cqc Board Meeting 22nd June 2022 - Wednesday, 22nd June 2022 at 11:00am - Care Quality Commission

cqc Board Meeting 22nd June 2022
Wednesday, 22nd June 2022 at 11:00am 









Start of webcast
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Chair’s Opening Remarks and Apologies
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Minutes of the Public Meeting held on 18 May 2022
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Matters Arising and Action Log
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Executive Team’s Report
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Learning Disability Programme update
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Update from the National Guardian
Update from the National Director of Healthwatch England
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Any other business
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(unintelligible) we were hoping that this would be a physical meeting, but you will all be aware of the rail strikes and with most of our members living somewhere away from London, it proved impossible to get together. So, hopefully this will be the last one,
but that is not within our control. Just a few words of introduction and then I will commence the formal business of the meeting. I have an apology from Jura Gill – one of our board members - he may be able to join us later

Chair’s Opening Remarks and Apologies

on, but I suspect not. Rebecca Lloyd Jones, our Chief Legal Officer has continued to be on jury. She has been on jury service, she has been there for about eight weeks now, so obviously an interesting trial. I also wanted to welcome Sean O’Kelly who
has just joined us both as a Chief Inspector and as a board member. We seem to be having a few connection problems with Sean, so I am going to ask Ian Trenholm to just introduce him at an appropriate time later on. Can I, last
but by no means least, welcome this month’s Equality Network Representative who is Sariat Olatunji. Welcome Sariat to this meeting. If I move on then to the formal business, are there any declarations of interest that people need to declare? Okay. We circulated the minutes of

Minutes of the Public Meeting held on 18 May 2022

Matters Arising and Action Log

our last meeting. They are here for approval, do people have any comments or can I take those as approved? Approved, thank you. OK. We then have the matters arising. My apologies, my screen glitched there. There is only one item on the Corporate Performance Report. There were
some things that we want to clarify, that is on rack and we will do that at a future meeting. So, that is showing a green status on the grounds that it will happen by the due date. So I have no other comments to make
unless there are any queries. In that case, could we just move straight on to the Executive Team’s Report. This is for noting and commenting as Board members may wish. Ian, I think the first four or five items are all down to you so perhaps

