. At the end of December, revenue budget
is underspent by 10.6 million, forecast to reduced slightly to 10.3 million by the end of the year. Capital is underspent by 3.3 million that is forecast to reduce down to about 400k by the end of financial year. Underspends are across pay, non-pay, largely due
to our adapted way of working as a result of the pandemic, for example a large reduction in travel costs. I will pause there, Peter. Chris,
Mr Peter Wyman - 0:56:13
help me. On Page 35 of the book, you red-rated our monitoring that we are on budget. I am assuming
this is some process point, but can you just help me? I can help you.
Chris Usher - 0:56:28
So, our ratings’ logic would deem that as a red, I think a common sense approach would say it is not red and an underspend of that scale does not deem
a red light. So, it is one we will take away and look at, probably been too fixated on the logic of our ratings. Well, and also the
Mr Peter Wyman - 0:56:47
wording. Because I mean monitoring is not the same as being on or below budget, is it? And
it implies that, you know, nobody is looking whether we are actually on budget. We are certainly looking whether we are on budget. Yes, I know you are. Thank you. Robert. Slightly similar point but a different slide. I think it is Slide 8 which is about managing
Sir Robert Francis QC - 0:57:09
risk to people and we pointed out, and it’s encouraging, the number of times we are triggered to inspect by information of concern, particularly from whistleblowers. I rather wondered about the relationship between that and what is called regulatory information, which I would understand to be
regulatory history, as not. Presumably at some point information of concern becomes regulatory history. I am slightly concerned as to whether there is an implication that we are not collecting the right information if only 4% of the time are we triggered to go somewhere because
of regulatory information. So there’s a… it could be a terminology
Chris Day - 0:58:03
issue, I don’t know. I think this is in part regulation from other organisation…, information from other organisations so it is not necessarily history per se. It might be information that comes from a partner
regulator or another part of the system. So, it is a function I think of the relationship we have with other organisations, not so much a function of our own history if that makes sense. Robert. Yes. I mean the vulnerability I would suggest that one
might need to look at, and I’m not sure whether this helps or not, is
Sir Robert Francis QC - 0:58:36
that quite often when information of concern comes in from a whistleblower, it is about something that has actually been going on for quite some time but just hasn’t been noticed.
Almost invariably there is a learning point to be gained as to why something wasn’t brought to light earlier. I wonder whether we have information in this sort of format or could produce information in this format which might sort of bring that to light a
little. Because after all, in theory, our regulatory approach should be detecting risk at the earliest possible stage and, inevitably, it doesn’t always do so. But it seems to me there is a potential for thinking about how you measure that, but obviously if the regulatory
information we talk about here is not that, then obviously this is not approaching that. I know that doesn’t sound very coherent what I have just said, but I think you get the point. Yes I think it is just…, I think it’s more contemporaneous information
Chris Day - 0:59:49
that comes in about say fitness-to-practise or something which comes in which wouldn’t necessarily have been triggered by a whistleblower, but may have been triggered by another bit of regulatory activity from
Mr Peter Wyman - 1:00:02
another organisation. Perhaps we just need to have a conversation, maybe come back just
to make sure we are all on the same page on this. I’m just looking at how sensitive as it were our methodology is to
Sir Robert Francis QC - 1:00:14
risks and whether there is a need for us to be able to measure that in a way which perhaps we are not doing so
Mr Peter Wyman - 1:00:24
at the moment. Do you want to come back, Chris, on that? So, let’s have a conversation outside this because I think you are right,
Chris Day - 1:00:31
Robert. I think what you are saying is information which comes from one source that then ends up being a whistleblower, should we
make sure that we have tried to look at the source of it? So, I get your point. I think the majority of this information is more contemporaneous around information from other organisations and the regulators. But I think there is a good point there about
if we are receiving late or not receiving information from a partner organisation, it ends up being a whistleblower then, really, it would be better to try and go to the source. I think the way this table is mainly focused on just contemporaneous information that
has come from a partner organisation, principally another regulator. I think it is worth a discussion offline. I agree. Thank you, thanks,
Mr Peter Wyman - 1:01:18
Mr Mark Saxton - 1:01:24
Mark. Thank you Chairman, and Chris, thanks for a very full report, especially the people data that you have provided. It is very good to see that we had 100%
independent panel members in selection for Grade A and above. Good to see that our starters by ethnicity are at a higher percentage than the leavers. Could I just look at the turnover chart, turnover and movement, and I wonder whether there is not something that
we should delve into a bit more. That is the number of leavers stating promotion for a reason for leaving. It seems to me that is quite a challenge to us, especially as we have, during this period, a lot of promotions and a lot of
acting up movements in our organisation. So, I just think that is something that is worth perhaps some further information, to make sure
Mr Peter Wyman - 1:02:35
that we are not missing something in that area. Ian. Thanks. I think there is a couple of things, Mark, in relation to
Mr Ian Trenholm - 1:02:43
that point. I think we have had a strategy of using temporary promotions quite deliberately because we know we are in the process of transforming the organisation. We know that we will be restructuring elements of the organisations and so we deliberately tried to give ourselves
some flex. But I think this is also the broader point, that we know that our pay scales are increasingly uncompetitive and so people will move on. But also I think it is worth saying that, you know, we are doing some really interesting things in
terms of transformation. We are giving people skills and experience that are very marketable in what, in a number of areas, is quite a hot market, particularly around technology and some of the other things that we are doing. So I think there is a number
of factors here that play into that notion of people on promotion, people are getting good experience while here and then moving on. Thanks. Stephen, I have seen your hand this time. So Stephen and then Jora. Thank you, Peter. What I wanted to ask about,
Chris, if could is Slide 9, which is the one about delivering independent voice publications and this looked like quite an interesting survey to ask providers - I think it is providers - whether they find our publications useful in helping them make changes. The reason
I kind of thought that was interesting was that, for me, it goes back to that goal in the strategy we published last year about overtime promoting service improvement across the system. And if these publications aren’t really doing that, or aren’t doing that as well
as they could, are we kind of missing a mechanism for promoting that goal of broader service improvement? I just wasn’t quite sure what this was telling us, but it raised a bit of a worry that there may be something about the content or the
approach or the communication channel or the something about those publications that they are just not adding the value they could in the view of providers? So I think there is some learning definitely for us here over a couple of things - who we target
Chris Day - 1:05:03
with what information through what channel? I think there is a lot of learning here. Just to say something, the other thing to say about the survey itself is that, as it says here, we did it over a relatively short period of time and in that time there
were some…, there was no IV product for some sectors. So I think there was, disproportionately, there were some people who thought well actually there’s nothing that’s aimed at me, so therefore I am going to (unintelligible) you. But I still think, having said that, I
still think there is learning here. What we aim to do in the new business year is to do an evaluation after every publication. At the moment we do it for the key publications, the key sort of stakeholder publications that we publish, like State of
Care. We aim to do it with all because I think it’s important we assess both the contents and the language, but also the channel that we use to reach. So, there is some value here, it isn’t quite as positioned here because of the way
in which the survey was conducted. It was just for two sectors, there was no information that they could say, yes this has been helpful to me in in the time period. So, I think there is some learning. We are going to try and do
it on a publication by publication basis, going forward into the next business year, if that makes sense. Good. Jora. Thanks Peter. It was just a question on the learning and development. I mean we have made
Mr Jora Gill - 1:06:28
good progress and it has been a strategy of
ours to look at Six Sigma and give folks, you know, the bronze, silver or gold. It is a good initiative. I think it would be useful to have an additional slide on the outcomes now. Like, it is very difficult to put it in one
slide, but we have reduced process a from x days to y days, or something, you know. Because this is telling me that good progress has been made on the L and D, but then you want an outcome from it. I don’t know, Chris and
team, if there is a way of putting a slide on behind this one? Shall I answer that one? So, we have got some really good benefits data now
Ms. Kirsty Shaw - 1:07:10
coming out of QI programme, so what we will do is we will have a look and
see what we can pull together in terms of…, we will probably do this as part of a quarterly pack. We just saw something that came to ET, actually it was some quite significant improvements that the team are delivering. So, yes, let’s take that away
and we will add it into the next quarter. Sally. Thank you and for the
Ms. Sally Cheshire - 1:07:31
helpful discussion. I just wanted to come back to the very first point that Chris made around ratings. So, there is an inevitability, isn’t there, as a regulator that you focus
on the people who need to be improved… who need to improve? And that we are putting our effort into those people who are requiring improvement or inadequate, but if you look on Slide 38 it is in the pack, our QA sample gives a lot
more organisations who are good or better. And it was a little bit about the point that Ted made ages ago, around how we highlight a lot more organisations that are doing really well, that are improving their performance and that have reached a good rating.
So, I think somehow there is a balance in our reporting that needs to give an overall picture of exactly what the landscape looks like there, in terms of providers, and how many of them are good or outstanding over all. Because we are doing an
awful lot to support them in their improvement and that doesn’t always come across to me in this report. So, perhaps there is a balance around reporting given that we will still focus on those organisations that need to improve, does that makes sense? I think
that we could highlight a lot more the quality improvements that we
Mr Ian Trenholm - 1:08:53
are supporting providers to make. I think that’s true. I think the only slight caveat at the moment is we are inevitably going into the higher-risk locations. So there is, I think we have
been talking about this in broader terms, around how we might reflect this in State of Care later on this year. There will inevitably be askew to the providers we go into, but I think I think it is definitely something we have been reflecting on
and I think Ted just wants to build on that. Yes. I think this is a
Professor Edward Baker - 1:09:20
real problem because of the pandemic and our focus on risk-based inspections. We inevitably find more problems than improvement because where services are just below risk, unless we judge them
to be really inadequate or very poor to start with, we are probably not going to be inspecting them in this situation. I think as we go forward and get back to our long-term plans for regulation, we need to take that into account and make
sure that we are capturing improvement and reporting on improvement, just as much as reporting on concerns. Because I think that message has been lost. As I say, as I was describing earlier on, there are some trusts that are still very much following that. But
there are some trusts who I think are probably of the mindset that, actually, things are getting worse overall and there is not a lot they can do about it. But actually the trust that I was talking about earlier on has demonstrated that despite the
pressures there are still improvements to be made, and I think that is
Mr Peter Wyman - 1:10:17
a lesson we need to get out there. Good, thank you everybody. Let’s move on. Kirsty. Thank you, Peter. So, this will be our update, our
Ms. Kirsty Shaw - 1:10:29
quarterly update on our change piece plus
I have got a people update as well. So, I’ll do the change piece first, stop for any questions if we have got any. Then I can come on to the people update after. Overall, we have made some really good progress across this quarter in

