CQC Board Meeting 27th September 2023 - Wednesday 27 September 2023, 1:30pm - Care Quality Commission

CQC Board Meeting 27th September 2023
Wednesday, 27th September 2023 at 1:30pm 

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  1. Ian Dilks
  2. Kate Terroni
  3. Ms. Kate Staples
  4. Ian Dilks
  5. Stephen Marston
  6. Ms. Kate Staples
  7. Ian Dilks
  8. Ms. Kate Staples
  9. Ian Dilks
  10. Mark Chakravarty
  11. Ms. Kate Staples
  12. Ian Dilks
  13. Kate Terroni
  14. Ian Dilks
  15. Joyce Frederick
  16. Ian Dilks
  17. Ali Hasan
  18. Ian Dilks
  19. Ms. Kate Staples
  20. Ian Dilks
  21. Mark Chambers
  22. Ian Dilks
  23. Ms. Kate Staples
  24. Ian Dilks
  25. Ms. Kate Staples
  26. Ian Dilks
  27. Mr David Croisdale-Appleby
  28. Chris Usher
  29. Mr David Croisdale-Appleby
  30. Ian Dilks
  31. Kate Terroni
  32. Ian Dilks
  33. Mr Mark Sutton
  34. Mr David Croisdale-Appleby
  35. Ian Dilks
  36. Kate Terroni
  37. Ian Dilks
  38. Drew Noble
  39. Ian Dilks
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  1. Mr Mark Sutton
  2. Ian Dilks
  3. Stephen Marston
  4. Mr Ian Trenholm
  5. Ian Dilks
  6. Mr Mark Sutton
  7. Mark Chambers
  8. Ian Dilks
  9. Mark Chakravarty
  10. Ian Dilks
  11. Mr David Croisdale-Appleby
  12. Mr David Croisdale-Appleby
  13. Ian Dilks
  14. Ian Dilks
  15. Mr Ian Trenholm
  16. Ian Dilks
  17. Mr Ian Trenholm
  18. Drew Noble
  19. Ian Dilks
  20. Ian Dilks
  21. Mr Ian Trenholm
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  1. Ian Dilks
  2. Christine Asbury
  3. Tyson Hepple
  4. Christine Asbury
  5. Mr David Croisdale-Appleby
  6. Mr Ian Trenholm
  7. James Bullion
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  1. Ian Dilks
  2. Christine Asbury
  3. Ian Dilks
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  1. Kate Terroni
  2. Chris Usher
  3. Ian Dilks
  4. Belinda Black
  5. Tyson Hepple
  6. Ian Dilks
  7. Christine Asbury
  8. Ian Dilks
  9. Kate Terroni
  10. Stephen Marston
  11. Ian Dilks
  12. Chris Usher
  13. Ian Dilks
  14. Chris Usher
  15. Ian Dilks
  16. Drew Noble
  17. Ian Dilks
  18. Kate Terroni
  19. Ian Dilks
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  1. Kate Terroni
  2. Mr David Croisdale-Appleby
  3. Stephen Marston
  4. Kate Terroni
  5. Ian Dilks
  6. Tyson Hepple
  7. Ian Dilks
  8. Drew Noble
  9. Tyson Hepple
  10. Mark Chakravarty
  11. James Bullion
  12. Ian Dilks
  13. Mr David Croisdale-Appleby
  14. Mark Chambers
  15. Ian Dilks
  16. Kate Terroni
  17. Mark Chambers
  18. Ian Dilks
  19. Chris Day
  20. Drew Noble
  21. Ian Dilks
  22. Christine Asbury
  23. Mr Ian Trenholm
  24. Belinda Black
  25. Ian Dilks
  26. Kate Terroni
  27. Ian Dilks
  28. Mr Ian Trenholm
  29. Ian Dilks
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  1. Kate Terroni
  2. Ian Dilks
  3. Tyson Hepple
  4. Ian Dilks
  5. Ali Hasan
  6. Ian Dilks
  7. Mr Mark Sutton
  8. Ian Dilks
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  1. Ian Dilks
  2. Ms. Kate Staples
  3. Christine Asbury
  4. Ms. Kate Staples
  5. Ian Dilks
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  1. Ms. Kate Staples
  2. Ian Dilks
  3. Ms. Kate Staples
  4. Mr David Croisdale-Appleby
  5. Ms. Kate Staples
  6. Mr David Croisdale-Appleby
  7. Ms. Kate Staples
  8. Ian Dilks
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  1. Belinda Black
  2. Chris Day
  3. Ian Dilks
  4. James Bullion
  5. Ian Dilks
  6. Joyce Frederick
  7. Mr David Croisdale-Appleby
  8. Ian Dilks
  9. Christine Asbury
  10. Ian Dilks
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  1. Belinda Black
  2. Ian Dilks
  3. James Bullion
  4. Stephen Marston
  5. Mr Ian Trenholm
  6. Christine Asbury
  7. Mr David Croisdale-Appleby
  8. Ian Dilks
  9. Ian Dilks
  10. Chris Usher
  11. Mr David Croisdale-Appleby
  12. Mr Jeremy Boss
  13. Ian Dilks
  14. Mark Chakravarty
  15. Chris Day
  16. Mark Chakravarty
  17. Ian Dilks
  18. Mr Jeremy Boss
  19. Mr Ian Trenholm
  20. Ian Dilks
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  1. Mr Jeremy Boss
  2. Nicola Wise
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  1. Ian Dilks
  2. Chris Day
  3. Ian Dilks
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  5. Ian Dilks
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  1. Webcast Finished