Executive Team’s Report

I will hand to you. Thanks very much Ian. So, I think if I can I ask Board members to take the first section as read. There are three things that I particularly want to draw attention to. One is pressure across the system, one is
the Leadership Review and one is Board changes. So, I think in terms of pressure across the system, there are a couple of specific areas we are concerned around, ambulances and maternity. I think what that is, they are tangible symptoms of enormous pressure across health
and care systems. I think I very much recognise that there is a public narrative, that the world is somehow back to normal, as we see in many parts of our lives we can continue to go about our normal business. Certainly, the news media tend
to talk about delays to check in for holidays rather than delays at the doors of general practice or emergency departments. I think we are seeing on the ground that those delays are very real and are very tangible and are very important. So, I mean
this does remain a concern for us and we have been looking at ambulance services in particular recently. Where we have got some concerns around leadership and culture in some places, and we will be continuing to talk about that over the next few months and
there are specific providers where we have taken action or we have asked for additional support to be brought in. I think many people are saying again and again that the long-term answer to this pressure though has to be found at system level. It is
about how individual providers work collaboratively together to come up with responses to addressing this pressure in in a particular place. Our response from a CQC point of view is inevitably limited by the powers that we have. But I think what we have tried to
do is to bring together frontline professionals to understand the problem in some detail, but also to help improve collaboration between organisations. We know that we have a very powerful convening power which we know, if used well, can bring people together and can start to
have conversations that maybe they would not otherwise have had on their own. And in all cases what we try and do when we bring people together is to try and come up with practical things that people can use, enhance guidance and so on, that
people can use to try and improve services. So again, there is a steady stream of those products. I want to move on to talk about leadership and the Leadership Review. The Leadership Review was carried out recently by Sir Gordon Messenger and Dame Linda Pollard
and that report was publicised recently. There are some recommendations for us in that report and I am pleased that they are already areas we have been doing some work on and they will be embedded within our Single Assessment Framework. One of the real positives
about our Single Assessment Framework work is that we are looking to try and bring in one place all the work we do around providers and systems. When new insights come from things like Sir Gordon’s review, Sir Gordon and Dame Linda’s reviews come out, we
can very quickly integrate them into our Core Assessment Methodology and start going out and testing the degree to which those recommendations have been adopted in the system. So, I am hoping that from the end of this calendar year that Single Assessment Framework we are
bringing will be a really important tool. It will help, I think, amplify some of the recommendations that have come out through a range of different views, both the ones that we know about in the past, but also those reviews that are to come. Finally,
the third area that I wanted to talk about, that is a big part of what I have been involved in over the last few weeks, is Board changes. We recently announced that Rosie will be leaving us, Rosie Benneyworth will be leaving us at the
end of July, to join the Healthcare Safety Investigation Branch as their Interim Chief Investigator. And Kirsty Shaw will be leaving us at the end of August to become the Chief Operating Officer at Homes England. I think it would be fair to say that both
Rosie and Kirsty have played really pivotal roles in in the development of CQC over the last few years. I think both of them will leave really significant legacies. I’m sorry to see both of them go, but I also know that both of them are
going on to really important and high-profile public service jobs and they will continue with their respective, you know, their respective significant contributions to public service will be continued in their new roles. We will of course have the opportunity to say a proper thanks to
both Rosie and Kirsty at our July meeting and thank them properly for their contributions, but I wanted just to announce that publicly. I think I am now going to pause and I hope welcome Sean O’Kelly to the call. I think Sean is now on
the call, so I am going to ask Sean just to say a few words by way of introduction. Sean, welcome as our new Chief Inspector of Hospitals. Might be on mute I think. Sorry, thank you. Yes, apologies for joining a little bit late. I
had some issues with the IT. I hope you can hear me now. Just to say, yes, it is great to have joined, it is great to be in this position. I look forward very much to working with everyone on the Board and the whole
of the CQC staff. I have just come from the East of England where I was recently acting as the Regional Director, before that I was essentially the Regional Medical Director for the east wing for the last few years. I have also been the Medical
Director for NHS Improvement working with trusts in special measures and Challenged Provider status and before that Medical Director in three trusts – small, medium and large - in the south-west of England. In the past I have had experience at the Department of Health working
with the (unintelligible) and CMO, and prior to that a period of time in in the US as an Associate Professor of Paediatric Cardiac Anaesthesia which is my professional background. So, as I said, I am very much looking forward to working with everyone and helping
the CQC achieve its objectives and its mission. I will leave it there, thanks Ian. Thanks. And so can I just echo Ian’s welcome to the Board and welcome to the Executive Team. So I think in in light of both Sean joining us on Monday
and colleagues are starting to leave us, I will be putting in place some interim arrangements. Sen will be doing his core job of Chief Inspector of Hospitals, but also he will be acting as Interim Chief Inspector of Primary Medical Services and working with colleagues
within the Director Group and the Regulatory Leadership function to offer medical leadership in the Primary Medical Services area. Kate will be taking on leadership of the Integrated Care System work alongside becoming the Interim Chief Operating Officer. Other executives will of course take on specific
additional duties and will be liaising with external stakeholders to cover particular meetings and types of work to make sure that both Rosie and Kirsty’s responsibilities are covered in the interim work. And over the next few months we will be reflecting on what we need
from an executive point of view and be looking to potentially make additional recruitments and so on, to cover specific areas. We will of course be looking at the way we use our director cadre at the next tier down, as well as our national professional
advisor cadre again who are an important part of what we do. And again, we will be talking about how we will be using them more overtly, but in the short term I am redistributing Kirsty and Rosie’s responsibilities across the current team with support from
the next tier down. So I think that is all I really wanted to say, Ian, for now. So happy to take questions on that section or move on as you wish. Thank you. Thanks. Robert Francis. Thank you very much, Ian, for that and may
I welcome Sean to the party. And probably if I asked this question next time, he would be happy to answer it rather than you, Ian. But it is about leadership and what you said, and sort of drawing some threads together really. First, about the
Messenger Report and I should probably declare that I was amongst those whom he interviewed. I just wondered to what extent a report, which is said to be radical in many ways, changes our perception of how we assess leadership in the terms of our regulatory
function, or does it not? And allied to that, is what you reported about the ambulance services. We all know what terrible pressure the ambulance services have been under up and down the country, but underlying what you told us and what I think we have
known for some time, is that certainly in some ambulance services, maybe many of them, there is an underlying, if cultural, leadership issue. I wonder what it…, bearing in mind the length of time that has been going on, I wonder what we are able to
do, as it were to change that picture, because it strikes me that from the point of view of the patient and the public that the issue has being going on for too long, and these are of course challenging times, but it has been going
on too long. So, it is really… they have both come up fortuitously at the same time, but they do seem to me to have some association. Yes. Thanks Robert. I think one of the things that is really important about our Single Assessment Framework is
that it is a set of questions that link back to the five key questions that you were responsible for creating. But what we need to do as a as a regulator is to find ways to take the insights that are offered by things like
the Messenger Review, and indeed insights from other academic research because I think there is a fair amount of academic research in safety culture. But I’m not sure we have then extracted that in a systematic way so that the questions we ask are the set
of questions that one would use to try and define culture. Because I think, the danger I think, is that we talk about culture in a slightly qualitative way and so we say we know good culture where we see it, and we know bad culture
when we see it. I think one of our challenges is to try and codify that in some way and that is not an easy activity as we know, but I think the fact that we have now been in business for a decade now as
CQC; I think we have created a body of knowledge there. We know that there is an increasing interest in academia around this, reports like the Messenger Report, I think, are also really important. I think what we need to do is to extract all of
that and then embed it into a series of questions and, you know, my hypothesis and I wouldn’t dignify it any more than this, is there is 15, maybe 20 questions that, when taken together, that pickup context and behaviours at a local level, will give
us a definition of culture in an almost numerical way. That is a big ambition I guess, but I think unless we can strive for that bold ambition, then we will all be continuing - us and everyone else in this – we will continue to
talk about culture in a slightly abstract way. So, I think that is something we can do very specifically. In terms of ambulance services, specifically we have got a programme of work we are doing to look at what is going on in ambulances, particularly working
with NHS England and Department of Health and Social Care colleagues as well. I am hoping that that will give us some insights, but I think there is still this “What is culture?” question which I think I would…, I am determined that we can we
can try to distil down and be much clearer about what that means and how it is defined. Thanks Ian. Any other questions for Ian Trenholm? Ok. If not, Rosie, over to you. Thank you very much Ian. Following on the conversation about ambulances and urgent and
emergency care, my first report talks about the work we are doing in urgent and emergency care. As you are aware, we have recently been into 10 systems and scheduled all of our inspections across the urgent and emergency care pathway. That has given us a
huge amount of information, both at system level but also when we have aggregated that together. In addition to that, we held a really good workshop with 250 stakeholders from across the urgent and emergency care system, both at local level and national stakeholders. Our plan
is to pull that information together to pull out the learning and to be able to share that best practice that we have been seeing in advance of next winter. So that actually systems can see and learn from what we have experienced over the last
few months. So that work is underway. The second section of my report is just to flag that Claire Fuller has released her report around Primary Care and Integrating Primary Care in in the ICS landscape. We very much welcome this report and we are bringing
a paper to the July Board to have a further discussion about this, as I think it is really a critical piece of work looking at the future of primary care and the future of integration at neighbourhood levels. So very much welcome that. Thanks Rosie. Any
questions for Rosie’s few comments? No, okay shall we move on? Kate, I think there are a number of things down for you. OK. Thanks and good morning all. So, I am just going to bring together the update on Local Authority Assurance and Integrated Care
System Assurance and let the Board know that we have made really good progress in identifying two local authorities and two integrated care systems who were interested in being… They suggested that we don’t call it a pilot, that we call it a kind of test
and learn approach, where we go out and we work through our methodology with those volunteering places to ensure that our proposed approach to how we assure local authorities and ICSs from April 23 is robust and is effective. So a big thank you to those
four places to enable that to happen. In order to deliver that, we have been successful in recruiting a small internal team who will be leading this work with some expertise that we are also drawing on from the sector. The output of those test-and-learn pieces
of work will be an opportunity to faster effect on our methodology and to make sure that we are plugging in the right requirements when we think about the digital platform we are building, when we think about the skills and capabilities and capacity we need
in the organisation to deliver this ambitious programme from April 23. So good progress on those too. Then just a brief note. Liberty protection safeguards - the consultation from the Department of Health and Social Care is live and at the moment. We are in the
middle of submitting our response to that. It is not only about the new liberty protection safeguards, but it is also about revisions to the Mental Capacity Act Codes of Practice. So quite a technical response about the Codes of Practice, just to make Board aware,
and there will be opportunities at a later date for us to spend more time together thinking about our potential role around liberty protection safeguards as well. The Department of Health and Social Care said they want to digest all the feedback they get from the
consultation first, before they then consider when a potential go-live date may be. Thank you Ian. Thanks you Kate. So, quite a range of points there. Any questions from my Board colleagues for Kate? Mark Saxton. And then Belinda. Mark. Thank you Chairman. Kate, thanks to the report on Local Authority
Assurance and ICSs, I was going to say pilot, but I will demonstrate my quick learning and go test-and-learn exercises. I mean it is really good news, but I just wondered how we got to select the participants. I wondered if it was to do with
patient acuity or whether it was to do with inequalities or resourcing challenges that we know the sector suffers from. I just wondered if you can give some background to that and perhaps what you are hoping to learn from this exercise. OK, so shall I
do local authority first? And then, Rosie, you might want to… So, local authority, obviously already established unlike integrated care systems, we wanted to make sure we had a good geographical spread, so that we were looking at different types of geographies when it came to
those two local authorities. And Rosie, do you want to come in on the ICSs rationale? Yes, certainly. We had a selection of criteria looking at, again, a mix of different demographics, geographical spread, ICSs and the two ICSs we have chosen are very different in
terms of their make-up, their size, their demographics and the kind of inequalities that might be visible in those ICSs, so we very much looked at getting a broader spectrum. What we are trying to learn is really… we have done a huge amount of co-production