Quarterly Change Report

terms of the wider portfolio. We are rated – the overall portfolio - as an Amber Green with lots of key milestones being met across all of the programmes within the portfolio. We have been doing a lot of work in terms of thinking about planning,
particularly thinking about planning for our Phase 2 deliverables, which is as we start to see us moving from the sort of design work into actually starting to deliver our new operational structures, piloting our new regulatory methodology and releasing our new tech into a test
environment so that we can start to test some of our new functionality and our data, the work we have done on and around our data. Overall, I think we are still having a slight challenge around accessing programme resources. The market continues to be very
buoyant in this space. However, we are making some good progress and making sure that all key posts in terms of those risk - so we’re managing that risk - have been filled. Also we have been thinking about our engagement plans for both our internal
and external activity. Really starting to think about how we bring our transformation to life so that people can start to really envisage what it will look and feel like once we have made all these changes that we are talking about. In particular we have
been looking at developing some scenarios and also personas so that people can really start to appreciate the new changes from their own particular perspective, be that a provider or be that an inspector or one of our colleagues working in one of our corporate services.
Going forward as a key focus for the next quarter will be around our business change and really thinking about how we support that implementation into both piloting and into live running. Really looking about how we can support our colleagues into that, making sure that
we are not overwhelming with too much change in any one time and ensuring that we have the right support there on the front line. Particularly thinking about how we are going to use our super users which are colleagues who have been specially trained to
support peer-to-peer learning to ensure that, especially as we bring in the new technology, they feel able to support…, to ensure good and consistent uptake. That work is currently ongoing and so is a line to our…, the work we are doing around our transformation…, sorry
around our communications so that we are able to say the right thing at the right time, so people feel confident in what we are doing. I will hand over to Mark in a minute. He will talk a bit more about the tech, but in
terms of our Pillar 2 Programme which is our organisational design and development, we are again making a progress in this in terms of delivering the organisational changes. We need to make sure we have the skills and capabilities we need to deliver on our new
strategy. During this quarter we have completed a detailed design for our leadership, of our regulatory leadership function and also our new network and hub model. So that we are able to really able to design a high level piece in terms of who is going
to be doing what. We are also starting to explore some work around our strategy, around our culture and looking at what are our cultural themes that need to be in terms to support our new ways of working. We have also completed our management of
change for Exec Level 2 colleagues and we are in the process now of starting to plan our management of change for the next layer down in terms of the organisation. We are working closely with the Tyson Hepple, our Exec Director of Ops, to ensure
that we have a smooth plan for transitioning from our current model into our interim operating model state, where we are realigning our senior management layers and then realigning the teams underneath those as an interim step, before moving further on into our multi-disciplinary teams. Mark,
do you want to pick up on the tech? Thanks Kirsty. So the regulatory
Mr Mark Sutton - 1:14:48
services pillar that we have is responsible for delivering new services, processes, data technology to support all of our strategic objectives, including our new regulatory approach. There are three main areas in
there: a data and insight programme, a regulatory platform programme and corporate services. So briefly on each. In our data and insight transformation programme, now we have entered all of our external surveys into a new platform. Our annual provider survey was carried out using the new survey technology,
providing a really great experience for people responding and a really significant improvement in efficiency and ability to access insights much sooner than previously possible. We are now nearing the completion of our work to establish the data and insight organisation which includes the creation of
new teams and capabilities, We have started to recruit into some of those new roles. We also defined a new tool set and governance that enables us to devolve the responsibility for data ownership throughout the organisation, and ensures that we have got high-quality data in
our new Enterprise Data platform. In regulatory platform, we have successfully implemented our new providers’ fee solution which integrates our provider billing process into the new dynamics environment. It gives us the ability to provide a more automated and efficient service. We have appointed service owners
now to drive our end-state vision and design of services, and those services and roles will really ensure that we deliver a joined-up approach across all of our aspects of people process and technology. And delivering key aspects of our strategy including smarter regulation. We are
making some really strong progress in the main building blocks of our regulatory platform, including a new provider digital service, internal solutions for delivering smarter regulation in registration and assessment and the publication of more up-to-date ratings for the public. In corporate services, we are focused
on driving transformation in our finance function through the provision of a new finance system. A delivery partner for this work has been selected and on-boarding is underway. So, you are not doing very much then, Mark, obviously? Anybody want to
Mr Peter Wyman - 1:17:06
come in on any of that? Perfect, that is really encouraging. Shall I
pick up the people bits now? I’m sorry…? Shall I do the people bits
Ms. Kirsty Shaw - 1:17:22
now? Yes. OK. So we have a separate session later on in this meeting on our staff survey, so I won’t talk about that now. But just a couple of other elements on our people
work. As ever, we have got a very busy programme across all of our people activity and just to pull a few bits to highlight. So, our Academy has been working really hard to think about the capabilities that we need to support developing through the
transformation, and in particular have been focused on the establishment of our new data and insight unit. Really looking at what are the needs…, the training needs there to ensure that that unit is set up and ready to go in the right way when it
goes live at the end of March. We have also been continuing to focus on supporting people to lead through change and coping with ambiguity as we go through a fairly substantial transformation programme. These courses have been really well subscribed and we have had to
put on extra ones as people have really…, and the feedback has been really, really positive. Really, practical type of skills rather than theoretical skills to really help managers lead in that environment. We have also a major programme of work looking at our culture and
that is a key piece of (unintelligible) transformation, but I am reporting it here. This one is…, what we have been doing is thinking about our culture and thinking about what is the culture that we need to support our transformation and our future strategy for
CQC going forward. Over the last month or so we have completed a number of conversations across the organisation to understand what it feels like when we behave when we are at our best. We have been able to use that feedback from those workshops to
start to develop some core principles around our cultural work. We are going to plug those into the work that we have going forward. That piece of work is a very collaborative piece, looking at how we build on the best bits of our organisation going
forward, but also looking at how we might strengthen some areas in terms of some of the cultural skills gaps that we have got to really start to think about how we realise that new strategy. So, we will pick up the people, the staff survey
Mr Peter Wyman - 1:19:38
results, in the next session. OK. You are getting away very lightly today, Kirsty. All right. Anything else? No, good so with everybody’s agreement, we will go to the people survey next. The reason is that we have got colleagues from Barking, Havering and Redbridge joining
us and I wanted them to join us for the last major session before lunch, so that they could then stay and have lunch with us and we can continue some informal conversations. So, Gill has very kindly agreed to come earlier. I hope that is
OK with the Board? And if it is, Gill and Paul, welcome as well. Can I hand over to you? Of course. Yes, sorry, I just need to get myself back into my notes. So, good afternoon everyone. We are here for our session on the