1.0 Opening matters

Mr Ian Dilks - 0:00:00
So, I failed my own test and the microphone was off, let me start again for the benefit of everybody. Welcome to colleagues around the Board table, a welcome to everybody joining us on the live stream or by later recording. This is to the public
Board Meeting of the Care Quality Commission on the 27th of September, Wednesday, 27th of September. So, we have a number of things on the agenda to cover this afternoon, we will try to keep moving reasonably quickly. I would like just to mention or clarify
one or two changes, or apologies. Sean O’Kelly is unable to be with us due to a minor operation, but we are delighted to welcome Nicola Wise who is Head of Inspections and will deputise for Sean today. As you regular listeners will know, or watchers
will know, we always have a representative from our Equalities Network, a representative from that group, so today we welcome Drew Noble from the LGBTQ+. I don’t think I have any other administrative arrangements to mention. So, just as a final administrative point, are there any
new conflicts of interest to declare? OK. And anything else people want to put on the agenda, urgent business or otherwise on the agenda? No, OK. So, let’s move straight away to a really very important topic which is the update on the Listening, Learning, Responding
to Concerns Review. As my board colleagues know and anybody watching in, we spent some time on a couple of sessions earlier this year, considering the outputs from the reports that were done and were presented by those responsible. We pulled together an analysis of the
actions that would be required by management to respond. So, the overwhelming theme is that the recommendations are accepted, but we need a little bit more granularity so that could be tracked. So, I think we are going to be Kate Terroni and Kate Staples presenting
Ms. Kate Terroni - 0:02:21
so, over to you. Thank you. So we’re almost six months since the publication of the Listening, Learning, Responding to Concerns Review, and this is our first opportunity to come back together as a group in public to update you all on progress against the significant
number of recommendations that were in the in the LLRC, which is how we describe Listening Learning, Responding to Concerns Review in a way that is slightly easier to articulate. So, the paper in front of you shows the work that Kate has been leading along
with other directors and colleagues in the organisation. It reflects areas where we have made good progress and it reflects areas where there is more work to do. You will note that there has been a huge amount of activity, but we are really keen as
an organisation that, as well as ticking things off the list that we have done, the required actions that we are also measuring and evaluating impact on kind of changes in culture as well, but without further ado, I will hand over to Kate to bring
Ms. Kate Staples - 0:03:18
highlights from the paper. Thank you, Kate. It bears repeating that the LLRC was a watershed moment for CQC. It was an opportunity for a long, hard look at the way we do things, the way we did things and, more importantly, it was an opportunity
for colleagues around this table to pause for thought and really commit to doing something to effect sustainable change. Those of you who are familiar with the detail of the recommendations will know that some are deeply practical, mechanistic things, relatively easy to achieve in a
short timeframe. Others are much more far-reaching and will require sustained effort over months and years, actually, to get launched and become part of the DNA of the organisation. The progress chart - you can see it at the last page of the report - gives
you a sense of where we now are. In putting that chart together, we have been careful to be honest, and I just want to dwell a little bit on a point that Kate made in her brief introduction about monitoring progress and making sure that
things are actually being delivered and being done. In the period since the paper was submitted, we – that is a group of us being led principally by Steph Tarrant in the Performance Team who has done a fantastic job - have been thinking about how
to hold ourselves to account for delivery. The way we propose to do that going forward is to ensure that each of the recommendations is mapped to one of our ET sub-committees which will own the responsibility of receiving regular updates on progress, but critically where
it is said that an action has been completed and an impact has been delivered, we will want evidence to be provided to that committee so that we can say yes, we agree, some sustainable and meaningful change has been delivered. So, we are going to
start rolling that out in the next few weeks. I think when next due at Board in November, so we should be able to give you an insight into how that is going. I also want to just highlight the “measure twice and cut once” phrase
that is in the paper. I want to highlight that because, given the importance and given the very resonant subject matter of some of the recommendations, particularly those about our racial fluency, and about reasonable adjustments for colleagues who need them, it is tempting to want
to rush to action and get something in place quickly. But the “measure twice and cut once” approach is specifically focused on making sure that when we act, we know that we are choosing the right course of action and something that will stick. So, in
terms of racial fluency for example, Tyson has done some wonderful work over the summer - and I have to sort of namecheck Blessing Hale as well from the network - in thinking long and hard about what sort of training and, frankly, challenge we need
around this table to look again at how we think about these things. That has yielded a really good design for a session that is going to be delivered, I think, on the 19th of October at SLT 30. So, it has taken a bit of
time to get there, but what is being promised, and what hopefully will come out of that session, is going to be all the more impactful as a consequence. Similarly on some of the more external-facing elements, Workstreams 1 and 5 which relate to whistleblowing from
the sectors and information coming into the organisation from outside - I’m going to name-check another group of people that is Hayley Moore, Jill Morrell, Helen Louwrens and Tracey Forester - all of them, in addition to busy portfolios of responsibility, have set aside time to
think about ways of bringing to life those workstreams. Some incremental improvements are already evident and there is a good flight path leading forward that will yield benefits. So, there has been a great slew of activity, much of it won’t have been visible to many
colleagues across the organisation, but it is being done and I am happy to take questions. So, questions for the Kates, anybody?
Mr Ian Dilks - 0:08:32
Stephen. Kate, firstly, thank you. I think it is really important and really helpful to have this sort of regular progress report. As you
Mr Stephen Marston - 0:08:51
said in your comments, this was a really important report for the Board, for the whole organisation and so it is critical that we do follow it up carefully, methodically and with real impact. So, a big thank you to you for all of that. The
other comment was just to sort of make the read across to the work that Kate Terroni is leading on culture change, because there were some very specific recommendations in LLRC, but there were also some quite general findings and conclusions about broader culture. So, I
think the work programme is not sort of unique and exclusive to LLRC. There are some really important broader developments going on around culture change and what it needs to mean for the organisation that I think will also deliver some of these recommendations as well.
So, we will need to sort of keep in touch with that as we go through.
Ms. Kate Staples - 0:09:52
Mr Ian Dilks - 0:09:54
Ms. Kate Staples - 0:09:55
Thank you. If I may? I mean you are right that the approach we took to implementing LLRC recommendations was not to make them something other, because that’s the fastest
way for them not to be effective, but to make them part and parcel of what we do, daily, on a daily basis. So, that has been happening certainly in relation to, for example, racial fluency where Nadia Rahman has been part of a little working
group that we have set up to make sure that all of the aspects of that work are moving forward in tandem and all pointing in the same direction. And similarly with culture, that things that are emerging in conversations about the way things are around
here are feeding into the work that Kate is leading on culture and the
Mr Ian Dilks - 0:10:45
nascent culture plan that Jackie Jackson has been preparing. Mark. So
Mark Chakravarty - 0:10:49
again, thank you, really valuable to see the progress. Probably, there would be two challenges that organisations face when they are
trying to make this degree of change. The first one is the gap between intent and action, and this really addresses that. There is a real action following the intent to sort of make that change. The second one is actually persistence. The only concern that
I would have about this being an action-based approach is that when the actions are done doesn’t mean the work is done. That’s only the beginning of the journey, not the end of it, so could you say a little bit more about how, other than
just the reporting that a change has been made and an impact has been had, how do we make sure that this then becomes that natural way of working and doesn’t snap back to older, more-established, deeper
Ms. Kate Staples - 0:11:36
behaviours? That is a very good question. I think,
to some extent, you can hardwire some of it in processes provided the processes align with human nature. The more the process and human nature are at odds, the less likely the process is to stick. I think it picks up a conversation that we were
having this morning about the extent to which we as individuals, particularly around this table, but also across the organisation, take the time to reflect and take the time to reflect particularly on what it is we need to do, and what it is we need
to stop doing, to make sure that things do change. So, it is both an organisational change in terms of systems and processes, but it is a collective and individual moment for reflection on responsibility to
Mr Ian Dilks - 0:12:43
behave as we ought to behave. The other Kate, do you want to come in? Just one thing
Ms. Kate Terroni - 0:12:46
to add, if I may? And Joyce might want to come in on this as well. So, obviously our commitment wasn’t just that we self-report on how we are doing, but that we have a proper evaluation around impact and that impact being embedded. That evaluation
is happening now, and it will come to a future Board as well, and some of the (unintelligible) are sitting on a team that reports to Joyce and we were having ongoing conversations with colleagues who helped us with the original report for that kind of
Mr Ian Dilks - 0:13:14
external challenge as well. Yes, just to add to that, the evaluation
Ms. Joyce Frederick - 0:13:16
looks at not just the data that you see in front of you, which is how we are delivering against those actions, but if they are embedded, what are the impact they have? There
is also the independent oversight built in as part of that evaluation, so we have the people who were involved in the original report coming back and helping us see are we actually making a difference. Because you are absolutely right, we could do some of
the actions, but it actually doesn’t make a difference on the ground. So, it is important that we look at that as well. Ali, and then Mark.
Mr Ian Dilks - 0:13:46
Mr Ali Hasan - 0:13:48
Thank you. It is really good to see the progress that we are making on this and thank you and the team
for your working for the clarity and candour that had been shared about how progress is continuing. It is also really positive and reassuring to hear that the focus is on making sure that things are done well, and they embed. I am interested to understand,