with stakeholders to get to this point, in terms of developing our methodology. We have worked extensively with most of the systems across the country and national stakeholders. We are really starting to put that into practice in terms of, this is what we think our
methodology should look like and how does that actually work in practice? Does it tease out those areas sufficiently enough that is going to really add value to an integrated care system in terms of regulation and how it works? Thanks for that. Just in terms
of timing for both exercises, can we just understand when we can expect some feedback? Yes. So they are going to be happening through July and August, Mark. So we will be digesting the output of that come the end of August and then there will
be a conversation in September. So, there will be a formal process where the output of our learning will go to the Exec. Team and then a conversation at Board. So, in the next two months there will be lots of busy work on these test-and-learn
places. Very good. Thank you. The lexicon changes, test-and-learn, not pilot. Belinda. Yes. It is just a quick question for Kate. You haven’t mentioned care home visits. I know you often mention it. So, I am just wondering if that has improved and you are not getting
the number of complaints that you used to get about it. Thanks Belinda. So I, so we haven’t stopped our focus on this. So our expectation now is that there aren’t restrictions and people are able to see their loved ones as they wish to. So
it is still a key area of focus when we got out into every care home. We are still getting a small number of concerns raised by individuals’ families that we follow up, as we have been doing particularly over the last 6 months, with a
real focus on what that is about. So, yes, this actually, I think, this is the first month in maybe 24 months that I haven’t mentioned visiting. But it doesn’t mean we have not stopped our focus on it, Belinda, when we’ve been going out and
inspecting. Thanks. Thanks very much. I mean if you just look back at the points that have been raised, there is a combination of current and go forward points with a number of observations about the current state of things which, obviously, we will be reflecting
in our State of Care Report coming up later this year. Let’s move on to internal Operations. Tyson. Thank you, Ian. On performance, not much to add to the written report. I’d like to say how grateful I am to the Operations Teams for a strong
performance in May, despite various distractions like half-term, the Platinum Jubilee Celebrations in our teams being encouraged to participate in a steady drumbeat of transformation come communications, as our transformation programme really quickens pace. But having said that, I just want to pull out two areas
and expand on those slightly. The first on registration. Really strong performance, 3264 applications completed in May, that is compared to 2795 in April, a 15% uplift. And on average, that is 512 better than the preceding two-month period. Also despite demand and the number of
applications coming in still being very strong, the overall number of applications in the system remained steady, so I think strong performance in May on registration. Finally, just really to highlight our inspection performance which has also remained strong, notwithstanding all I said in the beginning
about what else has been going on in May, 998 inspections were undertaken in May that compares to 920 in April, and we have 995 inspections either planned or have already been undertaken for June. So, just to add a few numbers to the written report
that was submitted a week ago. Thank you. OK. Many thanks. I have a question as well, but Mark Saxton, you go first. Thank you Chairman. Tyson, thanks a lot and congratulations on the registration performance and also the improvement in timeliness, it is really good
to see. In terms of inspection volumes, I just wondered could you give me a little bit of an insight into the split between the physical crossing - I forget the words that we use, sorry - crossing the threshold and also the DMA? I just
wondered whether the inspection performance or volumes have in any way been challenged this month because of the problems with transport access. Thanks Mark. On your first point, these are all physical crossing the threshold inspections. The performance of the DMA team is counted separately and
comes together with our overall figures on regulatory contact, and their performance remains strong. But the figures I have just given you are physical crossing the threshold that our inspection teams have done. In terms of the transport disruption, these figures were for May so they
would have covered the tube strike in London, a two-day tube strike in London. I think the impact upon our operations was minimal, largely because I think where our teams were expecting, where they were due out on inspection and they were expecting there to be
some disruption, they would have travelled by public transport the night before and probably stayed overnight. I shadowed an inspection of an independent hospital in central London on the first of the days of the London Underground strike in London and the teams were already there
by the time by the time I arrived. I live in London, I was able to walk once I had got off the train at Charing Cross, but the teams were already there. So, I think the impact on us within the CQC has been fairly
minimal and I am expecting that to be the pattern for June as well. Thank you very much, good to hear. And, Tyson, thank you to the staff for their commitment and ensuring that is the case. Sally. Yes. Thanks Ian, thanks Tyson. Just to pick
up on your last comment actually around regulatory and inspection activity more generally. So we are obviously delivering a thousand, roughly, crossing the threshold inspections every month, which is a significant achievement, but you said that didn’t include our direct monitoring work. So, can you give
us a sense of how many of the people that we regulate, we are kind of touching over a year. I think there is sometimes a perception that we don’t see people for very long time, and clearly there is an awful lot of activity. I
think there are three elements of this: one is the number of physical inspections, one is the amount of monitoring we do as a result of DMA team, and the third one is a quality statement that we publish on the website, having used our intelligence
and data to look at those providers that we think are probably of less risk to us. I think, from memory overall, we will be impacting on about - and I think Chris Usher has talked before about impacting on about, is it 70% of all
providers during the course of the year - but I’ll check that figure, Sally, and make sure that if I have got it very wide of the mark, I will correct it in the minutes. But, yes, it is a lot more than the physical inspection.
We now have quite a complex Arsenal in order to keep an eye on quality across the system. Thank you, that is really helpful. I think it just gives people a sense. Thank you. Thanks. Tyson, just quickly from me, as one of my questions was already
asked by Mark, but the other is on the registration teams, you said the high volumes of applications, they processed applications. Am I right in saying that to some extent that is tackling into a pre-existing backlog, so when we talk about processing applications, that’s the
ones we receive, but we are either staying on top of or eating into the backlog. Then, can you just say a couple of words about the technological improvements we are making in this area? The backlog has actually gone up over the last period and
that is because… the way in which we count the backlog is quite complex, but, strictly speaking, the backlog is increased because the managers have been working on the their existing workload rather than, sort of, opening things up being in progress and reducing the backlog.
We thought it better to do that than just to focus on the backlog, but I am fairly confident that - as a result of a lot of long-running process changes and also some changes to the way in which we present the data show on
our Power BI pages, so that I think our teams are better able to see exactly what’s going on – so, we able to make some progress. I think, performance in registration has tended to go up and down over the months, it does look as
if we have continued to make some good inroads into it. In terms of technology and technological advances, those are broadly connected with the regulatory platform and there is a lot of work going on with the teams, including training for the teams so they can
take advantage or the regulatory platform. That will also have quite a big impact on our providers and those who are applying for registration because it will make it a lot seamless when it comes to their interactions with us. Ok, thanks. I think it would be
useful just to keep an eye on the backlog given the importance of people coming into the market, but thank you very much for that. I see we have guests for the next session who have already joined, so perhaps if we can deal with the
remaining items reasonably quickly. Mark, there wasn’t really anything in your written report. Is there anything you wish to add? No. Just to confirm that this month, there is no significant cyber or information security issues to report. OK. In that case, can I just turn
finally to Chris Day, your parliamentary and engagement update and then we will take any questions. Super. Four quick items from me. We recently met with the Shadow Minister of Health to discuss the Ockenden report and our role in regulating maternity services. You will know
colleagues, last time we talked a bit about the maternity roundtable that were due to have, just before the last Board. The roundtable went really well, it was a really good listen event co-designed with stakeholders and both providers and the people who use services. The
report from that event is still being finalised, but there are probably three or four themes that are particularly important. Obviously staffing pressures is one, and a lot of conversations from the midwives who took part saying that they were…, a lot of them felt they
are in survival mode and there was a real sense of midwives taking the option of retiring early rather than maintaining their sort of role as a midwife. But actually at the same time, lots of really good examples of how teams were turning it around,
what teams are doing differently to support retention and growth. There is a lot about cross-team working, what does good care look like from different perspectives, how do people’s ability to speak up when things go wrong how do you create an open culture versus a
blame culture and how do support that by really good training that operates together where people are working together? That cross-team working, sort of, also moved over into close, trusting, respectful and multi-professional teams and team working. There was also a sense that if staff felt
safe, then it was more likely to lead to patient safety as well. So from that roundtable, the next steps are to finalise a full report with an output that will look to talk a little bit about what it means to be well-led in maternity
services, that Ian will focus on later, and perhaps lead to some other partnerships that we might do later in the year. We also wanted to give a practical guide for those supporting midwife services, rather like the Patient First, so we can get a real…,
what are the things that are good which midwifery services are doing, so that is something we want to take forward. The second item, I just wanted to talk about the external (unintelligible) advisory group and what we talked about. First of all, I know yourself,
Chair, and Belinda came to the last meeting. Thanks very much for your attendance. We talked about a couple of things, but probably most of note was the Single Assessment Framework. We (unintelligible) of what a year in the life of a care home, for example,
might be I think there is an importance there about gathering people’s experience. It should be a continuous process right throughout the year. There are also some questions about CQC, how will it implement this approach to ensure it is consistent across different areas and different
geographies. We talked to a degree about the technology and the support for that, in terms of how we can judge where we make decisions in one part of the country with the information against another part of the country, and how technology can act as
an enabler for those conversations. There was also, I think I mentioned earlier, some conversations about the wider funding of services and our role in calling that out. We talked a little about how we have used State of Care as a vehicle for doing that.
There was lots of concerns raised about long-term issues around funding, particularly in in domiciliary care. We went on to have a first conversation about this year’s State of Care where we talked about some of the themes of State of Care. We particularly, alongside those
things I’ve just talked about, we wanted to focus on mental health services for people, particularly for children actually, young people as they leave child and adolescent services and go into adult services. We feel from some of the work we have had, worked with groups,
with public groups and also from our own feedback, that that is an area of growing concern. Just to say, in addition to ESAC, tomorrow we have the first of the Provider Implementation Steering Groups around the Single Assessment Framework. So this is where that test-and-learn
really hits the road in terms of the feedback that we get from providers. We are doing exactly the same thing with regards to ICSs and local authorities next week, next Wednesday. Final two things, we have got a “Because we all Care” campaign - the
next spike in that work is around deaf and hard of hearing. As you know, it is a year-long campaign to encourage behavioural change and support people to give their feedback in care. You will probably know from the work we have done over the over
the months that has been a significant rise in Give Feedback on Care with more people trusting us with their information to help drive change and improvement in services. Indeed it has formed a large feature of our responsive inspection activity over the last two years.
This particular campaign has been really strongly supported by Paul Kirby and colleagues in NCSC to get their message and voice out about the definite hard of hearing audience. Future spikes will include long-term conditions, learning disabilities and autism and also an over-55 group that we
particularly want to focus on. Finally we have just launched the Annual Statutory Report we have on controlled drugs. As I say, it is an annual report, an update on CQC’s oversight of the controlled drugs regulation during this year and last year. It highlights some
of the issues we have found through our inspection activities. There is probably two or three that are particularly of interest. Providers…, the need for providers to include controlled drugs governance, the audit checks, etc., which were a problem before COVID, as part of their COVID
recovery plans, and the degree to which providers have got this as a focus of part of those plans is I think important. Those living and working in local health and care systems need to collaborate to reduce the risk of avoiding harm associated with drugs,
controlled drugs. So to what extent our health and care staff working together to make sure that an individual understands the drugs that they have been administered, indeed they are complementary to each other, and how…, linked to that how health and care professionals prioritise and
personalise the patient care in the context of controlled drugs. So, how they really understand the relationship one has on the other. I am conscious of time, Chair, so I will leave it there, okay? Happy to take any questions. Thanks Chris. You have obviously been
busy in recent weeks. Any questions for Chris? If there is no questions, I would just make an observation from my past experience. But I was pleased to see that we picked up on the Online Safety Bill. I think there is a…, I know from
other quarters that these things can be a rea risk. People don’t naturally think about what is or isn’t regulated to the extent they think about there is a presumption everything is. It is a real risk if that is a presumption and things that are
not regulated and are inappropriate are so easily available. So, I think it is an important area we may not be responsible if unregulated, but that doesn’t mean to say there won’t be concerns if harm is caused. So, thank you for that response. Let’s move