People Survey

People Survey results which we have shared with you all. I just - sort of by way of introduction - I think I will just canter through quickly some of the key highlights and then we will kind of open up. So, as you will know
from the paper, this is our first full survey since Autumn 2019. Quite a lot has happened since then. We have got a response rate which is actually really strong – 73% - so it gives us a really reliable dataset. This is a really, really
reliable picture of how people are feeling and experiencing working for CQC at the moment. Our response rate is down ever so slightly from our past surveys, but I would expect that. You do tend to have a higher response rate during a Pulse Survey then
a full survey, but it’s not significantly statistically different which causes me any concern. The results, as you’ll see from the paper, show an improvement on the last main survey in November 2019. We have seen several large increases particularly with regard to visitability of leaders
and the direction given by our senior leadership, which has gone up by 21 percentage points. That is quite a big jump and I think reflects the amount of effort that people have put into that over the last couple of years. We have also seen
the sort of increases in scores for the behaviours and values of executive leaders which too have gone up by 13 percentage points. So now sort of just over that 50% mark at 55% positive. Finally, significant increases in people’s responses to having the right equipment
and technology to do their jobs. I think we should remind ourselves, not only is that a really good jump from this survey, but it builds on an increase from the previous survey as well. So, we are seeing this telling an ongoing story about the
investments they were making to colleagues to help them to do their jobs well. We see the continued areas of strength which we have seen for many years in CQC around line management, team work, commitment to our purpose and values, and they have all shown
incremental increases, as well as being at the really high end of positivity. We do, however, have some scores that remain low and therefore an area that we need to continue to focus on. The questions around change where only 27% were positive about how change
is implemented. This is up 6 percentage points, but still lower than we would like and expect it to be. There is within this question group, however, a 31% neutral response and therefore I think that gives us an opportunity to really get underneath the skin
of this and address some of this. We do, I think, really also need to reflect the context in which we have been working over the last few years. So, we have, as a consequence of the pandemic, had to shift our focus on ways of
working in line with the pandemic as it has evolved, and also to be sensitive and responsive to the sectors that we regulate. The workload question also remains an issue for some colleagues, not all, but for some colleagues. Although there is a slight increase against
the acceptable workload question, so it is up three percentage points to 52% so tips us into that kind of majority place. Workload itself, in the qualitative stuff, is also cited by colleagues as one of the reasons why they would not recommend CQC as a
good place to work. So, for some colleagues this is something that we need to continue to pay attention to. Then finally, I would like to draw attention to the couple of questions around confidence that we will take action as a consequence of the results
of the survey. These…, the scores against these questions have stayed pretty static for a number of years and are broadly split between positivity, negativity and neutrality. Therefore, I do think we need to get better at closing the feedback loop around: you said, we’ve listened
and we’ve done this. That should be something that we should really be paying attention to in the coming weeks and months. We have seen, as you’ll see, an overall reduction in the Employee Engagement Index. This is particularly because two of the contributing questions have
dropped a little bit, so the “I feel proud to work for CQC” and “Working inspires me to do the best that I can” are both down by a few percentage points. I’m not unduly surprised that we have seen that slight decrease in the overall
Employee Engagement Index score. Given the context of where we have been working and our transformation work and our new strategy, you know, you might have seen a further decrease in that score. So, I think, while it is down slightly, it is not down so
significantly that we may have something to concern ourselves about, but we do need to keep an eye on it. We have seen increases against the wellbeing questions, which is good, because we all know from conversations we have had over the last few years, we
have put a lot of attention and investment into our wellbeing agenda. A small but ongoing decline in the number of people who are experiencing bullying, harassment and discrimination. So while that is good that it is going down, obviously we would all like it to
a place where it is zero. So, we are…, we do have a downward trajectory and I would like us to continue to work in, move in that direction. We did say in the paper that there are some notable variances between the Executive Directorate so
some scores are - this is an amalgamated, macro-level report and we do have differences. They are being reflected in each of the executive directorates’ work going forward, in terms of their own individual areas for focus. I think, therefore, I will just end on this,
as we have in the paper, the focus for us as an organisation needs to be on making better connections to this feedback that we are getting from colleagues. So we are demonstrating that we are listening, we are acting upon the feedback where we can
and we also need to really focus around this, connect that into our improvement agenda. Because we are doing a huge amount in terms of improvement, but we are perhaps not telling that story as well as we might. We then really do need to continue
the work in hand, to equip our line leaders to have good conversations and to implement change well. I’ll pause there. Thanks Gill. There is a tremendous amount of really good information
Mr Peter Wyman - 1:27:32
in there, and as you say some of it is good and some of it gives us -
while it’s not good - gives us a clear opportunity to focus. Who wants
Mr Mark Chambers - 1:27:49
to come in? Mark. Thanks very much Gill. I think these things are… it is great work. It is a comprehensive view of the organisation. There is some really insightful information in
here and there is a vast amount that is just tremendously actionable. So, I think it is great and I think is very timely in terms of, you know… We heard from Kirsty a few minutes ago on the work on culture and I think it
is a timely piece of collateral for us to use and respond to. The response rate, yes could be better but it is still good enough for us to know that this is real. And this represents where we are. If I could register a general
point and then a specific point, I am glad you mentioned the bullying and harassment scores. I was concerned, I think is the right word, by the specific scores that appear on Page 18 and Page 20 around the levels of satisfaction that problems with bullying
and harassment, and problems with discrimination internally, have been addressed. Concerned with the absolute scores in that you know zero people saying that they agreed that it had been properly addressed is not good and concerned with the direction that actually those scores are worse than
last time we did that. I think it is an interesting counterpoint that we seem to be doing a good job of dealing and following up and making sure that people are satisfied when they are experiencing that from people outside the organisation. So, I think
there is something really important there that we have to address, arising out of that. A more general point is those are disappointing scores in terms of survey action and people believing that things are really going to happen here. I know there has been a
huge amount of work on this and you described how we can better integrate. But I think we have got to be quite bold here and say the way that we have been feeding back, we are still a long way off the mark here and
how can we…, let’s have the courage to try some things that are different this time so that we can move the dial on those scores, thank you. So, Gill, rather than respond now, let me just bring in some other colleagues and then we can take
Mr Peter Wyman - 1:30:55
a response on more points. Sally, did you want to come in? Thanks
Ms. Sally Cheshire - 1:31:01
Gill. So, I was going to say first of all, it is a very honest and balanced report, which I think is a really positive thing. I have got some comments about the
link to transformation and then a question about the variability of results across the organisation. So, I think, I didn’t ask the question in Kirsty’s section when Peter said she got away lightly. But, I do think there is a connection between the way that we
do transformation and how it is successful and some of these results. So, whilst it is clear that there is more visibility of our exec. leaders and people are happy with that, they are still not convinced that we are going to take action. And in
terms of line management, I think there is a nuance between people feeling a lot more supported in their team, but not necessarily really understanding what their contribution to CQC is. So, there are those two aspects of line management, aren’t there? One is about clear
setting of goals and helping your team to deliver, and the other is about personal and professional support. It feels at the moment like one is getting better and one isn’t particularly changing. I think we would all recognise that successful transformation programmes, you know, may
well look at systems, processes, data, but the thing that really makes them work is culture and change, and that aspect isn’t there yet. I didn’t want to denigrate all the good work that has been done around the transformation programme, but these results mean that
those two things need to come together. Then my question is - so I don’t know whether Paul wants to comment - but I think there are different sections of our staff who, as you say, will have variable results and we don’t have those yet.
But it would be good to delve into them at some point and ask if there are any particular teams or categories of staff for whom the results are worse. So I went to a Disability Equality Network meeting some time ago where some of the
survey results were worse for colleagues with a disability. I think whatever the answers are to that variability, it would be good to look at them – not necessarily in a public Board - but to have a discussion offline about those. So thanks. Peter Wyman:
Thank you. Can I bring Stephen in, and then Mark Saxton? Stephen. Thanks, Peter. Firstly I do think as sort of non-execs, we should recognise and thank colleagues for some really strong results in this. I thought the results about team work, a very strong sense
of team and the team functioning well was really strong. The questions about values are very strong and are all credit to the Executive Team for getting some big improvements in your direct leadership results. So, I think there is some really strong positives in all
of this. The one thing I really wanted to pick up on was the juxtaposition between a very low result for “change is managed effectively” just at the point we are in the middle of a huge change programme and the very, very positive results for
the quality of team management and people’s confidence in their team managers. Where that is taking me is to wonder whether some of the sort of the change management, the communication about change needs to cascade more through the management chain, because that is where people’s
confidence lies. They may trust more, believe more, what their own team managers are telling them than they will any, sort of, central diktat from HR. So, I’m just interested in whether there is something we could work on around that combination of currently low confidence