I suppose over the next six months or so, whether you see focus being equally spread across all of the different streams of what we are looking at, or whether there are particular areas where there will be
Mr Ian Dilks - 0:14:20
more attention given to? I think we will
Ms. Kate Staples - 0:14:23
need to be much more acute in prioritising because we know that we have got an awful lot on, as transformation continues, colleagues in operations groups will be changing the ways they work in the coming weeks and months. So, we need to be both realistic
and ambitious, and I think we need to be intentional about which areas we focus on to achieve progress, making sure that we always do make progress and don’t allow ourselves to sort of come to a standstill. It will be a combination of importance and
capacity and capability at any given moment. The paper refers to a relatively extended time period for rolling out elements of training on racial fluency, precisely to accommodate the need to do it properly across the whole of the organisation and take into account other aspects
Mr Ian Dilks - 0:15:30
of activity. I think Mark is next and then you, Belinda. Thank you. I
Mr Mark Chambers - 0:15:34
am very pleased to see this reporting. I am very encouraged by the candour of the chart on page 4. I think it is great to try to see that and have
the confidence to show where we are still quite a way from the target and where we are struggling to start the process of improvement. I think that is not surprising with such a range of recommendations, but it is really helpful to see this, and
it would be helpful to continue to see this. What is particularly encouraging, of course, is that there has been very good progress on learning, and there has been very good progress on listening. There is more green there than in the other columns and that
is a large part of what this whole exercise was about. Having said that, there is quite a lot of red still on there, where we know it’s going to take longer and it is going to be harder, I think one of the challenges of
aggregating 84 recommendations and reporting it in this format is that we lose a little bit of the colour about what is in the red, So, I think you are going to have to find a way of helping us to understand where really important things
that we are struggling to get traction or find a solution for, where those are. I am looking at Freedom to Speak Up, for example where it is pretty easy to make rapid progress on the low-hanging fruit, but actually really making, developing a true Speak-Up
culture, there is a lot of heavy lifting late on in the in the game in relation to that. We don’t want to end up with some red at the end of the day in relation to this, if we can start to help with that
process, that would be really good. My question was how are we communicating this internally because I suspect some of our colleagues internally will be seeing the same challenge of saying, well, you
Mr Ian Dilks - 0:17:52
know, what’s in the red, and what’s in the green? We have been
Ms. Kate Staples - 0:17:55
designing an approach that tries to take it thematically and deal with areas such that they get the attention they deserve, so Freedom to Speak Up is one that is getting a lot of focus and focus on the Let’s Talk conversation that Ian led last
week. Next month we will be focusing on racial fluency because it is Black History month partly, but also because there are lots of things coming on stream. So, we are doing it thematically and one of the things I have committed to is, after this
conversation today at Board, is to write a short article so that colleagues who aren’t watching today will know that we talked about it, we had a serious conversation, we will hear what the Board wants us to do and we will also have an up-to-date
version of where we are and an honest assessment of the work we still
Mr Ian Dilks - 0:19:03
Ms. Kate Staples - 0:19:04
have to do. Belinda. Thanks. I just wonder if you could explain the scoring to me Kate, I don’t really fully understand our moderate distance to target, I mean, how did you
arrive at those? They are, it is not algorithmic, it is judgment. It is a judgement made by the action owner in the first instance, tested occasionally to distraction by the Performance Management Team led by Steph. It is trying to get a sense of, are
we a couple of days away from completing it or is it months away? It is bit subjective, but it is designed to be subjective with a bit of
Mr Ian Dilks - 0:19:47
challenge. Thank you for that, thank you Kate, I appreciate it. In my view, organisational cultural changes
are much more about how we do things rather than just what we do or
Mr David Croisdale-Appleby - 0:20:08
what we don’t do, which is what you referred to and I’d like to see that aspect of how we do things incorporated really quickly into behaviours. I don’t see the
Chris Usher - 0:20:22
need to wait for a long time for that or to carry out a subsequent analysis or whatever, so I would just put that before you that that that is more important than, if you like, just the transactional
Mr David Croisdale-Appleby - 0:20:35
aspects. It is partly about ways of
working, but it is not just the technocratic parts of ways of working, it is the emotional part and the engagement with people, so I suppose I’m asking for your assurance that that could be addressed perhaps rather more quickly than you were suggesting in your
presentation. Kate, shall I… Are you alright if I go first and then
Mr Ian Dilks - 0:21:02
can I hand to Mark who might want to talk about Speak-Up? Thank you,
Ms. Kate Terroni - 0:21:07
David, for the question. So, Kate talked about this work plugging into the wider piece we are doing at
the moment around culture where we want to look at all aspects of how we work as an organisation, our values, our behaviours associated with those values and how we kind of plug expectations in at all points and in the way that we work together.
So, that is an activity that is under way at the moment, that will take place in the next couple of months. So, this is not a long piece of work. This is a piece of work that is starting now, and this work will touch
on some of the stuff you see in the Pulse Survey around how we work together as an organisation, as well as the ambitions and progress we are making around Freedom to Speak Up also. So, this is very much at the heart of our cultural
Mr Ian Dilks - 0:21:56
plan that Board will be seeing in November. Thanks Kate. Mark. Thank
Mr Mark Sutton - 0:22:01
you. I agree with your statement there, David, that the engagement part of this is critically important and we can start doing that. I won’t talk about Speak Up because that’s the next agenda
item, but if I speak about reasonable adjustments. Together with our colleagues in the Disability Equality Network, we have already started, in fact nearly completed, the engagement piece around reasonable adjustments. What we have done is, we have seconded one of our colleagues from the inspection
community to spend time with a significant number of colleagues across the organisation who are in need of reasonable adjustments. Just to really deeply understand what are the challenges that people are experiencing and what it is that would actually transform their experience of working at
a CQC and that is a process that is almost complete now and it will inform and embed the work the way that we’re doing as a follow-up to that, to exactly Kate’s point about “measuring twice and cutting once” but that can happen quickly. If
I may, just briefly come back on that Chair? Kate, I understand that this is part of a much bigger process, but you know, on the basis that
Mr David Croisdale-Appleby - 0:23:17
the longest journey starts with the next step that you take, or the first step, it does seem
to me that we have a lot of information that we’ve gathered already that could indicate changes that could be made pretty well straight away that really would not be contentious. They would demonstrate the importance that you are clearly taking, but it would be more
obvious perhaps to everyone that culture is so important and those immediate changes, not tomorrow, but certainly in a matter of weeks, would be an important indicator to the internal staff about the way in which we are moving in this direction, rather than just waiting
Mr Ian Dilks - 0:24:02
until you know there is a have a very complete framework. So, I agree, but also, I would point to the example that Mark has given. We are not
Ms. Kate Terroni - 0:24:05
waiting for a cultural plan to get on and make the changes in the organisation that the
LLRC talked about. So, LLRC said we could do a lot better with how we support colleagues who have additional needs when it comes to interviews, when it comes to supporting them to work well at CQC. So, that activity has been progressing at pace, so
there is - and when you get into the detail of this report - there is a wealth of activity that has already happened and is making a difference. What is to be discussed further, and you will see, is how that all draws together into
the bigger cultural plan, but we’re not waiting for that to get on and
Mr Ian Dilks - 0:24:45
take some of the actions that are in the report. Thanks, David. I had a couple of questions, ones that have already been dealt with. But Drew, can I just turn to
you? Kate made the observation, this Kate made the observation earlier - that is working with our networks - I think I saw you nodding. But
Drew Noble - 0:25:04
do you have any comments on that? Sorry, I think we would like to express our thanks that we have
been involved to date as one of the workstreams that are part of the LLRC findings. I think we have had some really meaningful conversations, certainly the work that has been alluded to in regard to reasonable adjustments is one of many conversations that we’ve had
around this. It is a great demonstration of colleagues from (unintelligible) communities being given a platform to share what it’s like to work at CQC, some of the challenges that are faced, but also how we can improve the way that we regulate and monitor services
as well. So, I am really thankful for the opportunity to do so and wish to continue to build upon the foundations have been set. Thanks
Mr Ian Dilks - 0:25:47
very much Drew. I was going to ask anyway, but it seems to me to some extent it relates to
David’s question as well. I mean, I think commend the Senior Executive, I think one of the changes we have seen over the last several months is greater engagement with and use of organisations like the Networks. I think that is great and to your point
David, you know, we didn’t wait for the plan, or the management didn’t wait for the plan to start doing that. I think it’s a good example of a step that’s being taken. The other question I was going to ask – I think it has
probably been dealt with- so, I will frame it more as an action for the future, but I think it is great the way you have done the detailed summary. You know, it helps keep everybody honest, the having committed to a number of actions, we
haven’t just sent it away, it’s there, it’s visible. But at the same time, we have got to make sure that we don’t lose sight of the wood for the trees here. The big picture – we have an overall aim we are trying to achieve,
so it is probably related to the point earlier about which of these things are most important. But I think as we come back, of course, do keep on with the rather more granular assessment because unless we can do that, we can’t demonstrate to people
that we have done what we said we would do. But it would be very helpful as well to have some sort of high-level qualitative assessment as I said, and having done all of this, are we actually achieving what it is we set to do?
Not easy, I know, but I think that would be very helpful at some stage. It will of course be informed by other things we will be seeing like Pulse Surveys, but I think it would be helpful. Unless there’s any other questions, let’s move on.