Learning Disability Programme update

on. Our next session is an update on the Learning Disability Programme. Kate Terroni, I’m going to hand to you in a moment to lead this, but we are joined by Debbie Ivanova from CQC who is our Director for People with Learning Disability and Autistic
People, and Alexis Quinn. I know Alexis is known to the Board and people who have listened before. I had the pleasure of meeting Alexis myself the other day, so Alexis thank you very much indeed for joining us. Kate, let me hand over to you
to run the session. (unintelligible) Thank you so much. So, the purpose of our discussion today is an opportunity for us to talk to Board about the progress we have made in changing the way we regulate services for people with learning disabilities and autism following the Out of Sight
Report and the work of Glynis Murphy. So it is a chance for us to show Board what we have been busily doing, but also to invite Board to say what sounds good, what should we be doing further and faster, are we on the right
tracks? So, really welcome some challenge as well as, I think, celebrating some good progress that has been made. It is also an opportunity to think about the fact that we are starting to have this impact on services for people with learning disabilities and autism.
Where else might we in the health and care landscape want to take a similar approach to the approach you are going to hear about during the session today? Then finally, we wouldn’t have been able to do what we have done so far without our
Expert Advisory Group. So we have benefited from the start of this programme by a) having Debbie Ivanova’s focused leadership on this, but also having a group of experts, people who have experienced this care, and their families really steering us on our boldness and our
ambition on this front. Alexis is a key member of that, so in a second I will be handing over to Alexis. When I think of Alexis, I know Alexis as a mum, she is a teacher, she is an author, she is also someone who
has experienced the most unacceptable types of care. Alexis will talk to us a little bit about that now, and then I am going to hand over to Debbie Ivanova to draw out some key points from the paper and then have a discussion that says,
what are your reflections on how we are doing and where might we go next for this work? So, without further ado, a very warm welcome Alexis. Thank you. Thanks Kate. So I guess just a recap for those that don’t really know me. So, I
was teaching back in a grammar school in 2013, I had just had a baby, then my brother died. Really, all I needed was maybe some OT, maybe some psychological support to manage my autistic grief, but that wasn’t available in the community. I was admitted
to a psychiatric unit for a 72-hour rest. Now, psychiatric hospitals and other congregate settings, you know, exacerbate for many autistic people and people with learning disabilities, the more troubling features of those conditions. Most of you will know that autistic people thrive on routine, structure,
predictability and so noisy, chaotic, changeable and very sensory-charged environments are not very helpful. So, as soon as those doors shut, I was overwhelmed and this kind of distress cycle started, you know, where I get a sensory overload, have a meltdown, be restrained, be segregated
and it would just go round and round and round and round, and it was very difficult to stop. So, I was routinely restrained, injected, etc. and subject to mechanical restraint and long-term segregation. Now in 2016 I escaped the hospital after my Sections 3 had
been renewed for a further year. I was about to be transferred to a medium secure unit. 6 weeks after my escape, I was back working again, teaching in a prestigious British curriculum school, and I now work at the Restraint Reduction network. Now in some
of the hospitals that I was detained at, I was abused, sexually, emotionally and physically and the CQC were nowhere to be found. When they inspected some of the hospitals I was in, I was conveniently taken out on leave or I was secluded. That happened
a handful of times. If I asked to speak to an Inspector, the answer was no. I e-mailed the CQC, I heard nothing, my family e-mailed the CQC and they were told that the CQC don’t investigate individual complaints. The abuse I was suffering, and also,
you know, lots of the community, you know, which I’m now sort of very connected to, have all been falling for many years on deaf ears. You know, I was pretty cross to be honest with the CQC and I was reluctant, when Julie Newcombe suggested
that I work with you, to do so and I think many families are. It seemed like, you know, you were looking for something and you were seeing something completely different to what our experiences were of inpatient settings. It was like a completely different lens
I guess. Then you started doing the RSS work and I was interested, but sceptical, you know, and I don’t have much tolerance, I guess, for empty promises or some sort of political rhetoric. However, you guys have really delivered. You know, from the outset, you
have listened to people in need, you have included them, you have prioritised our voices and been true to, you know, what people have told you. You know and you now see, I think, what we are seeing and your new inspection process is picking up
on the fact that people might have a nice care plan, but actually none of is happening. You know, all that for 17 people on the ward, everything’s fine, but there is that one person, like I was, that was detained in a long-term segregation, who
are routinely having their rights violated, sleeping on the floor on a mattress. And actually, you know, you guys are saying that is not OK, you are not going to rubber stamp such things as good. So, I think, we are grateful to you for that,
you know, I certainly am. So you might think, you know, that Kate and Debbie rolled me out today to say what a good job they have done, but actually, I think if you knew me, I wouldn’t do that. Not if it wasn’t true. For
me and I know a lot of the families that we are connected to, the culture of the CQC has changed. Families have much more trust in the inspection process and believing that you will follow through, you know, on getting safe, appropriate care for people.
So I am grateful that your progress report, your Out of Sight Progress Report actually told the truth and that must - I get it – have been a bit of a challenge. Yes, we all know that care is not where it needs to be,
but not many organisations are willing to say that, you know, and it is us, I guess, that suffer as a result of that. So thank you. That is the end of my five minutes, I believe. Thank you, Alexis, and people who have had the
pleasure of hearing you talk or have read your book, know that you tell it how it is and that is why we have benefited so much by having you around the table, steering this with us. So, thank you so much for joining us Alexis.
Debbie, do you want to come in and just draw a few bits from the paper and then we will hand back to Ian as our Chair to invite comment and challenge. Thank you. Yes, it has been great to have this opportunity today to look
at what has been achieved and set out priorities alongside Alexis’ really powerful story. Actually I will spare Alexis’ blushes, but hearing her speak was one of the biggest motivators for me to get involved in and to lead this work through. It is also Learning
Disability Week, the purpose of which is to raise awareness of what it is like to live with a learning disability, hence my very colourful background. So it is a great opportunity to have this discussion. I wanted to start off really by saying that leading
this work over the past 15 months has been an absolute privilege for me. It has shown us, I think, what can be done when we focus in on people’s experience and look at what does that mean in terms of stretching our role as a
regulator, recognising our responsibility to be part of the change that needs to happen. It is not easy and when we are taking a strong line in our regulation, in 27% of the 1231 inspections in services for learning disabilities in the last year did not
meet the regulations, so have breaches. 40% of hospitals inspected had breaches. Alongside shaping that model of care in our registration, and you’ll see in the paper, the specialist registration team has already had impact with 50 applications withdrawn before they get to going into the
process, and we have 11 - I think it’s 11 - notices of proposal in process at the moment to refuse to register a service that does not meet right support, right care, right culture. This inevitably has an impact on the market and it is
a difficult time, so it isn’t easy. We try to balance that with seeking to improve services, particularly through the work on supported living, but it has to be the right thing to do. We need to be shaping the market and we can’t be responsible
for approving more mini institutions where people live in large groups and their needs are not met, where they are not part of the community. This isn’t what people want and this isn’t what evidence shows supports people to lead that full and fulfilling lives. So
where do we go now? Well, looking at the year ahead, these are what I think we should do and I really want to get your views on whether this is the right approach. I think we need to keep up this focus, we need to
keep doing what we have done this year, plus take a closer look at health needs. Too many people are still dying young and with now sick people being brought into the leader work so they are looking at the deaths of people with a learning
disability and autistic people that happened too early, looking at community support, how do services offer the support needed to stop people going into hospital, not just a focus on getting people out, and also getting our staff to feel really confident on how they could
be part of highlighting and reducing restrictive practice. So, we need to keep up that focus. I think Kate already mentioned we need to look at how we can use some of this learning across other groups of people who draw on services. Then I think
the other bit that needs to really tied, is we need to focus on ICSs’ responsibility here, how they recognise, plan and commission to meet people’s needs. We need to look at this in both our ICS and our local authority assessment. So, that is kind
of my highlights and I’m really keen to hear your views and questions. We have also got Rebecca Bowers here who has been leading the work on inspections, if there were any questions around that area. Thank you Debbie, so back to you please Ian for
any comments, reflections or challenge. Oh you are just on mute. How could I do that? I was going to invite comments, but I see them coming in. Belinda, first you. OK, Hi. I read your book, Alex, it was fantastic. I read it when Kate
recommended it many, many months ago in one of your blogs. I am a psychiatric nurse by profession, so it gave me wonderful insights, so thank you for that. I suppose my other two questions really are, how can you maintain the focus, you know, so
we keep it in the public eye? And what areas do… you know I see it naturally lending itself to sort of a dementia setting or, you know, seeing problems in maternity services with people covering up what has happened and there has been some concerns
in lots of parts about that. So, how do you see it extended into other services, mental health services, and also, you know, people with learning disabilities do die much younger, as do people with a diagnosis of schizophrenia so, you know, it is a big
field to look at and I just wondered what your plans are, to mention the focus? Can I go first and then hand over to Debbie? So, Belinda, if we think about how we have organised ourselves at the moment, as a as an organisation. So the fact we have a Director for
People with Learning Disabilities and Autism, we have a Director for Mental Health, we have a Director with a focus on Inequalities and Integrated care system, so as I say, Debbie’s leadership on this over the last 18 months has just accelerated what we wanted to
do. I think keeping the heat and the focus and the pressure on through. We had Out of Sight then, as Alexis said, published quite a hard-hitting follow up report that said not enough progress had had an impact on improving outcomes for people. So we
will continue, we will continue to shine a spotlight on this. We will continue to inspect and close services that are not good enough. We will continue to stop new services coming online if they are not the model of best practice that we expect to
see. So, we aren’t stopping on this agenda. What we desperately need to see is we need to see all the other parts of the system doing their bit as well. So, as we called for a long time ago, we need that consistent crisis response
in the community that means that Alexis doesn’t go for a 72-hour stay that ends up being a year’s long stay with horrible outcomes for her. We need that crisis response in the community that just holds the person steady during a period of crisis, and
we haven’t got that yet. So, we are not going to stop talking about this and we are not going to stop putting the pressure on. As to where we go next, so your thinking is the same as ours, dementia services, understanding risk of closed
cultures on maternity wards, mental health, long-stay hospitals, etc. There are many other areas of focus that I think we need to give a bit more consideration as to where we go to next, because it is a huge amount of work to deliver what Debbie
has done and we need to make sure we are prioritising the way that we need to. Debbie, is there anything you would want to add to that? I think just keeping up the independent voice publications, having a set of articles. So we are going
to have the one coming out about acute hospitals and people’s experience in acute hospitals in September. Then a little bit later, there is going to be one on how autistic people are managing to access GPs and dentists and other primary care. We need to
just keep that focus and keep looking at this as a whole system-wide issue and keep the attention, I think, on it, rather than it being stories of the awful care people are receiving. There will inevitably be those because that is what is still being
found and we are still obviously finding those things in hospitals. But what we also try to do each time that happens is to have a really strong media statement around that. So, we are making clear this is just not acceptable so the focus is
coming from both those ways, what needs to be done but also where care is just not good enough. Thank you. I think you are doing an excellent job in raising standards and improving care, very impressive. Thank you Belinda, Kate and Debbie. Stephen Marston. Thanks
and firstly a huge thanks to Alexis. I found that hugely powerful, very moving actually and I think what you did, Alexis, has kind of proved to all of us just how important the work is that Kate and Debbie and all of their colleagues are
doing. So certainly, from my point of view, I am strongly, strongly supportive of the work that Kate, Debbie and colleagues are doing The bit I would quite like to follow up though is where Debbie finished, which is sort of, how would you want the
role of ICSs then to develop in this space? Because we are just at a point in time where we can shape how ICSs are set up, we can try to define what good is in the capabilities that they need. In order to feed into
that discussion about the setting up and operation about ICSs, what would you like them to be doing to carry on and respond to the great work you have been doing. I think this is where there are some posts in the legislation who are going