Mr Peter Wyman - 1:35:06
in change management but high confidence in team managers. Thanks. So, I am going to ask Ian to respond to that particular point in a moment, Stephen. Let me just bring Mark in and then
Mr Ian Trenholm - 1:35:10
we will go to Ian and then then back to Gill. Thanks Chairman and
Mr Mark Saxton - 1:35:19
thanks Gill. Nice to see you again and thanks for very full report. I mean I echo a lot of the
comments that my colleagues have already said, so I won’t repeat those. But what I wanted to…, well I will repeat one, which is one Stephen said, that there is some really good responses here. The top five questions and the five most improved questions particularly,
so congratulations to the team for doing that. But there are challenges that have been highlighted already. What I wanted to suggest was are you going to consider looking at our People Plan as a result of this survey? Because it seemed to me – I
mean we have got some…, we have got line management capability in the People Plan and we have got some great line manager feedback in this survey, so you know I wouldn’t be playing with that. But I wondered whether, in terms of employee experience in
the People Plan, whether we shouldn’t be looking to focus around valuable contribution and culture as a real part of that? I wonder whether in inclusion, which is in the People Plan, whether we shouldn’t be looking at wellbeing and support for ways of working? So,
I just wondered whether that is in your mind, to look at the People Plan, reflect on the learnings from this survey, and then be in a position to communicate some really strong actions as a result of this survey, but in a way that is
both strategic and operational. Thank you Mark. So, Ian and then Gill
Mr Ian Trenholm - 1:37:08
to wrap up. Thank you. Thanks. Just a couple of responses on a few of the things. I think the feedback points, you know, people have been confident that action has been taken is,
I suppose, disappointing on one level, but on another level not unsurprising. If you think about what we did in 2019, we recognised that issues around leadership, issues around having the right tools to do the job were two particular things where we spent a lot
of time and energy. We have been rewarded with, I think, a recognition those things have improved. I think what we have not then done is loop that back around in a very “you said we did” kind of way. So, as Gill identified, there is
definitely an opportunity to do that. This change point is interesting, it is an interesting one I think, because when you talk to frontline teams about change and ask them to give you an example of when things were not done well, the examples are almost
always around short-term operational and tactical changes. So, you know, we changed the guidance on Topic X and it wasn’t well communicated would be an example that we get given. So, I think there is a danger of conflating the transformation programme with change. I think
when you ask people about change, they are often talking about two things at the same time. So, I think we have got…, an awful lot of work has gone into communicating what we are doing around transformation and that has taken and we have deliberately
tried to take people on a journey, but a lot of those things for many people is just not real yet. They haven’t moved teams yet, they haven’t got new technology yet, they have an…, they are not using a new methodology yet. That is starting
to…, going to happen over the next few months, but when people talk about change, they are talking often about examples from a number of years ago and they are talking about examples where we have made short-term tactical changes. Obviously, during the pandemic, we have
made a lot of those short-term tactical changes because we have had to stop doing a lot of the things that we were doing and start doing something completely different. I do know there are inspectors that see crossing the threshold as a unit as the
as the unit of activity that we do. They are less convinced perhaps by looking at data and by doing remote monitoring type activity. That is not that is not something which is universally shared, but it is something that we know we need to keep
demonstrating the value of those sorts of approaches. But I think COVID forced us into a mode of working which, for many inspectors, was very unfamiliar and that left them, I think, feeling like they weren’t on top of their portfolio in the way that they
would have liked to have done. So, you know, when we when we start to dive into some of these things, you will see examples of that, where people are quoting examples of things which are not actually the transformation programme. So, I am not suggesting
we kind of ignore the change questions, but I do think we need to recognise the sort of, the two-speed nature of that change programme point. But I think I would echo the comments, while I’ve got the floor, of others. Just a thank you to
my Exec. Team colleagues, but also, you know, the senior leaders right across the organisation, who have really give jumped into this idea of addressing culture, being present for their teams through what has been a really tough couple of years. I think we have seen
some really good examples of people being supported. I think that is fantastically reflected in the ratings that we have got. Thanks Peter. Thanks. Gill. Thanks. I will try and address most of the remaining points that were raised. I think there are some really valuable comments
from colleagues which reflect the complexity of the nature of the feedback that we have. So, this is, you know, in addition…, it’s higher than 2,000 people telling us how they individually experience working for CQC. So, when we amalgamate up together, there are always going
to be some sort of slight complexities and sort of pause points around, well this says this, but something else says something ever so slightly different which may feel like it’s contradictory at times. I won’t over the point that Ian has raised around, sort of
change, and Kirsty may want to come in and reinforce it. But I think Ian has probably adequately sort of covered off what we what we experience as a bit of a an organisational complexity around how people are experiencing day-to-day change, as opposed to ongoing
transformational change. I think, Mark, you are right to pick up on that data around the bullying and harassment and discrimination from an external perspective. So there is the two things that people feel more satisfied, feel more able to report it but then more satisfied
with the outcome, and I think we probably do need to look at and understand what sits behind that. And is there learning that we can take from that to address in the other areas? Sally, I think you make a really valuable point about variability.
We are getting the data through now. It takes a while for us to pick up, sort of, whether there is an impact in different areas of the organisation, not just in different functional specialisms. But also is there a grade issue where some people have
responded differently? Is there something to do with protected characteristics which is what we’re looking at now in terms of data? So happy to bring that back to a Board discussion in the future, if that is an appropriate thing for a private Board discussion. Happy
to do so. Then I think Stephen’s point around, kind of, do are we managing the, to our best endeavour, and I think that was my intention by saying we want to look at how we can cascade things more clearly through the line. So we
know we have got colleagues who have good relied trusting relationships with their line leaders, so can we better equip those line leaders to be the conduit for corporate messaging, in the way that perhaps we have done it and at a more senior level, as
it stands? And, I think finally, Mark, yes, you and I have regular conversations about the People Plan. This is our opportune moment for refreshing it, for thinking about this data against a whole range of other data. How do we use that as a vehicle
for demonstrating our People agenda for the future, given that the plan is nearly a couple of years old now. So, that I think has probably covered off most people’s questions or comments. Great, thank you. I want to thank Paul. You haven’t said a word,
but you did all the work, so thank you very much indeed, Paul and
Mr Peter Wyman - 1:43:40
thanks, Gill. That is great. Good. Chris, I think your guests are sitting outside… As they are coming in, shall I just quickly introduce
Chris Day - 1:43:57
what this is, would that be…? Why don’t you just wait for a second? If you are speaking, just put the microphone on first so you will be heard better. So, welcome colleagues. So, this item, the history of this item.
I think CQC has taken a view of areas and systems of care for a number of years and we have always been concerned about the relationship between different parts of the system and how different providers have an impact on each other for people’s experience
of care. This research has sort of two parts to it. One is to help us and inform our own thinking around assessment of ICSs’ local authority, and particularly around how the relationship between different parts of the urgent and emergency care system work. But secondly
and importantly, it is also to support Barking, Havering and Redbridge University Trust themselves. And there are not many times when organisations volunteer themselves for this type of research. I just want to pay tribute to Matthew and his team for being part of that work.
There is an important point for us as a regulator. We are there to support change and improvement, and also to understand what lies behind care in an area, as well as just to assess it on a particular day. Ted, I don’t know if want
to say anything before I hand over to Grace? Thank you Chris. Just to
Professor Edward Baker - 1:45:48
say that colleagues around the table will know that I have been concerned about urgent and emergency care for a while and I have been reporting to the board about the ongoing
concerns about. In truth it has been a problem all the time I’ve been Chief Inspector, but over the last year or so during the pandemic, it has been particularly bad and effectively across the country, urgent and emergency care has been in crisis for about
a year now. The situation out there, on the ground, is really no better despite the fact that the Omicron surge is beginning to diminish. It is no better than it has been. I think it remains a major concern and I suppose my take on
that is that our traditional approach of regulating, of going in, inspecting, producing a report, taking enforcement action is really not going to contribute very much in this situation. We need a different approach to regulating. An approach that is about helping people find solutions and
supporting them in that. So, I very much welcome this initiative and I think it is really, really helpful in that regard. And, of course, it is linked to what Rosie was talking about earlier on at the meeting, about our integrated approach to a urgent
and emergency care going forward. So, I really look forward to this discussion. Back to you, Chris. Great. Well, I will hand over to grace to just talk through the results. Hi, I’m Grace Taylor. I work in the Public Engagement and Insight Team at CQC
and our team led on this research and partnership with BHRT. So, I am just going to give a really high-level summary of what we found on the research and I am going to hand over to colleagues from BHRT to talk about what this means
for them, and some of the next steps that you are considering locally. I appreciate that there are a few statistics that I am going to be talking to, so there is a link to slides if anyone needs any visuals to look at whilst I
talk this through. So, feel free to have a look at them. So, just a little bit of background. This research took place in December between the 11th and 19th at King George and Queen’s Hospital. The research was done in person. We spoke to 422