1.1 Chair’s opening remarks, Apologies and Forward View

2.2 Freedom to Speak Up Update

Kate, in particular Staples, thanks so much for that. We now have…, are moving onto Freedom to Speak update - something to approve. So, Mark I think this is with you, and are we joined by Carolyn Jackson, Jenkinson? We thought we were going to be
joined by Carolyn. Hi Carolyn, welcome. So, I’d just introduce the topic. Mark over to you. Thank you very much and welcome Carolyn I
Mr Mark Sutton - 0:28:20
just wanted to introduce by saying that this Freedom to Speak Up agenda is incredibly important. I am the executive sponsor for
Freedom to Speak Up. What Carolyn is going to talk about in a little bit here is about our improvement plan that we have got to support improvements in our Freedom to Speak Up capability. This is work that we have spent a bit of time
ratifying with the National Guardian’s office. I think, to the point that we talked about just now about “measuring twice and cutting once”, we are taking a little bit of time to make sure that we get this right and we don’t rush to action too
quickly. There is work that is ongoing but I think it is important that we take that time (inaudible) conversation we had earlier on this morning was, I think the really key element of Freedom to Speak Up is about how we engage with the organisation,
how we listen to our colleagues and we have got a number of actions that Carolyn and I are taking to ensure that we really listen to the organisation to understand what is important to our colleagues, but I’ll hand over to Carolyn for a fuller
update. Thank you, Mark. (inaudible) So, thank you, everybody. I mean we continuing to do as much work as we can on raising awareness about Freedom to Speak Up and as you will have read in the paper, we want to get some additional resources so
that we can them be more proactive with the work we do because most of the work that I do it is more reactive at work. So, responding to people when they come to me and we want to be able to, you know, obviously, do
far more proactive work. So, our group was hoping that you would approve the paper, they ask for additional resource and we would move on that. I have been very supported by Mark; it has made a huge difference actually having Mark as Exec Sponsor for
this work. It is Freedom to Speak Up month next month. Ian and myself and Mark, we led an all-staff call last week about Freedom to Speak Up and actually some of the feedback that I’ve had from that has been positive. I think staff want
to see more of the Executive Team talking about Freedom to Speak Up and what they think about being able to raise issues that they want to talk about. I mean, Ian does a lot of that work in his (unintelligible) conversations, but Mark and I
plan to do a bit more and we have got a bit of a plan to do a sort of a national roadshow if you like, to try and reach out to more people and to encourage people to come and talk to us. So, has
Mr Ian Dilks - 0:31:13
anybody got any questions at the moment? Questions? Stephen. Firstly, very much welcome the paper and all the work that you have done Caroline and Mark. I hope we will approve the increase in resource, I
Mr Stephen Marston - 0:31:26
think it is important and indeed chatting to Mark earlier, it’s
very hard to know how much resource is going to be enough, because we don’t really know how much unpent demand there may be in the organisation to have a Freedom to Speak Up Guardian that people can talk to. But I hope we can work
on the basis that if we agree this is the next step, then you know we will keep it under review, so that, you know, we don’t overload the two additional Freedom to Speak Up Guardians if it turns out that they are kept very busy.
So very much welcome that. The other point that I wanted to make is that this is very closely related to the finding in the Staff Survey about feeling safe to challenge the way things are done here, which I think we’d all recognise is a
poor result. You know it is a very low rating from staff in the organisation about feeling it is safe to speak up. This set of interventions, the appointment of two new additional guardians working with Carolyn is a really important response to that, as well
as to the recommendations of the LLRC Report. The final point I would make is that this mustn’t be instead of a wider culture in which managers also are receptive to concerns. If you like, the big risk in creating identified colleagues who are Freedom to
Speak Up Guardians is that other people feel, well in that case, I don’t need to bother. Actually, this has to be in addition to a culture in which managers are open to hearing, really actively hearing concerns, worries, problems, whistleblowing cases from staff and their
team members. So, this is a reinforcement of a of a culture that encourages people to speak up whenever they see problems, issues, concerns that they have, it’s not instead of. Thanks. I think Stephen makes a great point. I think it was a conversation that
myself, Caroline and Mark had on our all-colleague calls last week was, there is something here for me about the concept and the process,
Mr Ian Trenholm - 0:34:02
so in terms of numbers of people and numbers of Speak Up Guardians, which is part of the process almost. But conceptually,
I think you make a really good point that, you know, if you are succeeding at a Speak Up culture in the organisation, you almost don’t need a Speak Up Guardian because your line managers are having routine conversations. I think, you know, we know from
work we have done things like QI programs and other improvement work, people are just saying I think it would be good if we did this in a different way and people are being listened to and managers are working constructively with their teams. Equally, I
hear frequently examples where an individual has had a particular problem with something, and they have praised their manager for the way in which the manager has stepped in and been constructive. So, in some respects, the Guardian is almost the exception handler in this. I
am kind of hoping that what we’ve got at the table is proportionate. I think if it is not proportionate, then we will look again at it and that is part of the reason why we have got an Executive Sponsor in the form of Mark.
We have had guardians before but have that sort of top-level support that Mark is offering Carolyn. So, I think we have got a good process here, but it sits on top of, I think, what is already, you know, an OK set of things. But
I think we just need to examine that some more and we need to just be very thoughtful about if we are seeing increases, why are we seeing increases and that might mean more guardians or it might mean, let’s look at the broader cultural work
we are doing and the support we are giving for managers, and maybe there’s a different response. I think it is absolutely the right
Mr Ian Dilks - 0:35:42
point. Mark. Thank you. I strongly support this and thank you for your help and support so far in relation to this.
I am glad that there is more resource coming to help you. I think I’m
Mr Mark Sutton - 0:35:56
Mr Mark Chambers - 0:36:00
also glad that you’ve addressed the administration and support as well because we want our guardians listening and acting on concerns, not dealing with admin, and we know that… I know,
Drew, that for our network colleagues, one of the challenges is admin support for what they do. So, anyone who is doing something in addition to their day job, it’s important to cover the admin support. I think we have really got to be great at
this. You know, if our model of regulation is increasingly about listening to feedback and ensuring that people are comfortable raising their concerns with us, then we have got to be exemplars in how we do this internally. The two big barriers are always fear and
futility, and I think we have got to be careful that futility is an easy one to deal with, or at least an easy one to deal with superficially because you can just do lots of (unintelligible) about how you have listened and acted on what
you’ve been told. Fear is deeply cultural and the controls and protections that you need in place to ensure that people don’t suffer detriment 12 months on when it comes to the end of a performance cycle, or they are not turned down for another job
two years on when they are applying for a move within the organisation. Those things are really hard to track, and I suspect quite a lot of those will be some of the red issues that we get to in the LLRC actions as well. But
it’s really important to for us to do that, it is really important for us to deliver on everything in that in that action that relates to this theme amongst the 84 recommendations in the LLRC. It is really important that we continue to give you
the support that you need. So, I guess you know, I am hoping that we are going to work out how we can see more of you and hear more from you, or as another triangulation point for us in terms of judging how much progress
Mr Ian Dilks - 0:38:28
we are making on that journey. Other Mark So, one quick comment, and
Mark Chakravarty - 0:38:31
it probably relates between the three items we’re discussing here - Freedom to Speak Up, psychological safety and then a broader cultural conversation, It is also just an acknowledgment that we’re doing this
in an unusual timing coming out of the back of COVID, the disruption that that has caused with changes in the way of working, and also a fact that we have always had a dispersed organisation and it will remain dispersed with hybrid working. So, creating
that psychological safety, that trust in a hybrid environment might require different actions for doing that than if you are all in the same physical space. So, there’s maybe also - as you’re adding the resources in - it would be good to see if you
are already thinking about how they can actually touch an organisation that is dispersed, that works in a hybrid way. What are those day-to-day behaviours that we can implement that changes that sense of
Mr Ian Dilks - 0:39:24
trust and safety? I think it is a comment rather than a
question unless you wish to… David. Thank you Chair. In your brief presentation, which I thank you, you mentioned about becoming
Mr David Croisdale-Appleby - 0:39:35
proactive rather than merely reactive. It seemed to me an important part of that, following on what Mark said earlier about fear and futility being
two great concerns, there is the actual ability of people to be sufficiently self-confident to actually bring these things forward and I’m not quite sure reading the paper how we’re going to address that. I mean, people do come forward. I do… I mean although I say that the majority
of the work that we do is reactive, that’s because we spend most of the time just you know dealing with people when they have come forward for support. But we do go back and check with people as well, to make sure that they have
not… they don’t feel that they have suffered any detriment from speaking up. That is more of an informal follow-up. We don’t do anything…, very formal monitoring. Thank you. I understand that point. My point really was slightly different to that. It was saying that, you
know, at any level in an organisation from shopfloor to Board, whatever, there are those individuals who feel more self-confident about speaking up than others, and there is a danger in any organisation that you listen to the people who come forward and do that. There
is then either a significant minority or a substantial majority, one doesn’t know, who are not coming forward because they don’t feel the self-confidence to do that, in addition to the points that Mark has raised about fear and futility., but there is that aspect. Now
Mr David Croisdale-Appleby - 0:41:15
for this to be really effective, I think we need to think about how best we can address them. Yes, completely. And some of the things that
Mr Ian Dilks - 0:41:26
we do, I mean yesterday I went to one of the networks, on their all-staff call, did a presentation about
what Freedom to Speak Up is, how you can talk to me, the sorts of things that you might want to come and raise, we talked about going to your line manager. So, we try to raise awareness in a lot of different ways and the
other thing that we - I say we because there are some Freedom to Speak Up ambassadors that help and support a bit - but if we get some intelligence as well. I mean, you know, I am an inspector by background, so if I get
a little sense that something might not be quite right, we will seek people out a little bit, to a certain extent. I mean, obviously, we can’t just be doing that all of the time, but sometimes people just need that little bit of support. So
Mr Ian Dilks - 0:42:19
yes, very aware of that. Thanks David. Can I just come in on the back of that? I think to answer your kind of underlying question, David. I
Mr Ian Trenholm - 0:42:23
think it is not entirely Carolyn’s job. I think Carolyn can talk to the Freedom to Speak Up
part, but I do think, you know, what we are doing is looking for ways to design in opportunities that people can talk about things. So, if we look at transformation, for example, we are creating opportunities for inspectors to be part of the design team
where the designers are working alongside inspectors in real time. When we have gone live with our first release, we have listened to what was being said, we have recycled that information back in. I run a series of curious conversations which are groups of about
10 people where we just sit and talk about issues that they want to talk about. I know a number of other colleagues run similar calls or face-to-face meetings. So, we try and create those spaces where people feel that confidence to speak up about whatever
it is that they want to talk about. I think, you know, it would be fair to say that if I think back to my own experience, you know when I was 25, 30 years of age in my first job, I would not have e-mailed
the Chief Constable of Surrey Police to tell him what I thought, but I probably would have spoken up if something was genuinely dangerous or illegal. So, I think there is something here about creating a series of opportunities for people to talk about a range
of things which is what we are trying to build into the range of engagement mechanisms and the Speak Up Guardian process is kind of an important component of that, but there is a lot of other things, I think, that go into that. This whole
Mr Ian Dilks - 0:43:57
Mr Ian Trenholm - 0:43:58
issue of culture change, this whole issue of people development, is really important because we do need our inspectors, in particular, to have the self-confidence to call out things that they see when they are on inspection. I think that building of self-confidence is part of
our overall organisational development activity, so I think it is a big package of things. Drew, you wanted to comment. Thank you, and Caroline, thank you for the work you have done to date on this. We, as
Drew Noble - 0:44:24
Chairs, handle some matters of concern. We share
themes and trends with our Executive Sponsors, and we signpost to people the Speak Up process where appropriate. Recognising the comments that colleagues have raised in regards to the level of fear and futility, I wonder if, actually, there is, recognising the trusted position that we
have within our own communities, more of a duty for the Chairs and Co-chairs to do more with you and with the programme to better support our colleagues in providing a conduit for colleagues to share concerns. Yes. I mean absolutely Drew, that is one of
the things when we get more capacity, we will be able to do. No comments from others, just one from me, and also a way of summary.
Mr Ian Dilks - 0:45:14
I mean there is obviously… - thank you very much for the papers - there is obviously huge, widespread agreement. We know it is going to cost, but
that is absolutely essential, this is important so no problem with that. The point is being made that this is a step, a bit of a guess if this is right, so we will come back and look at it again. In that context, just to
say, I mean a different way of saying the point, Ian, (unintelligible) made that if you got the culture perfectly right, there wouldn’t be any need for any of this. So, I suppose I would liken it to using risk management, speak through a second line
of defence. You know if something is not going right, there is a way that people can get their voice heard in another way. It would be completely naive to think that we will get to the stage of no reporting. I mean an immediate response
from any Board I have ever sat on is if there is no speaking up, there is something wrong with the process, not that the organisation is perfect. So, we work on the assumption that we will be reporting. What would be really helpful from you,
I think, is to understand and report back to the Board on themes emerging as to why it is that people felt it was necessary to do that. Because I think that will instruct, maybe it will input to culture, but also some of the process
things we are talking about. So, it will be really helpful in a year, 6 to 12 months when this comes back, to understand what you’re learning and why it is that people felt it necessary to use that approach as opposed to all the other
stages that Ian talked about. So, thank you very much indeed for the work, Mark. Thanks for that, we know it has been well-appreciated and I do appreciate your feedback on these things as well Drew, so thanks
Mr Ian Dilks - 0:47:01
for that. So, Ian, we have a couple
of papers from you and your team, so I will hand things over to you. Thanks Ian. If I could just try and talk to both papers, perhaps at
Mr Ian Trenholm - 0:47:15
the same time, and then colleagues can answer questions, either I or colleagues will answer questions. On one
level, I would like to sort of apologise for the length of the papers in the pack, but I think it does talk to the fact there is quite a lot going on at the moment. I think there is a significant amount of work that
we are doing in the wider world. We have got a wider world which is very much under pressure. I think what we are seeing that translating to is, as we see the sectors that we regulate under pressure, we are seeing increases in the amount