to be responsible for services for people with learning disabilities, but if you think about that, I think it is one or two posts, and then there’s all these other priorities. So, I think it is going to be very much about how do we continue
to keep the focus, that actually it is not just about acute care, it is not just about older people services, it is about a whole range of people, mental health needs and learning disability needs are often the ones that are then just dropped to
the bottom. So, it is going to be about keeping the focus on that and making sure that people really do understand what is the needs across the whole of their population. So, what is the ICS planning to do to meet the needs of the
people. Do they know how many people out of the area? Do they know how many people need to come back? What is their plan for actually the community support, the services, the crisis intervention? What is the plan for those local services to actually meet
that population’s need? And then I think alongside that, what have they learned from the leader reports? What are they learning from those action plans? Are they implementing them? Are they checking that those are following through? Looking at things like annual health checks and the
GP services. Not just the numbers, but the quality. Are they looking at those mental health and physical health? How are they intervening early? How are all those systems fitting together to make sure that people with a learning disability and autistic people have access to
the right services at the right time? And that preventative addendum, that prevention agenda say that we stop those people going into hospital in the first place, is where the focus really needs to be. You’re on mute. So I have done it again. Thanks Debbie.
I was just saying I think we probably have time for three more questions, from Sally, Mark and Robert. Take them in that order. Sally. Thanks Ian. And thanks to Alexis, particularly, for sharing her story. I live with family members with learning disabilities and autism
and I know how traumatising poor treatment can be, so you are being very brave coming forward and I applaud you for that. I was trying to reconcile before today our report from last time, Kate and Debbie, which we spoke about in terms of the
shocking nature of improvements that haven’t yet taken place. Then today which is obviously quite positive in terms of CQC and what Alexis has to say about our change in culture. My question is about how we hold other people to account in this. Do we
have any powers to do so? And is there a role for people like Alexis, and other patients and members of the public to be able to tell such powerful stories to a wider range of people than just our Board? Shall I start? So we,
as a result of our original Out of Sight Report, the Department of Health and Social Care set up a group called Building the Right Support chaired by the Care Minister and the Minister for Mental Health, so that is the formal route where all the
key stakeholders who have a role in making this change were calling for, sit around the table. And there is a route for people with lived experience of this care and families to influence that and at each one of these meetings, Debbie comes along with
our heartening stories from the work that Rebecca Bowers and her team have done to say that we are still not seeing improvements when it comes to the quality of care. So, that is the official forum, Sally, the government has set up in response to
our Out of Sight Report and we will continue to kind of challenge and play a really key role in that. Debbie, do you want to come in? I think just to say that we absolutely know this isn’t job done and actually the report, the
follow up report to the Out of Sight that we brought last time so clearly shows that, but that is part of our way of putting pressure on the system, putting pressure on people to recognise that these changes need to happen. And, certainly, with the
Building the Right Support delivery board which happened yesterday, the action plan should be coming out fairly soon and there will be some working groups to take things forward. But there was a lot of healthy discussion about - this makes it sound by picking on
two or three areas as if a lot of the things are sorted and they are not - so there is a subgroup of the What’s Good Looks Like called the What’s Good Looks Like Subgroup, and Alexis is a member of that group, as I
am. That group is actually coming together to issue a report fairly soon, which we don’t want it to be just another report that sits there, but it will actually indicate what all of the organisations who are part of the Building the Right Support Delivery
Group need to do to change their principles, the actions that they need to do and the way they need to move forward. Alexis I know you are writing a forward for that, I don’t know whether you want to add anything about the impact we
hope that is going to have. I think mostly my forward has been very similar to your Out of Sight Progress Report in that it really is just saying how things are right now and that we really don’t need any more reports, other than the
ones that I guess you have to, and Debbie to say things haven’t changed, that you know and it needs to. I hope that we’re not here in 10 years. Thank you Thanks both. Mark Saxton. Thank you Chairman. Firstly, Alexis, can I echo Stephen and
Sally’s thanks to you. I also found what you had to say extremely impactful, so thank you. I also want to say that the Glynis Murphy Report had a significant impact on, I believe, all Board members and a significant impact on our organisation. But more
importantly is our response to that report, that we follow eagerly here at the Board level. But I have two questions, so thank you, Alexis, again, really, really impactful talk from you. Two questions, I think they are to Debbie, so Debbie I just wondered, alongside
the rejection or withdrawal of poor registration applications, have we had an increasing better applications from more caring safer services? That is the first question, and the second question, if I may? In terms of the change in our inspection approach, I wonder if you could
talk to us a little bit about the training for our teams and, specifically, if you are making some elements of the training mandatory? Thank you Mark. The first question I actually can’t answer. I don’t know whether we have an increase in applications for services
for people with a learning disability. But what we do have is an increase in people talking to us early, which is what is really important, because it is at that point that we need to be able to shape the model. That is not just
in adult social care, so I have been having early conversations with NHS England at the moment about their plans for some of the hospitals. We do still have a problem about some of these things can just be built in already existing places without us
having a say to it, so there is still some of those issues that we need to tackle. But people are beginning to understand that we have a model of care and they are also beginning to talk to us early when they are beginning to
plan. However, still too many things are getting to the stage of coming to us that are just not acceptable, hence the number of notice of proposals to cancels that are in progress. The second one, I am actually going to bring in Rebecca because she
would be the person who could answer that question for you best. Hi Mark. Yes, in terms of training and hello everyone, yes we do have a training plan for our staff that is mandatory. We have got a base level of training that really does
look at culture mind-sets of our staff to enable them to feel confident and competent to deliver our new approach to our inspection activity. So all our staff - we expect they are inspecting services for people with learning disability across the health and social care
sector - need to have attended that training and carried that out. We are in the process of developing a second stage of training with our national expert which will be very much looking at restraint, inclusion and segregation, and actually how to identify that and
with that clear focus. As we have said, you know you said how important Glynis Murphy’s approach and the report was around, you know, leading our change and the focus on observation that we have used in our new approach has been critical to us understanding
the culture of services. And so we are having a massive focus on that in terms of our ongoing development and training for our staff, so yes and it will be mandatory. Hope that’s helpful. That is, thank you. Thank you very much indeed colleagues. Probably the last question, Robert Francis. Thank you, Ian, and thank
you, Alexis, for what you told us and everything you are clearly still doing for us. It is really arising out of your story that my question arises. I mean for a long time and it’s not just in in this field, I have long held
the view that insufficient attention is paid to the significance of individual stories, such as yours, in that we always look at things in a quantitative way and add up numbers and the numbers often conceal the real evil that is being done to some people.
The question really I have is this, that when someone like you comes forward asking for help with your story, it seems to be that there are two immediate issues. One is really the core CQC business which is what are the implications for the system,
for the place where the service is being provided, and so on? It seems to me that what you identify - and it is not just in the field of mental health services - is the gap about how do we then ensure that you the
individual who has brought this to light, who has lived at experience, is actually properly looked after, now and then? Now, sometimes the story comes too late for that because we are talking about something that is historical, but quite often the story is something that
is about ongoing care. At the moment, I mean we do, I am sure, refer individuals or refer the story to the provider that someone is accountable, but doing that. But I just wonder whether there is a feeling that both we, and the system will
generally, could do something more immediately to remedy whatever is happening to the individual who has brought us some appalling story? I think any one of us could take that. If I kick off and then Alexis or Debbie you want to come in say. So,
in a situation that you have described, Robert, the first question will be as a safeguarding issue, a police matter doesn’t need to be referred to a statutory organisation that needs to take specific action if someone has been abused. The other component is that if
it is an individual complaint, that we have got our ombudsman routes for people to have their complaints redressed. However, we want to know everyone’s individual experiences. I remember Debbie saying to me, early on in this process, she said, Debbie said to me if there
is a service providing outstanding care to 19 people, but one person is having their human rights abused, how can that be a good service? And I think that needs to be our…, that needs to be our mantra. If one person is having an experience
like Alexis did in the service she was at, that is not acceptable, that is not a good rate of service. So, there is a challenge we need to give ourselves to say every individual voice is incredibly important and we need to make sure that
one person’s rights being abused is enough to warrant us saying that a service is not meeting standards. Debbie do you or Alexis want to come in? I don’t think I have got anything specific to add, other than Alexis, have you? I think she has left the call. I think she said she… Oh she might
have had to go because she is speaking at another event afterwards. I just think, Robert, it is really important that we keep a focus on safeguarding. I am starting to worry a little bit about some of the thresholds of safeguarding and whether it is
applied consistently across the whole country, whether it is applied consistently between different settings. Do we expect something different in terms of safeguarding for somebody in hospitals, or somebody who is in a care home, for example? So, I do think it is a really important
question and whilst we can tell from the information that Chris gave us, that more and more people are talking to us, I still worry about the breadth of people that are talking to us. Is it the person who is in seclusion? Is it the
person who is detained? Is it the person with dementia who is in the bed in the corner of a large care home, probably not. So, we still have to really kind of make sure that we are reaching out in as many ways as we
possibly can to get information from people. I know Alexis did say to me the other week that she knows that people are still thinking I don’t know how to contact CQC. So, we have still got more work to do, so as both the response
in terms of safeguarding, the response in terms of listening and making sure that those people are then supported in that service. Because, of course, as Alexis said, people knew she wanted to talk to us so they moved her out of the way when we
came in. So, we just need to make sure all of the doors are open to enable people to have that say. OK, Kate and colleagues, thank you. To add to how impressive, Alexis says she is, as you say, speaking at another conference up in the
north of England, so dialled in, stepped out of that to dial in to join us today. I think everyone would agree, very impressive session and a credit to the Executive in a way that, you know, we start with the session, someone telling us how
bad CQC was even if that’s offset by the major changes that some of the people in this virtual room have made. I think one of the challenges for us –and I’ll just leave this rather than have another debate -, but Debbie you made the
point about shaping the market and that is the debate we have started to have elsewhere. I mean we are providers, we hold explicitly…, we have no regulatory powers to tell the people exactly what to do. But I think there is a clear expectation we
will have a role and how we can do that, I think, is a point we need to debate right across the piece, but certainly including this area. I suppose as a related point, one of the challenges I always think with commentators on these, as
Alexis said the one thing we don’t want is another report. It is one thing to comment on what is happening or not happening and to continue to do that, but I suppose if things don’t change, the question is: why not? And maybe it is
related to shaping the market, but I think the challenge for us is to advise others on what policy interventions could be made that would make a difference, and it may be a series of them over time. But it is very difficult to sit back,
know that you have identified a problem and then just not see any changes. So, I think, a thought for the team and anything you can bring back to the Board on what interventions are needed and any thoughts on shaping the market, I think would
be very interesting for us. If I could close the session down, I mean just starting again with Alexis, I mean, I think it is a shame she has gone, but I think her story is both shocking and inspiring. I spent an hour or so
with a recently, just to get to know her better, and I didn’t stop telling other people about it for days. Mainly the inspiring bit rather than the shocking bit, but I would like to thank her – we will do that afterwards. But Debbie and
Rebecca, thank you for joining us and your contribution and Kate for leading the session, very good indeed. So thank you. We are a few minutes behind schedule, but we are not too bad. If we could carry on. We are now having an update from