Research into A+E Admissions at Barking, Havering & Redbridge University Trust & the Implications for CQC System Thinking

people whilst they were actually accessing A&E that day. We looked at different ways that we could do this research. So we looked at working with organisations like local Healthwatch, for example, in the area, but ultimately, especially due to COVID at the time, it made
sense to work with a supplier like Ipsos-MORI. So we worked in partnership with them as well. I think it is fair to say we all got together to design the methodology and questions and how we would approach it together, and it worked really well.
So, I am just going to really quickly go through what we heard just so people have that at the top of their mind. So in terms of the context of the patients attending A&E when we did this research, we saw that a third of
patients that had visited A&E that day, had also visited it before in the last six months and that most of the patients who were presenting at A&E were presenting with a new issue, rather than an ongoing one. That extended to patients with a long-term
condition or disability, who are not typically attending because of that, and I think the BHRT colleagues are going to talk to how that might have challenged some views about how people with chronic conditions were interacting with A&E services. So before going to A&E, we
are just going to look at what patients said was most important for them before they turned up at A&E that day. Most people, that’s 52% of patients, told us that the most important thing for them was that their condition or their problem was addressed
quickly. Then 45% of people told us it was most important that they were really confident in the advice and treatment that they were given that day. It is also quite interesting to note that 31% felt it was important to them that they were able
to access all the services they needed in one place and 28% felt it was most important that they saw a clinician in person, so that was what was driving them that day. We also heard that 30% of patients felt that they were most likely
to come to A&E because a health and care professional had told them to and 24% said it was because they felt their condition was really serious, which is maybe unsurprising given the services they are accessing. 17% came to A&E because it was easy for
them to get to and 14% because it was just the quickest way for them to get treatment, and another 40% because it was just outside of opening hours of their GP practice. We also – it is just important to note that the reasons for
people attending A&E did vary by demographic. There is a bit more detail of this in the paper, but that included ethnicity, working status, age, gender and long-term conditions and disabilities. So, for example, patients from ethnic minority backgrounds were more likely to say they went
to A&E because their condition was very serious or getting worse than patients from white ethnic backgrounds. Patients who were not working were more likely to say they went A&E because it was the quickest way of them getting care So, now I’m just going to
quickly talk to the journey to A&E for those patients who didn’t contact another service first. They just went straight to A&E that day without speaking to anyone else and for these people, the key reasons for going to A&E were because they needed something they
could only access at A&E or they felt their condition was serious or A&E was easy for them to get to. We also heard from a small group of people that it was because it was outside of their GP opening hours and from 13% that
it was just the quickest way that they could get care that day. And now moving on to a different group of people, those people who did contact another service first before they went to A&E that day. So the main reason that this group subsequently
went to A&E was because a healthcare professional or someone else at a health service told them to and that was 45% of that group. 13% made that choice because it was outside of the opening hours of their GP practice, so they couldn’t speak to
them that day, and 13% just didn’t feel like their GP practice would be able to see them at a date or time that was convenient to them, so they might have been able to see them but not at a time that worked for that
person. Just important to note that when people did try and contact someone before going to A&E, 60% of that group were able to speak to a healthcare professional however 33% were not able to speak to someone before they went to A&E that day. And
just in terms of the types of services people were trying to contact, NHS 111 is the most likely place people will go before going to A&E, or this group of people at least, and their GP practice was the next most common option. So now
I am just going to quickly talk about what happened for those people that tried to contact a service before going to A&E, but they just weren’t able to speak to anyone. So, for these patients they went to A&E because there weren’t any appointments available
when they tried to contact their healthcare service. That was 35% of people. Or they weren’t able to get through to the service that they were trying to contact. We also heard from 15% that they just weren’t able to see, speak or chat online to
someone quickly enough for them, or they weren’t able to see someone in the preferred location. I am conscious of time. So now I am just going to talk about the journey for those patients who tried to contact another service and they were able to
interact with a healthcare professional. So for those people, 76% of them, the healthcare professional told them to then go to A&E. For 9% the healthcare professional told them to go to A&E if their condition got worse and it did, so they went to A&E,
and for 8% their condition just hadn’t got any better since they spoke to someone, so they then decided to go to A&E. Then a quick look at awareness and satisfaction of those healthcare services that people accessed before going to A&E. Just important to note
that when people had interacted with the health service, before they went to A&E, most people were satisfied with that service although satisfaction was slightly lower for mental health services and GP practices. So that is a really quick overview, there is more detail in the
paper of what we found in the research, but I am just going to hand over now to colleagues from BHRT to talk about what it means for them. Thanks everyone. I am Matthew Trainer, Chief Exec of BHRUT. I am joined by Dr. Karim Ahmed,
who is our Improvement Director for our Emergency Department, and James Avery who is Director of Nursing. He is also currently Site Director for Nursing for Queen’s Hospital in Romford. One of the reasons we are interested in this is BHRUT has for a long time
had some of the worst ED performance in the country. Our Type 1 performance is currently the worst in London by a significant margin and one of the things you can’t help but notice about the site, is that when you arrive at Queen’s in particular,
you see a long queue of people waiting at the front door, in the queue for what is an urgent treatment centre that is operated by some of our local GP partners, and are then referred through into our ED. But it is not uncommon. I
am pretty sure that by the time I get back to Queens now, they will be 20 or 30 people waiting for triage, and a further queue of people waiting to be seen by GPs. And there will certainly be at the minute around 30 DTAs
in the ED at Queen’s waiting to be placed. What we are interested in all of this is understanding why so many people turn up at the site. It is a very busy site and there is a high level of demand for it. Quite often
in the NHS, we look at things retrospectively when we know what was wrong with that person and we say that person didn’t necessarily need to go there. We wish they had done something else. Actually, we were more interested in why did they make this
decision in the first place, and what really came through I think in the survey, was this this demand to be seen quickly. And this demand not necessarily for urgent care and treatment, that fits the urgent treatment centre specification, but for urgent access to a
primary care offering or something analogous to a primary care offering. I think rather than us looking at pathways retrospectively, it was what motivated you to come here today and there has been some really interesting stuff in the data. Actually, a lot of people tried
to do what we tell them to do, which was contact other services but they got referred in any way. For some people there is a really clear economic dimension to it. If you live in some of our boroughs, which are among the most deprived