3.0 Reporting updates

of risk that is there. We are seeing increases in the amount of enforcement notices that we have to issue, increases in the amount of things like safeguarding activity and exploring that, for inspectors to explore that takes time and takes energy to do. The work,
I think, also as a consequence of that, is becoming more complex and what we are continuing to try and do is to balance speaking for those that use services with making sure that we are trying to take into account the context in which people
are trying to deliver services. I think that is a constant challenge for us to… (inaudible) things at the same time. Challenges like workforce availability in services are a big issue, I think the cost-of-living crisis in sectors that are high users of power, food and
industrial consumables again are placing enormous financial and practical pressure on those who are delivering services. We have got a number of things on our agenda that talk to that. But I think we have a series of pieces of work in our report, things like
the national maternity programme, urgent and emergency care, dementia care, intermediate care, services for learning disabled and autistic people. They are all aimed at balancing our inspection and assurance work with making contributions towards improvement. I think, you know, when we talk about our strategy, we
talk a lot about making a contribution to improvement in all of our transformation work is trying to make us more effective in that space. So, we are trying to make sure that we are true to our core purpose of providing the public with assurance,
as well as promoting improvement. Alongside all of this our pilot work on local authority assurance and integrated care system assessment is continuing. That is, stating the obvious, one of the largest expanses of our powers since we came into being as an organisation over a
decade ago. We are looking forward to welcoming 190 new colleagues from the MNSI programme which is currently hosted within the Health Service Investigation branch. They are coming across to us on the 1st of October. I think that is a real opportunity for us. I
think it is an area, maternity is an area that we have identified repeatedly in various State of Care Reports as being an area that we have significant concern on. I think bringing the investigation capability across to us and bringing our ability to collaborate together,
both for the work that the MNSI team are doing, plus the work we are doing, I think, offers a real opportunity for us to improve safety in maternity services. We have gone live with our first really important release of our new regulatory approach and
will be continuing further releases during October, including opening up the provider portal. We said for a long time that we want to make ourselves easier to do business with, providers constantly tell us that sending us paperwork and just dealing with us is hard. We
know that opening up the portal will make all of that much easier. It will also mean that from a reporting point of view, internally and externally, that will also improve. We have had some really constructive conversations with our trade unions. Over the last few
months, we have resolved both last year’s pay dispute and also we have made sure that we have been able to give our colleagues a good pay rise this year as well. I am really grateful to the constructive way in which trade union colleagues have
talked to us on a range of topics and I am looking forward to working with them closely over the coming year as we think about our pay scheme in the future. I say all of this really just to make the point that we are
at a point in in our development as an organisation. It is probably, arguably, one of the busiest times we have ever seen. We are transforming the organisation. We are trying to make sure that we are doing our day job, as it were, in an
environment which, externally, is pretty tough. I just wanted to make sure that we were all, as a Board, completely sighted on that. I think, having said all of that though, I think the importance of all of this is that the work that we are
doing will put us, as an organisation, on a much more sustainable footing. It will mean that we are making investments for the medium-term. I think there is always the always the risk of this at this time of year and at a point where we
are seeing such busyness externally, to focus on the here and now. I think what we are trying to do is pull off that really difficult trick of focusing on the here and now, as well as making sure we are making investments for the future,
whether that is in technology, whether that is in terms of organisational design, whether that is in terms of culture, which is obviously a conversation that we have just been having. So, I think lots of important items on the agenda, lots of important pieces of
work in the report. I am happy to take questions and obviously colleagues can contribute as well. Thank you. OK thanks. Christine.
Mr Ian Dilks - 0:53:27
Ms. Christine Asbury - 0:53:33
Thank you. I had a question on Page 24 about Key Result 2, and it is partly a clarification and partly a question, and
I think I might have raised this before anyway. It states that 85% of inspections this financial year were triggered by risk and then in the colour-coded section further on, it says that the target of increasing inspections triggered by risk is not met. So, I
just wanted to understand, and I do appreciate that either. risks are increasing or we are identifying them better - I don’t know which of those two things probably a combination - but what is the target? Given that we are trying to increase the number
of risk-triggered inspections, what…, how are we going to…, what is the strategy around regulating and identifying good and outstanding practice? Chris will correct me if I have got this wrong, but I think the measure is increasing from the percentage from last year and whilst
Mr Tyson Hepple - 0:54:31
we’re at 85% this year, I think last year we were slightly higher, so that is why the measure in the business plan is not met, although 85% is still a lot of risk. At the moment, as we are going through going through the…, sort
of hopefully the end stages of our transformation programme, we are particularly focused on risk at the moment. But I think there will be discussions about how we how we operate during the winter because last year the Adult Social Care colleagues did a lot of
increasing capacity inspections during the winter. But also, I think, as we look to adopt our Single Assessment Framework going into the new year, I think that we will be much more agile then when it comes to looking at good providers and then judging whether
they are “outstanding, or indeed “requires improvement” providers who are good. So, I think our focus on risk will continue in the immediate term, but the performance measure was slightly down on last year. I think that’s right, Chris? Answer your question then, Christine? Any other
Ms. Christine Asbury - 0:55:33
questions? David. If I may, Chair it is really a comment to Ian. Ian,
Mr David Croisdale-Appleby - 0:55:39
I think you passed rather quickly over the fact that you successfully resolved the pay situation and I think it is worth commenting that that is a great achievement, and you know you did it sort of (unintelligible) really. It
is tremendous to do that. Most organisation that are comparable to ours have not had that success. I just think congratulations should be given to you and your team in bringing that off. Thanks David. I think our colleague, Jackie Jackson who is our Director of
Mr Ian Trenholm - 0:56:13
People really deserves the credit for that. Jackie has done a lot of work with colleagues in the trade unions, but also, I think there is some credit to our trade union colleagues for coming to the table. It takes two to tango, I think, and
I feel they have been very constructive recently as well, which has been really helpful. Yes, but it is a great success. Thank you. I appreciate it. James. Thank you, Chair. I wanted to amplify the point
Mr James Bullion - 0:56:37
at this Board, we, between now and our next
Board in November, we will conclude the pilot stages for our Local Authority Assurance Assessment. So, we have completed the fieldwork in five of those, and we are now at that stage of writing reports with indicative ratings and sharing those with the local authorities. Following
that will be in discussions with DHSC about us moving formally from pilot mode into delivery mode. So, it has been a significant amount of work to get to an organisational design to deliver that. We are on track to deliver that, and it looks as
if our methodology and our quality statements that we have used have got to the heart of whether a local authority is implementing the Care Act or not, and the feedback from the councils involved has been positive. They have all felt as if our process