Update from the National Guardian

the National Guardian. We are joined by Jayne Chidgey-Clarke. Jane, I can see you have actually joined us, so perhaps I should just hand over to you to give your update. Thank you very much, Chair, and thank you very much Board colleagues. It is an
absolute privilege to be here again today. I can’t believe it’s six months since I was here before, I don’t know where that time has gone. And on the day after Midsummer’s Day, so time flies when you are busy. Indeed it has been a very
busy time and I hope that the report that we have laid before you helps to give some more detail. So, just a few opening remarks that I would like to make and then I will allow plenty of time for discussion because I feel that’s
where the check and challenge would be really, really helpful for me as the National Guardian. So in terms of, just by way of background, I come to the Board on a minimum of twice a year. As I say I came last six months ago
when I was new in post. Hopefully the paper will give you enough depth for the moment, but you will soon be having our Annual Report which is due to be laid before Parliament just before recess – it is in its final stages of formatting
and sorting, and that will be coming to the Board to supplement what you have today. In terms of headlines that I would like to give you, the network is ever growing Freedom to Speak Up Guardians. We now have over 850 guardians - it has
increased from when the paper for you was written - in over hundreds of organisations. We have a steady rise in cases reported to guardians. Since the outset of the National Guardian’s Office, we now have over 70 thousand cases that have been raised to guardians
which might not have been raised within their organisations had the valuable, additional route of speaking up not been present. I am very aware that the Guardian route, as set out by Sir Robert in the Francis Report, is an additional route from existing HR direct
line management and other routes of speaking up in an organisation, and they are all vital. The Freedom to Speak Up Guardian isn’t a panacea for sorting the rest, but it is an important additional group and those cases continue to grow. What we do see
though, which is a real worry, is a steady increase in the proportion of cases where detriment is indicate. It is not huge, but for all those people who are speaking up and then suffer detriment, it is…, it absolutely can be life-changing. So that is
a very worrying sign and I will talk more about that in a moment if you would like me to. The implementation of the Guardian role in itself is work in progress and what we see is variation in how the role is implemented. Clearly, individual
organisations will have their own take on how they want the role to work for them, but what we do see in our recent survey is that - there’s a link in the report for you too - shows that some guardians still do not have
protected time to carry out the role. It is a busy role with case handling and the proactive work and if guardians are not given protected time in order to do that, than that may have implications for how they can fulfil that role in a
meaningful and impactful way for the organisation. What that also says to me is the importance of the CQC’s role in inspection of the well-led domain and particularly when it comes to Speak Up culture which is obviously the Freedom to Speak Up guardian role and
implementation is part of that. My team work really closely with your teams on that, and I’m really, really pleased about that and I will continue to emphasise the importance of that work because, without that regulatory support for the implementation of changes to culture and
organisations, we are not going to get to where we want to be. The report talks about, as you know, about the new training that we produced last month – I actually think it is two months ago now - on the final follow up with
Health Education England for leaders. My ask of you today, as a Board, is to commit to undertaking that short, sharp piece of e-learning training in order to then have the conversations at Board, around for your own organisation, you know, for us and CQC. How
speaking up is going for you, both for internal staff and obviously the Speaking Up arrangements externally. I think it is a really good time that that training is here because I am told that by the end of this month, NHS England will be launching
their new policy on Speak Up - the universal policy which will speak to all organisations with NHS contracts, that is including primary medical services, that is including obviously the trusts and wider. What is really important that rules apply to national bodies, so I would
urge you to use that as a as a reset opportunity for your own Speaking Up arrangements, alongside that guidance, and I will be delighted to speak with you about that. The final thing I want to just talk to you about is a technical issue
and that is to let you know about a change to our complaints process. So historically, the way the NGO was set up, complaints were about the office itself and the way we conduct our business were handled by NHS England and Improvement. That now has
been taken in-house to CQC, as indeed we work and we are CQC employers and Ian is our accounting officer. So the complaints process from the 1st of April is now sitting within CQC, so it is a technical change, but it is an important change
to our process. I think I would like to just let you know that there hasn’t been progress - which is highlighted in the report - on the Adult Social Care White Paper commitment to working with the NGO, with the part of Adult Social Care,
working with the NGO to see how the Freedom to Speak Up role can be implemented in Adult Social Care. Unfortunately, due to some technical issues around funding, release and vehicles for funding, that work hasn’t been able to start yet because the Department of Health
and Social Care have not been able to tell us how and when the funding will be, but I know they are working on it. So that is why, if you are wondering why I don’t have a progress report on that really important piece of
work, and I know Kate Terroni and colleagues are very keen to see how that work emerges to give that important Speak Up routes to Adult Social Care colleagues, alongside health colleagues. But I will keep you updated, hopefully in my next report I will have
some movement on that. I think I am going to stop there. There are many other items in the paper. I’m really happy to take any questions comments and hand back to you, Chair. Thank you, Jayne. We will take questions from, I was going to
say anyone. Mark, I see you have a question there, perhaps Mark, well let’s go to Mark first, but Robert it might be useful to have any observations you have, given your links obviously to this function. I suppose the worrying statistics that we see about
how things are moving in the wrong direction, any observations from you on that and indeed from anyone on why we think that is happening, but Mark, let’s deal with your question first. Thank you Chairman and thank you Jayne. Can I say first, I really
like your heavy branding behind you as you are talking to us, I think that looks really great. It is a super report. I did go into the Annual Report, Speak Up Report, and notice that last year the Speak Up was very heavily impacted by
COVID and a great increase in questions arising out of COVID to the Speak Up guardians. I just wonder how you see that reshaping, as we go forward, because I noted that, for instance, cases dealing with bullying and patient safety decreased in that year, in
the Speak Up Guardian Report. And I just wondered whether you think there is going to be a reshaping going forward in terms of the cases that you very, very good system picks up and deals with. Thank you Mark. I think that is a really
interesting and important question. I mean, we don’t know what cases are going to come, what it is going to look like until we see it. I think, personally speaking to guardians when I visit their network meetings and when I’m out and about, I think
obviously items related to COVID for example PPE and things like that, that has all abated, so we will see a shift in those particularly COVID-related workers’ safety issues that were being raised. I think from what I’m hearing and what I’m saying in the system,
with the continued pressures on the workforce, with recovery and workforce shortages, I think we will continue to see Speak Up cases around patient safety and those impacts on workers. Sadly, I don’t think I am hearing that there is going to be a great change
at the moment in the amount of cases around bullying and harassment. Also we have changed our coding to actually capture, if it’s not full bullying but it is behavioural, if it is civility and respect, and we are trying to capture that because those are
important issues that workers are bringing up to their Freedom to Speak Up Guardians as well. I am not sure whether that is still the impact of COVID. I think people have changed. Generally society - I see in terms of social media and interactions with
people in terms of what impact negative impact that might have had on wider behaviours - and maybe that is still being reflected in the workplace, in terms of our health and social care workplaces. So we will keep a very close eye on it, we
will be reporting that and we will be trying to understand that with organisations, and really importantly, talking with organisations about what are you doing to overcome that, because that is the key to this. It is the action that follows out from this information. Thank
you. Ian, would you like me to… Mark Chambers. Sorry, Robert, no, I did ask you to comment so you come first and then Mark can go from you. Thank you. Well I think, firstly, Jayne and her office are doing fabulous work, but I think we need to remember that the
Freedom to Speak Up agenda - and indeed my report which is now quite a long time ago - is not just about the Freedom to Speak Up National Guardian. That was but 1 of 20 recommendations. The reality of Freedom to Speak Up and what
needs to be done about is that it is everyone’s business. It is a cross-cutting agenda. It particularly needs the right sort of leadership - cultural leadership - and we had a bit of a discussion about that earlier. But if you are looking for one
barometer of how effective leadership is, then looking at the Freedom to Speak Up figures in their Staff Survey would be a starter for 10. But there is no doubt at all – not actually confirmed by the figures - that the pressures that are leading
against a Freedom to Speak Up culture are increasing. They are increasing in part because of the pressures of demand, the pressures from the top for results, but above all, as Jayne has alluded to, the workforce shortages which mean that people who are have things
to speak up about are increasingly pressured not to do so, for entirely the wrong reasons. For people who are short of time, short of resources and want to get a job done - whatever that job might be - resent being told that something is
being done which is wrong when, of course, they should…, good leaders would accept and welcome that. This is of course not a problem that is limited to the health service. Those of you who watched that depressing programme on television last night about the problems
with the United Nations would have seen encapsulated there all the things that go wrong with organisations that do not listen to complaints. So I think our role, if I may put it this way broadly and I know we do this, is that wherever we
go out, wherever we go in and inspect anywhere, we should be looking at the Freedom to Speak Up culture there, and not just about concerns, but how free people are to contribute towards the improvement of their organisation. Organisations where that is done, where there
is a tradition of civility, of listening to people and acting on what they say, probably never need a Freedom to Speak Up Guardian to be honest. But I mean there is a long way to go and this is a boulder that will continue to
have to be pushed uphill long after Jayne and I have left the scene, I’m afraid. But there we go. You left a challenge there for what we should be looking at in inspections, Robert, maybe leave that on the table for a moment. Just go
to Mark, your question. Thank you Jayne, and for all the reasons that we heard about, you know, your work is more important than ever. So I was going to sort of echo Robert’s points, that, you know, the problems are not related to the Health
Service and there’s some…, one of the things I wanted to commend you for is your focus on one of the barriers to Speaking Up which is fear. Futility is the other one, but that is relatively easy to deal with, but fear is the big
problem. And safety in speaking up is quite an intangible thing to measure at times. You know there are some good measures around, you want the proportion of people speaking up who feel the need to remain anonymous to fall, so that people are more open,
but it is a really big problem out there. Wearing another hat, we did a survey across 10000 corporate employers across Europe at the end of last year and 43% of people who had spoken up, said that they had experienced retaliation. I mean that is
just a shocking statistic and those people will be advocates against speaking up in the organisation. So you are really right to focus on this and one of the things I would commend your office on, for what you do, you know, your efforts to learn
and capture best practice from other sectors and this pan-sector network that you run, I think is a best practice and I would commend you for that. Thanks Ian, can I just come back in for a minute? Do you want to respond? Yes. Could I just thank you for those words? And I will absolutely take them back
to the team, and you are absolutely right. The learning from other sectors is absolutely key, both good practice where people are being challenged and also sharing our experience and the challenges that we are having. That just feels incredibly important because we haven’t got it
right. I do just want to come back on that point that has been made in terms of the wider Speak Up culture. I prefaced my introductory remarks with the fact that the Freedom to Speak Up Guardian route is just one of a number, and
it is that wider culture and I am consistent in my speaking about that, in my writing about that, in my encouragement when I go work with organisations and talk with boards. The new national guidance to come reflects that and obviously we are working really
hard with yourselves to make sure that inspection through the regulatory framework addresses that as well because it is… Indeed, Sir Gordon Messenger’s recent publication of his review makes reference to the fact that sometimes Speak Up culture can be seen through a very narrow lens,
and was encouraging us to make sure that we widen it. So, thank you for your ongoing support and I look forward to obviously presenting our Annual report to you outside. It will be between the next meetings and if you have any questions, comments, want
me to come back earlier than 6 months, please just ask. Thank you very much. Ian Trenholm, just to conclude, Robert made the observation about what we should be doing in looking at this. Do you have any observations on what we are or might be
doing? Again, I think it is something that we are already doing a lot of work in terms of looking at cases. I suppose the only area that I would gently disagree with Robert on, I think he made a reference to counting numbers, which may
not have been the thing said. But, I think, we do look at individual cases and whilst we don’t investigate them, we do look, we do look and say is an individual case particularly important? And if it is, that may very well trigger an inspection
and a deep examination of something. so I think, we don’t just count the numbers in this area and I think really, it is a question of keeping at it really. I think, as Robert rightly said, this is something which is on people’s agenda, but
I’m not sure it is there yet. And how we broaden it out and how we scale. Jayne and I had one or two conversations about how to scale the influence of NGO, which may be something short of more guardians. So, I think a number of things really.
Thanks very much. So, Jayne, thank you very much indeed for joining us. Thank you for your report, and well done even though some of the conclusions are a bit depressing. I think one point coming out from what Mark said though is that it would
be wrong to think that this is solely a problem for the health system. To some extent it is a societal problem. That doesn’t give any excuses, indeed it probably just makes the whole thing a little bit more complex, but I think it is useful
to bear that in mind but thank you very much indeed for joining us Jayne. Thank you very much, Chair. Thank you colleagues. I look forward to seeing you soon and continue working with you. Thank you. Robert, last formal item on the agenda is your