in London and in the country, if you’re on a 0-hours contract, it is an economically sensible decision to go to an urgent treatment centre front door at 6 pm and spend three or four hours there and be seen and treated and sent home, rather
than see your GP two or three days later and then possibly be referred into the hospital for a scan the following week, and then have to go in for an outpatient’s appointment. Talking to some of our local GPs, one of them who I speak
to regularly about this, she said she will speak to a patient some mornings at eight o’clock when they are handing out their appointments and offer them something at two or three this afternoon. And she has confirmed to me this isn’t a one-off, this happens
pretty regularly. They will offer an appointment that afternoon, three or four o’clock or the next day, and they will get a notification mid-morning to say that patient has turned up at Queen’s, because the patient isn’t prepared to wait or perhaps is not able to
wait to access the service in the way that we would traditionally like them to do. For me it’s a kind of, sort of, Amazon Prime level of demand. You know you can either have this delivered on Friday or you can have it in the
next 24 hours. I quite often just go in and click, I will have this the next day please actually. I think there is a mentality shift here that suggests we need to think differently about how we make that front door model work for us.
Because it does put pressure on the Emergency Department, more of those people are referred through into ED. It does put pressure on emergencies there and it just generally gives people a pretty poor experience. I think we need to move away from saying actually we
have got a brand that people trust. A&E, the lights are on, 7 days a week, 24 hours a day. When there’s something going wrong, whether it’s through chaotic (unintelligible), whether it’s mental health, whether it’s the police pick someone up, whether it’s someone who can’t
get to their GP and they are worried about their sick child. A&E is now the only part of the NHS where there are no barriers to access for it. I think what we are increasingly seeing is this ability to walk in and access a
service in the presence of other kind of have rationing barriers, it is driving more and more activity in here. And it is driving it in a way that makes quite an unhealthy environment around certainly our front door for urgent and emergency care. Really the
way out of this for us is a range of things. It is about some of the (unintelligible) I mentioned a minute about changing the way we run the front door. It is also really importantly about working with the system. We were in the fortunate
position of being the last acute trust to be inspected before you suspended inspections before Christmas. But I have to say, Sam and Max and the team brought in a really expert team and carried out an inspection which, I can say hand on heart, the
staff felt was a really worthwhile experience. It was a professional, high-quality team who came in and made good quality judgments and the approach to it with sensitivity and in a way where the staff felt able to raise their concerns without feeling that would be
blamed unfairly, by either us or by the Commission for raising those concerns. But it was also done in the context of looking at what’s happening with our UTC provider and other local providers, and a recognition that actually the out the urgent care system is
a system. It depends on people’s different access points. ED is where you see the fire burning most brightly. But, actually the roots of it are entirely in the system around it, in the way in which we work. Actually, the approach to this is encouraging
us and it is encouraging us working with local partners through our urgent and emergency care transformation board to use this data, and perhaps think a bit differently and think about next winter, actually because that is what we have got to start planning for now.
How do we take the steps now that we have got our system in a much stronger place, based on this insight, based on the experience of this system inspection, so we can really try and turn the dial, not just on the performance which is
unacceptable, but on the experience of patients who come to us. And really importantly for me, the experience of our staff as well, because at the minute it is a pretty thankless task for them coming into such a busy, tension-driven environment, day-in, day-out as well.
Karim and Janes, they are very much on the front line in this and they will just say a little more about that. So in terms of the front door, one of the things that came through on the back of the visit is a real identification of the need of different parts of the system
to be working much more closely together to produce a patient pathway. So, if you think about some of the patient stories that we have just heard, those patients are accessing multiple services and then arriving at the front door of what they think is an
accident and emergency department, but actually is a much more complex system. So, the work that we have been doing since the inspection is really looking at the front-door service for the acute sites, both with the stories that we have just heard in mind and
looking at the individual patient journey as they go through that. If I give you a story of the first patient I saw, having joined BHRUT as Improvement Director six months ago, entered our triage room within the emergency department so angry before I had even
opened my mouth because of the journey they had already been through to get to the point that they were seeing a consultant. So we have gone to the front door and we have looked at the patient pathway. We have looked at what we are
doing that is making the patient pathway harder. So, the repetitions and the queueing systems that we have. We have identified those areas where we think that we can remove some of that inefficiency and created a patient pathway which is really about what is the
absolute task of this point of the pathway, how do we make sure that there is no repetition and no excess queuing, and how do we move the patient as quickly as possible to the place where they are most likely to go to. The complexity
of that is if we take something like chest pain for example, if I say well if someone is having a heart attack, they absolutely need to be in Resusc. within 10 minutes of arrival, the problem is the patients don’t come in with “I’m saying
that I’m having a heart attack”, they come in saying they have chest pain and 99% of patients with chest pain don’t need to be at Resusc. So, putting into place quite complex processes to ensure that the right patient is moved into Resusc. without overwhelming
it, whilst ensuring the patient who is having a heart attack gets into Resusc. in 10 minutes is part of the real challenge. It is actually a microcosm for the entire system, so what we have in our urgent treatment centre is a very high volume
of patients coming through in a centre that was originally designed to remove the urgent care patients who are going into the ED out of the ED into an urgent treatment centre. But actually what we think that that we are seeing in our urgent treatment
centres is a very, very high volume of patients who are actually now choosing, or are unable to access primary care or urgent primary care, so are choosing to attend the urgent treatment centre. That is then having the onward effect of the urgent treatment centre
being overwhelmed themselves and the kind of perverse movement of patients who would have been in the urgent treatment centre back into the emergency department, to help cope with the primary care or primary care demand that we are seeing in the urgent treatment centre. It
really underpins why it has been much more of a useful exercise to start looking at the system as a whole, rather than each individual trust or each individual organisation and the performance of that. Obviously, what we are now moving into in the redesign of
the front door, is a collaborative working, a model between multiple organisations, and we are now at the stage we are trying to work through the regulatory and the legal aspects of having multiple organisations collaborating to deliver a service on a an acute site. So,
we should be seeing over the next…, sort of working through some of the difficulties of that, the complexity of that over the next weeks with a real aim to ensure that we are getting the right patient to the right place at the fastest time,
but without overwhelming that service. Because we have got very sensitive, we can pick up all the heart attacks, but in order to do that we are just moving all the chest pains through. So, we are looking to make sure we have got both a