3.1 Report from the Executive Team

had an anticipatory impact on them looking at their own services and the quality of people’s experience. It has been very successful at bringing in the voice of lived experience in those areas, with independent meetings with those people really bringing their voice through. So, I
think we can assure ourselves as a Board that actually this process and this new significant duty Ian was outlining is of significance and will be a weighty amount of work. The other point I wanted to make is that both the LA work and the
ICS work gets us back into systems work and so some of the questions that are raised in the Update Insights Paper about dementia or intermediate care, we now have an opportunity at system level to start asking those questions. So, it is really a significant
moment for CQC and moving into this territory between now and Christmas time. Thank you. Thanks very much for the update, James, and
Mr Ian Dilks - 0:58:42
no doubt we will be hearing more at the next meeting or before. I mean, I suppose we have to accept the fact
that the local authorities were positive, to some extent self-selected through the pilots. But let’s not detract from the progress. What I found particularly pleasing was the anticipatory element because I think a big shift or certainly (unintelligible), to say, make sure we are doing that
our work in a way that encourages improvement. So, if the sheer fact of this coming up is requiring people to look again at what they are doing and do things better, I mean that is the real win for the system isn’t it? Rather than
the fact that ultimately out of this they may get a rating. Christine. Thanks. I just wanted to amplify that again because my son happens to
Ms. Christine Asbury - 0:59:26
be a community activist worker in the north-west, and he told me that the moment the local authority assessments were
introduced, he saw a change in the local authorities he is working with. So, it is felt from both sides, not just from local authorities saying they are doing it, but actually from people working within the community. So, either that is very positive really and
it shows that there is an impact on improvement. It turned into a mini self-congratulatory session, but thanks very much James. Well done.
Mr Ian Dilks - 0:59:55
Any other questions Ian? OK. Ian, I mean you covered a huge amount in your oral update, and I think we get the
point that there is a huge amount going on. In some ways it makes summer a critical time for this organisation because there’s a few things are going to get slightly worse. We were through a period of a few things peaking and going down, but