Update from the National Director of Healthwatch England

update on Healthwatch England. I think we are being joined, or are joined by Louise Ansari, so can I just pass that over to you. Thank you. Actually we are not. Louise, I’m afraid, has had to present her apologies owing to an unavoidable diary clash
with a legacy obligation in relation to her previous job. But she assures me she will be present for future reports, so stepping bravely off the bench is Chris McCann to be the new Louise at least for this meeting, so I will just hand over
to him. So, as Robert said, I am stepping in for Louise today. For those of you who don’t know me, I am Chris McCann. I am the Director of Communications, and say campaigns, in Healthwatch England, effectively I am Louise’s Deputy. So, hopefully, you have
all had the chance to read the report that was sent. I think it does give an outline of an organisation that is really sort of delivering a pace at the minute. I think Louise’s note at the top of the report captures it well, just
in terms of sort of the range of activity that we have been doing, you know creating impact on policy and practice, highlighting the key issues that patients and people are experiencing and healthcare and are coming to us with. So, we have continued to have
major impact in the media, particularly around issues like NHS dentistry which is an area where the amount of feedback that we are receiving has expanded almost exponentially. Pre-pandemic it was about 5% of what we heard, and now it is regularly pushing up around 22
to 25% of what we hear. It has gone from being, sort of, relatively mixed, almost overwhelmingly negative. We launched our campaign on accessible information which in the initial phase had a focus on people with sensory impairments. That was an opportunity to influence the Accessible
Information Standard which is mandated within the NHS. We are moving on to focus on accessible information, specifically around people who don’t speak English. We had the opportunity to engage deeply in the delivery of the Fuller Review of Primary Care. We sat on the expert
reference group on that and we are very pleased to see some ideas that we pushed on around community of care and the benefit of neighbourhood care teams being reflected in the final output of Dr Fuller’s Report. We continue to engage with local Healthwatch to
make sure that they are able to develop the integrated care systems which, you know, we know will be going live officially from July 1st. We also continue to roll out a comprehensive training offer to the local Healthwatch network to try and ensure that we
are providing them with as much capability and capacity to deliver for the populations of their local areas. More internally focused, we have had a complete review of our finance procurement processes to make sure that we are probably aligned with CQC systems and reporting. I
would like to highlight they really impressive way that the CQC Finance and Procurement teams have helped us to develop that, particularly Ryan Mills who is our Finance Business Partner and Ben Groves, the management accountant. So, we have developed more aligned processes and we have
also been developing new processes for our dispersal of income to local Healthwatch. Then I suppose it would be remiss of me not to mention the fact that in April, we had the announcement that our august Chair, Sir Robert, will be stepping down from the
role in November 2022. Just to reflect on the high impact that Robert has had as Chair and how he has played a real role in developing and improving Healthwatch England as an organisation, improving our profile and improving how we operate generally. So happy to
take any questions around the report. Thanks very much, Chris. The message that you were playing Louise today had not reached me, but welcome. Any…, there are no questions in the box at the moment. Just a quick one from me, the report did in relation
to Ockenden say that you are undertaking work on maternity services and see how evidence can support the review. Can you just add a little bit more about what that will mean in practice? Well, at the moment we are still scoping that work so it
is very early stages. So what we will do initially is have a look…, do an evidence review of what we already have on the books, and then we will go out to local Healthwatch to try and understand what they are hearing about it. Once
we have an understanding of that sort of background level of knowledge, we will then sort of tailor our approach and see if we do some sort of bespoke engagement on it. Sally. Thanks Ian, and thanks Chris and Louise in her absence. It is obvious
that you are doing sterling work across a whole number of fronts and the length of the report shows that. I just had a question about risk because when you and Louise came to Audit Committee, you talked about funding for Healthwatch, and Robert might want
to comment as well. But I noted on the report that your now operating at about, round terms, 50% of the funding compared to the level when Healthwatch started. That feels like a significant risk and a potential problem, and I just wanted to flag that
again. Because we have talked about it at Audit Committee, but we haven’t necessarily talked about it here, so any comments that you have, I think, would be helpful. That issue around funding, not just for Healthwatch England but more broadly for local Healthwatches, is something
that we do…, we are very attuned to. So in the network in particular, we know that there are some Healthwatch who are operating on very limited budgets and we continually monitor to see where those issues might arise and we make interventions, but the commissioners
try and see what we can do to mitigate that. We are continuing our conversations with DH about, you know, how we can mitigate the impact of the reduction in funding. Whether it might be something we can do in terms of the mechanism of how
I the funding is delivered to local Healthwatch in particular, just to create a bit more transparency, and we also do look at opportunities to bring in income from external partners to work with local Healthwatch to help with their budgetary pressures. But I think, as
Robert will confirm, it does sit right at the very top of our risk register and, you know, it is something that we do put a lot of thought and do do a lot of work behind the scenes to try and mitigate those impacts. Mark Saxton
Sorry, could I just come in on the funding point. It is a matter of considerable concern and a risk, particularly in relation to the network. There are some parts of the country where you wonder how they manage to do any work at all. If
I can give you one example and I won’t name the part of the country, but there is one Healthwatch is facing a cut in its grant from its local authority from over £140000 pounds to £90000, and I am talking about a big city environment.
We are doing our best to persuade the local authority to change its mind, but what we are told is what they receive is a matter for them to allocate. Anything the Department of Health says is but guidance, and they have a number of other
priorities, which of course we will understand. But I personally fail to understand how any Healthwatch living in a big city environment can actually do anything effective at all at that level. That is not a…, that is probably the worst example I am aware of
at the moment, but there are many others and it is an area of significant concern to me, as I indicated in my letter notifying my retirement. I think we have just to go to keep pressing… That was a very public… pressing the button on that one. Let’s
take up a couple more questions. Mark Saxton. Thank you Chairman. Chris, thanks very much for coming in and briefing us on this report. As always with Healthwatch, it seems to me you go where the challenges are, so to hear about access, elective recovery, access
to dentistry, GP access, digital healthcare, these great reports to have. Just a couple of comments, if I may, one when you say that the largely negative feedback that you are hearing. Well this has a big impact on staff on the frontline and so, I
really hope that providers are listening to feedback from you because they need to support their members of staff on the frontline and help to build morale. So I think that is really important. The other point I would like to make, there is a heavy
emphasis on accessibility, be it the information standard, be it access to dentists or GP access, can I make another plea? One of your great reports in the past was on patient transport and access to treatment, and patient transport. It was an incredibly powerful report
and actually got ministerial action and I think, you know, when we are talking about elective recovery and people coming back to the system, is how they get to the system. And, you know, I have just asked whether we are going to do another report
on that, on the transport challenges which when you read some of those stories in that report, it was really, really challenging to read. So, I just hope that we, you can… well, that is in the plan for another future review? We don’t currently have
a plan for a flagship report on that non-emergency patient transport issue, but we do continue to engage with that…, with key stakeholders on an ongoing basis. Like a lot of the insight that we based that 2019 report on are still valid, and we know
that issues around patient transport were something that was a big issue during the pandemic and continues to be so. So, although, we might not see a flagship report like the 2019 report around that, you will continue to see interventions with us on the issue,
and we do continue to press the case behind the scene on non-emergency patient transport. Thanks Chris, and I forgot to say thanks to Robert for his leadership of Healthwatch from a member on the Board of the CQC, so thank you, Robert. Ian, you are on mute So, I have done it yet again. Again, so Mark
is still with us for a little while, so Robert is still with us for a little while yet, so we can save the speeches for later. Chris, last comment from you. Just to say Chris, thanks for a great report. I just wanted to press
that point about the partnership work. I think Healthwatch has been a really strong partner for us in our work, everything from urgent and emergency care, maternity services, ICSs and local authority, dentistry. And particularly as we move to State of Care, the work we will
be involved in the 5000 voices, where Chris’ team are providing case for the evidence of how people experience care across a pathway. I think that would be very…, going back to our earlier conversation, the point you made, Robert, about it is important to talk
about people’s experience of care, not just a series of numbers. I think that would be quite useful and powerful an issue as State of Care. So just a thanks to you and the team, Chris, for that support. Thank Chris and again, I do think,
you know, there’s strong relationships across the organisation, but I do know that Jacob and Ben who lead our (unintelligible) and Policy teams really do have strong linkages with your own teams. I think it’s a really mutually beneficial relationship. Thank you very much indeed everyone.
Chris, many thanks for standing in for Louise. Don’t take it the wrong way, we look forward to seeing her next time, but thank you for coming this time. I am happy to stand down the next time. Thanks for the great work. We note the
report, we also note the funding difficulties, so there will no doubt, one way or another, be a resolution of that, but thank you for the update we note that. We will close that session. That brings us almost to the end of the formal business.