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Audit & Corporate Governance Committee Summary of 28 January Meeting

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Audit & Corporate Governance Committee Summary of 28 January Meeting

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sensitive and a specific system. So just a…, it is a hugely valuable piece of work, so thanks to Grace and team for producing it, with a National ED Experience Survey, linking that together with our outcomes of this information, really gives the opportunity to work
with partners in terms of redesigning a model that actually will deliver to actually what is required. We know, as Karim has alluded to, a lot of our patients are frustrated with the current system, a lot of our staff equally find it extremely difficult working
in, what has been described as a hugely-pressured system. So, really, really helpful. This has opened doors in the perspective that it isn’t just a hospital talking about how difficult it is, it is a very valuable piece of work, that is well-structured and that we
can take to our urgent care board, talk through and actually produce a response, as we would from an inspection report in terms of what is our response. You will see at the foot of the paper the points that we are taking forward in terms
of delivering on the change. So, well, thank you for the a piece of work. It is extremely valuable and I think it just underlines the absolute urgency in terms of acting quickly to this response. Our services are designed as they are, but our patients
are clearly telling us they have huge issues in terms of access, that we obviously now need to respond to. So, can I thank you all very much
Mr Peter Wyman - 2:05:47
for coming today, and also probably more importantly, for participating in this research? I thought it was really
interesting. It was great research, not least because it really confirmed most of the prejudices that I have had for a long time, so I love research that does that. You are going to stay, I hope, and join us over our usual lavish Board lunch,
so people be to have a conversation with you, out of the meeting because time is going to prevent us from having a long sort of discussion now. But James or colleagues, I would be really interested very quickly, was there anything that came as a
really big surprise to you in the research? I think the main thing that surprised us was the number of people who had actually spoken to another service before coming to us. I think we had a premise that we were seeing quite a lot of people
who had not bothered with that actually, but the onward referral numbers were higher than we thought they would be. I think lots of the rest of it was consistent with the impression we had of how the local system was working. I should also say
that that there is no sense at all of us, as a trust looking at primary care local and saying you should be doing more than you are currently doing. They are also incredibly busy. I think what we can see is an overheated system as
a whole that has manifested in this one place, but by and large, I think the findings, as you say, it supported a lot of the theses that we had going into the process. That’s great. And another one of my prejudices is that that the
Mr Peter Wyman - 2:07:18
whole system is overheated, so I agree with agree with that as well. I think we could spend the rest of the day talking about it, but Ted wants to say something, at least I always do, as our Chief Inspector
Professor Edward Baker - 2:07:28
of Hospitals says… Well, thanks.
I think it is a fascinating survey and it is great hearing your reflections on it. And I think it does reinforce what you were saying, that this is a system issue. This is not just about an emergency department front door and an urgent treatment
centre front door. It is actually understanding what motivates individual people to make individual decisions about seeking care. There has been a tendency in the past to describe some of these attendees as inappropriate attendees, which I always think is very unfair because if you actually
look at the individual, they are often taking entirely the right decision for them, not the right decision for the system, but the right decision for them. You know, what more can we ask of people, that they take a rational decision in their own interest
in these circumstances. If the system can’t cope with that, then the system needs to change and it needs to understand what people are seeking. I think there’s some real indications from the survey that can help in that direction. It seems to me that people
sometimes are seeking an X-ray or blood test, or perhaps to see a specialist. And we can’t, they can’t do that there’s no way they can do that apart from going to an A&E department which, you know, doesn’t seem at all sensible to me. I
think reading between the lines of your survey, I think some of it may have been people seeking a face-to-face appointment when, so far, they have only been able to access a healthcare professional through a telephone. I just don’t think we understand the dynamics of
that. We assume that people are very happy with telephone calls and it is interesting people did say they were happy with NHS 111. But actually if you look at their behaviour, you kind of think well actually they may say they are happy, but they
are not being reassured by the episode, and that that must be the issue we need to look at. So, I think we do need to understand this behaviour much better, and is not going to be the same in each part of the country. I
think these surveys need to be done locally, all over the place, so we understand motivation in different parts of the country, with different populations. Last word to Chris. Just to say, once again,
Mr Peter Wyman - 2:09:30
thank you to Matthew and his team for taking part in this
Chris Day - 2:09:36
survey. Ted is absolutely right though and our aim is to do a number of these surveys with organisations to help understand the local picture. I say this will all help contribute to our understanding and oversight of ICSs which, I think, is an important part
of this. I think the key point to remember is this is not people doing the wrong things. People are doing an entirely rational thing. And it is how does the service respond collectively to the way people are using services, and how do we think
about the way in which we set services up locally to meet people’s needs?
Mr Peter Wyman - 2:10:08
Great. Sadly, we do need to move on, but I hope you can stay for lunch because I think a load of us would love to continue the conversation. I will have a wager with you Chris, that when you do the surveys around the country, there will be the same issues. The proportions will be different,
depending where you are, but the issues will be the same, we will see.
Mr Peter Wyman - 2:10:27
Great. Can we… we have got about 10 minutes more business and then we will be with you. But if we can move on… Sally while Louise is going to join us,