3.2 Corporate Performance report (including Transformation Update)

just at the moment everyone is very busy so well done. I think, we will move on to the Corporate Performance Report and so, Kate Terroni, I will hand to you in a moment, and Mark Sutton and Chris Usher. I think we are going to
invite Stephanie Tarrant for your team, Chris, to join us. Welcome Stephanie. Whatever we discuss or agree, we end up giving all the hard work to you anyway, so it probably makes sense that you join us. Right, Kate, I’ll hand over to you. Thank you.
So, I am presenting to you today performance of the first quarter of
Ms. Kate Terroni - 1:00:51
this financial year 23-24. I am going to hand over to Chris shortly, talk you through the Performance Report and an update on finance, and we have got Steph here to support us
with questions and then Chris will hand back to me where I will just walk you through the final page in the pack. It talks about risks that exceed tolerance and I am just going to give Board a brief update on where we are with
those red risks that exceed tolerance. But I will hand over to Chris now. Thanks Kate. So, this our quarter one finance report, including
Chris Usher - 1:01:20
July where possible, acknowledging there wasn’t a Board in August. There is a lot in here, so I will just run through
some headlines, and it is also a new format report that we have included in this return. So, we have chunked this up by the strategy themes, so just looking under people and communities. So, the Key Result 1, which is Safeguarding Alerts and Whistleblowing, so
we have met some of our corporate KPIs however, as the report shows, we have not met our target. This is primarily due to a temporary issue following the go-live of a contact service in July, largely relating to our ability to refer Priority 1 Safeguarding
Alerts to local authorities. I am pleased to say that was resolved at pace and levels are now back where expected, but for this reporting period that is shown it is not met. There is a similar story, if you like, in NCSC response times in
in the first quarter. NCSC was exceeding all targets, however, in July. We have seen a dip in performance on safeguarding and mental health outlines, again, largely due to the impact of our contacts service roll-out. We have seen improvement from that point, and we are
now close to, if not on target again, so both those areas just had a dip in performances, as you say. Just moving further ahead, Key Result 2, just under our smarter regulation theme, sorry, people in communities’ theme. For the year, in July, 16% of
our inspections have been carried out based on people’s experience and feedback, so I think this is an important demonstration just in the impact of people’s feedback on our approach. Yes, we will inspect based on risk, but in 16% of occasions we have actually responded
directly to the feedback we have had from the public, kind of demonstrating how this really informs our approach and how we are able to adapt. I was going to talk about inspections triggered by risk, but I will not touch on that because we have
just covered that, so I’ll skate on for now. In terms of out-of-hours inspections, just moving on to our next theme on smarter regulation, so we aim for 10% of site visits to be undertaken out-of-hours. We are seeing progress in this area, we are currently
at 10.2%, we were at 9.2% last year. It is worth noting with this measure that there is still work to do on defining kind of out-of-hours and what our definition of that is and that will help and enhance our reporting around this. But as
the measure stands in the business plan, we are showing well, we are meeting the target that we set out. On Key Result 7 which is around registration applications, currently, 29% of registration applications are over 10 weeks old in the system. That is an increase
from last year, so we are aiming to reduce that, but currently that is proving a challenge. It is worth noting, though, that the volume of applications received is increasing, increased by 7.8% from that period. So, it is a story of a larger backlog, but
with increased volumes as context. Just moving on to some of our key results around protected characteristics, so Key Result 17, we have seen good progress in this space. So, we are aiming to increase the percentage of colleagues with protected characteristics, so colleagues of minority
and ethnic origin has increased from 14.7% at the end of 22-23 Quarter 4 to 14.9% year to date. Similarly, those declaring a disability has increased from 10.8% to 11.7 over the same period, so both heading in the right direction. However, we are seeing a
challenge in moving, nudging the dial, if you like, on those colleagues reporting protected characteristics which is Key Result 18. That has kind of stayed steady through each month of the year, so more work to do in that space. We have included a couple of
pages on milestones. So, we have a number of milestones within our business plan, some have other interdependencies with the wider transformation, both in rolling out our Single Assessment Framework as well as our new regulatory platform. It shows some progress we have made, but in
a number of areas there is more work to do which links to a lot of the key results I have talked about. I will not touch on risk because Kate referenced that she would come back to that. There are seven risks that are currently
outside of our, exceeding our tolerance that we set which I will hold on talking to. So, if I just finish with our finances. At the end of July, there is a 1.3 million surplus on revenue expenditure, we are currently forecasting a 3.7 million deficit
for the year. This includes 1.9 million of work that is currently unfunded in relation to our COVID inquiry. The remaining pressures relate to pay agreements which have been handled in year, not part of budget setting. So, we are kind of actively looking to mitigate
those pressures. Our capital budget is 1.8 million overspent for the year to July, that is forecast currently to be 1.4 million by the end of the year, but current indications are that will increase, and we will see that overspend increase by the time we
report on this next time. I will pause there if you want to touch on risk and open up now for any questions from anyone. If we…, we will take risk separately, that was the question I asked and we will come back to that outside
Mr Ian Dilks - 1:07:17
tolerance, but questions on any other aspect of the report? Belinda.
Mrs Belinda Black - 1:07:28
Thanks. I am back to my out-of-hours again. For me, an out-of-hours inspection is not one that starts in hours and finishes after out of hours, I have probably said that at every Board meeting when we
have ever spoke about out-of-hours, I’ll say again. But I know that you were looking at things, Tyson, about genuine out-of-hours over weekends, nights, bank holidays, that type of thing. I think you thought that might be concluded around October time with the unions, to see
people properly supported and paid for doing that type of work, I just wondered if you could give us an update on that. No, no, very happy to Belinda. The work has been a bit delayed for reasons I won’t go into, but I am confident
Mr Tyson Hepple - 1:08:09
that we will put some momentum behind it, and I’m sure we will talk about at the regulatory governance committee meeting in a couple of weeks’ time. We are still talking to the unions about it. We are looking at the health and safety aspects and
the remuneration aspects. When that goes live, we will then adopt the new definition and the new definition is that the entire inspection takes place outside of hours or takes place entirely at the weekend or bank holidays, or a substantial part of it, at least
3 hours happens before 8 am and 6 pm. So, we are getting there, we are just not quite there yet. I think when we move into the new world, that is when we will adopt a new definition. You are quite right, the definition we
have got at the moment is not the one we want to carry on with. I think I know Belinda well enough to say you will keep on getting the
Mr Ian Dilks - 1:08:57
question until she is satisfied. Others were Christine and then Stephen. I don’t want to pre-empt
Ms. Christine Asbury - 1:09:02
the discussion that is going happen in a while, but I just did think that it is worth noting that Key Result 19 which is increased positive sentiment on recommending CQC as a place to work, is recorded as met. I wouldn’t want it to look
like the Board feels complacent about that, but that it is recognised by the Board that there is a concern around it, so I just wanted to say that in this section. Worth for the record having a response to
Mr Ian Dilks - 1:09:29
that, Kate. Thanks, thank you, Christine.
So, it is met technically because it improved on the previous stat.
Ms. Kate Terroni - 1:09:34
The previous stat was something like 36%, so none of us are resting on our laurels, thinking that it is a good enough statistic. In an ideal world, everyone working at CQC would recommend
it as a place to work, good point and where (inaudible) this is not a good news story on that one. Stephen. Thank you, Chris and others, for
Mr Stephen Marston - 1:10:01
the report, thank you Steph. The one request I think I would make for future reporting is the
use of the rating “monitor” and “on hold” because I think the majority of items here are not, in fact, rag-rated as to whether they are met or not match, they are just “monitor”. I think probably it would be more useful if we had a
sense of well, what does good look like, what are we trying to achieve here? So, we are not just kind of watching it, but we have a sense of direction and purpose as to where we are trying to get to, and then you report
on whether we are getting there. So, it is really just a request that we try to remove these various “monitors”, never mind the “on holds”. Second question, Chris, was you reported your expectation that as things currently stand, we are projecting overspends on revenue and
capital. Can I push you to give your confidence level that, by the end of the year, we will be fully within budget on both revenue and
Mr Ian Dilks - 1:11:07
Chris Usher - 1:11:12
capital? Thanks. Thanks for that, Stephen. It is all a process, revenue, yes, except we have got a problem
and a challenge with the COVID expenditure because it is currently not funded. So that aside, I think revenue we should be on budget, capital less confident. That is a challenge at the minute and, as I alluded to, I have seen our kind of latest
figures increasing in overspend in that territory which, at this moment in time, I would say, would be a challenge to come back on budget. So, that one is very much work in progress, revenue more
Mr Ian Dilks - 1:11:52
confident. Any other questions? I mean just before we come
to risk, well, but firstly, probably picking up on Stephen. Can I come to you in a second, let me (unintelligible). Before we come to risk - firstly, picking up on Stephen, I do take your point, “monitors” are not very helpful. Whether or not we
should put something in or whether we should draw out a distinction between performance indicators, which is where we want to see whether we are performing at a level we want, versus other things which are factors for information and there are certain things about volumes
of what is going on in the sector. It is interesting, I think, for us to know as a Board because we have to respond to that, but if it is without our control, I would probably record it separately and not a monitor, but we
can sort that out. I just want to be clear, there are a number of things in here, where we have got gaps on measures or on the milestones, we say they have no update. So, how soon will it be before we close those gaps,
Chris Usher - 1:12:58
and we are going to be able to have some updates? Sorry. Next board we will have a full update and any gaps will be addressed. Drew. Thank
Mr Ian Dilks - 1:13:09
Drew Noble - 1:13:13
you. New additional figures around sexuality under Key Result 17. I think this is the first time that
has been included, so thank you for drawing together that information. We know that there has been a historic challenge around declaration for not just sexuality, but a number of protected characteristics. which may very well be as a consequence of some of the findings mentioned
already from the Pulse Survey. I also recognise that there is a higher percentage for the LGBTQIA+ community has not stated, so there is work for us to do as a network to address that. I am hoping that those figures are going to increase as
we continue the important work that we’re doing around culture. I also wanted to just acknowledge the fact that we are also doing some quite fantastic work with the Diversity and Inclusion team around recruitment, and hopefully that will again contribute to an increased rate of
declaration from the outset when somebody joins the organisation.
Mr Ian Dilks - 1:14:15
Thank you. Thanks Drew. I appreciate that. So, Chris, I don’t know whether you or Kate is going to take this, but there are a number of things where we are showing our risk as now being
outside appetite, exceeding tolerance for the phrase you use. I mean the concept of an appetite approved by the board is relatively new, so I appreciate this is settling down and these things are inherently subjective. But if we’re saying these things are not with any
appetite the Board has described, can you give us a brief overview of - keep it brief under the circumstances - but why, and what are we doing about it, and what sort of timescale? I think for the future, if we are going to report
to the Board things that are outside appetite, it would be helpful to have that in the report because that is really, I suppose, the feature of a dynamic risk management framework is that the key point of identifying it is out of appetite is to
say so what do we then do about it. But for now, if you just give the Board a brief overview, that would be helpful. Yes, happy to. Thank
Ms. Kate Terroni - 1:15:15
you. So, the first one on the Risk Annexe that is outside appetite is we don’t have effective governance
frameworks in place. This is one where there has been work undertaken, but not sufficient in order for it to bring down and the exceeding tolerance judgement that it has got. So, there has been an important piece of work Sacha has been leading around how
we make decisions underneath the Exec Committee. So, we have done a refresh of our ET sub-committees, refresh our terms of reference, installing Exec colleagues as chairs of those subcommittees, so therefore more sub-committees for the ward. We are in in train of creating a new
sub-committee to support us with organisational prioritisation that we will update you all on soon. So, there is work in motion, but it is not sufficiently progressed to bring down that that judgment. The next one is we don’t deliver transformation effectively within the organisation. A
huge topic that I won’t get into now. The key thing I would say relates to a comment Ian made earlier. So, we went live with some really new important ways of working back in July. We listened to our colleagues who work in the organisation
who said that they needed a bit more time to get ready for the new, the second wave of new functionality, new ways of working to go live. We listened to that, and we planned our approach based on that feedback from staff, so it is
still a high risk. It is still exceeding tolerance because we are in the kind of final 6ish months of delivering this pretty epic transformation programme, but the way we are mitigating that is demonstrating to our people how we are listening and, of course, correcting
according to their feedback. The third risk is the risk around getting the right data from external stakeholders. Helen Louwrens who reports to Mark Sutton had a session at ARAC, our Audit and Risk Assurance Committee, maybe about a month or so ago, around the work
they are doing in TDI, our data and insight directorate, to have a dedicated resource to address the issues around getting timely access to information from partners. But again, that work needs to have progressed further for that risk to come down. A couple of others
- the risk around not attracting and retaining our workforce. This is for very specific pockets within our organisation, so pockets within technology, pockets within legal, so this is a specific risk. I think in legal the risk is as high as ever and much to
the challenge that Kate Staples and her team are having to deal with, predominantly around retaining. We get in great colleagues, we support them, and they do some fabulous work for us and then they move on, so that’s an outstanding and a risk. Anthony (unintelligible)
in Technology is doing some interesting work around how we can get people in and grow them within technology. So that risk remains, but it’s with kind of specific pockets of the organisation. We have got a risk around ensuring our colleagues are sufficiently engaged in
culture change that we have already talked about before. Lots of work underway to support our colleagues through change, needs to be presented as a coherent cultural plan that you will be seeing them in a month or two’s time. Then the last two red risks-exceeds
tolerance is around our operational workforce being productive and ensuring that we accurately and timely assess the quality of care out there and providers. Just to flag to Board that both of those risks will be having a deep dive in Regulatory Governance Committee in a
couple of weeks’ time, chaired by Mark Chambers, where they will get into the depth of mitigation on that. Then, following that discussion, we will review whether that exceeding tolerance is still the right judgement for those two items. Thanks very much Kate. I mean for
Mr Ian Dilks - 1:18:57
those kind of less familiar, of course we are not saying that all is fundamentally broken, but I think it is a part of the process. Someone else says you know that things are not as we would like, and we are going to have to
take some action to deal with it. I appreciate some of these are not within our control to deal with. If a market is very hot in certain skilled areas, I think it would not be surprising if a lot of organisations would have to report
they find it very difficult to get the IT staff they needed. Any other questions or comments for any of the team, including Stephanie? OK, well, Steph, you got off relatively lightly that time on updates - a few things your boss has committed you to