Any other business

Can I just check with colleagues whether there is any other business points people want to raise? It doesn’t look like it. So, I think that is the end of the agenda. Just two other things, or one other subject heading. We do, as you know,
- and I am addressing this comment particularly to members of the public listening - but we do provide the opportunity to members of the public to pose questions to be addressed by the Board. We do have a couple, again from Robin Pike. I’ll take
them individually. The first was a question of how the CQC gain assurance that all patients in NHS hospitals are able to have visitors? Ian Trenholm, perhaps pass that to you in the first instance. Thanks Ian. And thank you, Robin for the question. Just a
couple of things to say there really. There is published guidance on the NHS England and Improvement websites entitled Visiting Healthcare and Inpatient Settings. That was published on the 8th March, I think the latest version is Version 4. It sets out the principles that hospitals
need to follow and there are four key points to that guidance: Providers are expected to facilitate visits in a risk-managed way; Visits should be accommodated for at least one hour a day, and ideally longer; there should be a maximum of two visitors at the
bedside, and where face-to-face visits are not practical, then virtual visits should be facilitated. Additionally, there is guidance for maternity services and that guidance was last updated on 1st April this year. That sets out that NHS providers of maternity services should facilitate pregnant women having
a support person of their choosing with them, at all antenatal, intrapartum and postnatal contacts; that support people and parents of babies on neonatal units are not considered to be visitors and should not be treated as such; they should be able to be there. There
are also recent government recommendations published on 14th April this year that visitors to hospitals should continue to wear a face covering. I know Robin also went on to ask how are we ensuring that hospitals are adhering to this. So these guidelines and recommendations and
the guidance recommendations have been updated in our inspection framework for acute core services which means when we go and look at acute core services, we take these guidelines into consideration. This means that when inspectors cross the threshold to inspect services, they are equipped with
the most up-to-date expectations around visiting arrangements and can seek assurance those are in place for adults, sorry for patients rather, and visitors. Where we have…, where we do have concerns, these are followed up by the local team conducting inspection, and additionally our national centre
that has been coding inquiries by sectors when contacts are around visiting issues. You will have heard Kate Terroni talk about this in relation to Adult Social Care sector, but we’re talking here about hospitals in particular and other NHS settings. Then between March and May
there are 122 visiting frequently-asked question enquiries, of which 7 related to hospitals so the majority are related to non-hospital settings. This information is always passed to the local team contributing to the wider, ongoing view of quality and safety of provision. So, I hope Robin,
you can see that it is something that do continue to take seriously and it links back to the guidance that NHS England produced on a national level. Thank you. Thanks very much Ian for that comprehensive response. And then the other question – I’ll take
in the first instance, but might ask Chris Day to add. The question said if the Commission decides to reduce the number of its public Board meetings to six a year, will it conduct some of its strategic meetings in public, as too parliamentary committees. It
is probably worth clarifying a number of things implied in that question. So, we have made the decision to reduce the number of meetings. To be quite clear though, we are not reducing public meetings at the expense of others. Like I think most, if not
all, arms-length bodies, we hold Board meetings part in public and part in private. The reduction applies to the Board meetings in total, so there will be a similar reduction in public and private. As I said previously, that was a recommendation from the Board Effectiveness
Review which is something we decided to accept. But I think, importantly, it does bring us very much in line with all the other ALBs that we have looked at. I think the vast majority have six meetings a year, some maybe one less, five for
example. So, I think this is just good practice that allows us time to do things between meetings which currently, I think, becomes a little bit difficult. We are planning for one meeting as soon as we finish the previous one, which was not effective. Compared
to parliamentary committees, to be clear my understanding of parliamentary committees is they meet in public only when there having witnesses giving testimony, so I think the comparison is not quite right. Therefore we are not proposing, to the extent, we have private meetings to in
some way open those up, but I do want to assure you that we are not, in any way, attempting to reduce the amount of what goes into the public domain. So we have, as part and parcel of this, also been looking at how transparent
we are as an organisation, to make sure that we are putting as much in the public domain, on a timely basis, as we can. And, Chris, you have been looking at this, so perhaps I’d ask you to add a couple of words. Sure. Thank
you Ian. So, we do alongside the Board, we have some regular contact points with both providers and people who use services. The first one mentioned today was is the External Strategic Advisory Group, which meets every six to eight weeks, and it looks at some
of the issues that CQC is seeking to drive on, both in terms of policy, in terms of what it does, but also how it improves care in health and social care. We bring together the voices of people who use services and the voices of
providers in those discussions, and I think they are very fruitful. But we also…, CQC uses a wide range of methods to engage people to build, what we feel are constructive two-way dialogues for people who use services and organisations. So, last year we engaged just
over 27500 thousand people in co-production activities, and so far this year we’ve engaged 14000. We use a combination of face-to-face and online process to do that, so I think our System Lab which allows us to develop and have conversations with people who use services
and providers together on particular topics. The views have been used recently to help us to, sort of, have a view on our role in improving safety in maternity, and also to design our new assessment framework. So, we will continue to deliver and work with
those areas, alongside our conversations at that Strategic Advisory Group level, in addition to the public Board meetings that you see. I hope that helps. Thank you very much indeed Chris, and obviously we will keep that under review. So, I hope that answered the two
questions. I think that brings everything to an end. For those of you listening by the webcast, I hope you have found the meeting interesting and useful. We hope that, RMT permitting, we will be able to hold our next meeting together as a Board in
Redman Place, but thank you very much indeed everybody.