Audit & Corporate Governance Committee Summary of 28 January Meeting

do you just want to do the ACGC Report? Yes, thanks, Peter. So, this is just a short report from our quarterly Audit and Corporate
Ms. Sally Cheshire - 2:10:51
Governance Committee. There is nothing fundamental to report. Our internal audit programme is progressing as we get towards the end of the
financial year. There were no high-risk reports, we expect that programme to be finished. The National Audit Office - our external auditors - have highlighted no particular concerns as we look forward to producing the Annual Report and accounts in the summer, although we remain concerned
about the timetable for laying, not just CQC’s, but many sets of accounts due to local government pension audits and we’ll try and keep up the pressure there. We have addressed all the points that we needed to as an organisation coming up to the year-end
and we had a discussion about the recent Board Effectiveness review and what that might mean for our Committee. But not really anything risky or contentious to report, Peter. That is what I like to hear,
Mr Peter Wyman - 2:11:53
thank you very much, Sally. Louise, welcome, and I’m sorry
to have kept waiting for a second, but we are trying to catch up on time. So Robert, do you want to do some introductions? Well, I will let Louise in a moment speak for herself, as I know already she is very capable of doing
that. But before doing that, I would actually like to register – I
Sir Robert Francis QC - 2:12:13
hope on your behalf - my thanks, our thanks to Chris McCann and his team for their sterling work during the interregnum since Imelda left us for keeping - I was going to
say keeping the show on the road in the same way that a Tesla can drive without the driver, but that is without the car either blowing up or suddenly braking without any warning. But I would like to thank them for a very hard working
in making my job in the interim as easy as possible. Thank you. I will hand over to Louise. Thank you very much Chair. Thanks Robert. So, thanks for having me here today and it is really great to be here. It is a real honour
and privilege to have been given the post of National Director for Healthwatch England and I have had such a warm welcome from Ian and from Robert and from the whole Healthwatch team. I am really looking forward to meeting lots of you over the course

Welcome to the new National Director of Healthwatch England

of the next few weeks. I will tell you a little bit about myself, not going into too much detail, but my working life has mainly been in health issues, as you might imagine, but also in communications and in equalities areas. So, for example, I
set up a campaign called Let’s Kick Racism out of Football when I worked at the Commission for Racial Equality many years ago, which unfortunately still exists, that campaign and I will touch on issues of inequality a little bit in my short introduction a bit
later on. So, I have always been absolutely passionate about ordinary people having a say in shaping society and in shaping their health and care. You know, we do pay for it after all. I know that CQC colleagues will share this feeling and want to
continue to make it a reality. Healthwatch England and the 151 local Healthwatch are absolutely central to this happening. Incredibly influential and necessary organisations that my impression, as an outsider of the organisations, has absolutely been confirmed in my first few days. So this is my
seventh day I think in the post. Obviously, we are in this context, an incredibly difficult context where I know that Healthwatch have made a big difference in the pandemic, in shaping services have raised some incredibly important issues including access to GPs, including all the
work they have done on access to dentistry, and today’s great work the launch of the accessible information campaign which has got some really good media coverage. It has really struck a chord, I think, with the public and with the health system. I think there
is a really, very significant role Healthwatch can play in supporting post-pandemic recovery and we will want to work closely with CQC on this. And the pandemic of course has really, as everybody here will know, has really highlighted the inequalities in health outcomes that were
already present, that we have seen for years. So, we all need to do much more to hear from those whose views and needs are not being heard. Actually some of the work that has been done by local systems, with the input from local Healthwatch,
on things like vaccine take-up has been really instrumental in making a difference to health outcomes during the pandemic. We have to spot issues in the planning and delivery of care and ensure that people who receive care help shape good services. So, I really look
forward to working with colleagues around the table, colleagues in the network and colleagues in the Healthwatch England, to try and make a real difference in the delivery of health and care in the coming months and years, especially obviously in the context of the changes
in the structure of integrated care in local areas. So, thank you very much for the welcome and I look forward to coming back and reporting
Mr Peter Wyman - 2:16:43
on the work that Healthwatch is doing over the over the months. Thanks Louise. Louise, I hope you have got
time to – if you are not rushing off anywhere - stay and have lunch and have a bit if a mingle so that people can talk to you. But thank you very much for coming today and a very sincere welcome. Which leaves us with

Any other business

any other business, if there is any? And if there isn’t, that just leaves us with two questions from our friend, Robin Pike. Both, Rosie, for you I think. The first is how does CQC capture intelligence from patients regarding their experiences with GP appointments? Does
CQC access the Friends and Family Test responses? That is the first question and the second question is, how does CQC currently regulate medical services for people in prison? Rosie. Thank you very much,
Ms. Rosie Benneyworth - 2:17:40
Peter. So, firstly, with regards to the experiences of people using GP
services, we use a whole range of different collections, both national and local intelligence gathering which include the GP Patient Survey, experiences shared directly with CQC through our Give Feedback on Care web form, information gathered and shared by local Healthwatch groups. We work with the
patient participation groups in the practices, we look at comments and reviews collected by NHS choices and also look at evidence that the practice provides us. We also speak to patients when we are out on site inspecting. In regards to Friends and Family Test, this
was paused as a national collection for general practice in 2020 and NHS England and Improvement are currently piloting a new approach to collecting patient feedback. We at CQC currently only access this at a local level where the practice is still collecting the data. So
moving on to the second question, in terms of prisons. We work very closely with Her Majesty’s Inspectorate of Prisons. We schedule inspections together, so we go in on site together and have really strong working relationships, so we can understand the healthcare provision within prison,
but also understand the relationship of that healthcare provision with the wider prison environment which is really important. So, can people get to their appointments? Are they supported with their needs in the wider prison environment? we look at all aspects of provision within a prison,
including medical, dental, mental health provision. We have been testing our off-site and clinical search work within prisons, which is really starting to help us get deeper into outcomes, looking at clinical outcomes and those aspects. We also are involved with HMIP and a variety of
other inspectorates, looking at thematic work and that can be aspects like mental health provision. We work looking at a whole variety of transfers of care between when people are in prison and out of prison as well, so a whole variety of work. Thank you.
Great. Thank you Rosie and that is the end of the public board
Mr Peter Wyman - 2:20:00
meeting. Thank you all very much indeed. Those of us that are here for the seminar this afternoon, we start at 2:15. Thank you.