3.3 Pulse Survey Results

delivering in November. Thank you. Moving swiftly on, as they say, Pulse Survey results, I think we’re going to be joined by Jackie Jackson. So, Kate, shall I just hand over to you, and Jackie to… Obviously, we have seen the paper and the results, but
comment on in a bit more detail, and I will allow time for questions,
Ms. Kate Terroni - 1:20:27
thank you. Thank you. Thanks all. We are having a conversation today about our Pulse Survey that we undertook in May of this year with a real focus on diversity and inclusion.
So, we needed to get really key information from the survey to inform the equality, diversity and inclusion strategy and the workforce and disability, race, the workforce disability equality standards and the race equality standards. The item with which we will have next. Just want to
note the timeline, so the survey happened in May. We had very early insights from the organisation who provided the survey for us ahead of last Board, but not sufficient in order to have the full conversation then. So, I just want to note the time
that has elapsed in terms of us having this conversation, but also to say we haven’t not been doing anything over the summer since we’ve had this these findings. I will hand over shortly to Jackie to talk you through the findings. I think it would
be fair to say they are very disappointing results. There are the odd, there are some examples of where we see improvement, but nowhere near where we would want our organisation to be. We all know that a happy workforce means that we are providing a
high quality of service, and it is really important that our people are positive and are feeling well supported to do their job. So, we take these results very seriously and there is a wealth of action happening on the back of that. So, without further
ado I will hand over to Jackie to bring to light some of the highlights from the paper. So there has such a lot of information has been shared in the pack and Board have got the full suite now. I don’t intend to go through
any specific line-by-line. I think what we can highlight is engagement in the survey was significant, that over 2000 colleagues took part.
Mr David Croisdale-Appleby - 1:22:26
That said, I think, just to echo Kate’s words, you know, that the contents were concerning and saddening to read. I think it would
be naive not to acknowledge that. In saying that, I think prior to the survey, which was a golden thread to LLR and also transformation and the work with Nadia and the Staff Networks and Mark, we had already started to undertake a considerable work programme
in terms of some elements that were highlighted in the Pulse Survey. Just as a reminder, the Pulse Survey, a number of questions were specifically targeted to inform our D&I strategy and the RES and DES reports. So, that has given us quite rich data in
terms of the work we already started to do and what still needs to be undertaken in terms of colleagues who have got protected characteristics. So, what I was going to do really was just to share some of the activities that are underway that we
are considering. Nadia is going to also outline some of the work that she is doing as well and then happy to take any questions from there. So, in terms of thinking about colleagues with disabilities, we are overhauling and looking at the end-to-end recruitment programme
to support colleagues who want additional support and take that one step further to looking at the recruitment areas that we actually target. So, we can be an employee of choice for those in society with disabilities. We have got internally the Inclusive Leadership Pathway and
as of the last tranche of colleagues, 39 people were on the programme and 7 colleagues had gained promotions. So, we are tracking that through, looking at feedback and monitoring the performance of colleagues who have actually undertaken the training undertaking workshops to really start to
pick the findings from the survey. A lot of the data in there, whilst we are concerned about it, is quite hard to disseminate, so we need more work to be able to really understand what we are being told and what the response says. Nadia
can cover that off in some of the workshops that she has been arranging and hosting. A lot of work on reasonable adjustments with our Staff Network colleagues in terms of how we support colleagues throughout the employment life cycle. We have, with Mark’s sponsorship, a
good piece of visionary work done which will start to inform further the work that we have already started. Then working with TU colleagues, as well, because I think we have got to acknowledge that our TUs work with many organisations and can bring their thoughts
and ideas and what they have seen work really well, so that we can work with them to implement what we think fit for CQC. I think that covers everything, Nadia, do you have anything you want to add? Thanks Jackie. Just to build on Jackie’s
point we will be engaging widely with staff from September to November, for example, there will be externally-facilitated, focus groups, we will be supporting directors to have conversations with their teams, we will also be engaging with the Equality Networks and other expert teams for example
mental health and wellbeing, estates, health and safety, so we can further explore the results and that will enable us to tailor our interventions in the short and long term. Just to add, I think, as well as the golden thread with the work that we
are looking at here, with the LLR report, and also the work on culture and transformation and the Speak Up Guardian, I think it is just part of one global offering. I think the important thing is also to make sure it is joined up and
it isn’t a siloed approach. So happy to take any questions. Questions.
Mr Stephen Marston - 1:27:21
Stephen. Firstly, thank you, Jackie, Nadia and colleagues. It is really important to have this information, painful though it is, so good for you for collecting it and reporting it in the honest and
frank way that you have. Please, can we keep tracking progress? Two much more specific points, one of the most significant changes from the previous survey is the proportion of discrimination that is attributed to senior leadership. What do you make of that? The second quite
specific question - there are two responses in here, one is about primary reason for continuing to work here is, by far the most popular reason for continuing to work at CQC is work-life balance and flexibility. And there is another one, which is the most
common form of, I think it is abuse and harassment, is in the form of e-mail. Where this is taking me, just kind of wondering, do we need to do a piece of work about people’s experience of working from home? Because you are much more
likely to get e-mails that you may then find offensive if you are not in the office. People are clearly finding an awful lot of beneficial gain, hence the work-life balance question which is strongly positive. But I wonder whether it is worth asking people, are
you also seeing some negatives, particularly around sense of team, the ability to have those softer conversations, the socialisation that goes with being in the office? I just wondered whether this is giving us some indicators that it might just be worth consulting colleagues, specifically, what
is your experience of working from home versus working from the office? Do we need to have another look at that? Thanks. So, if I come to leadership first, clearly the data, you know, is telling us a story. I think the challenge with this at
the moment is in terms of the back-up data we have. So, if we are to look at some of our casework, Speak Up Guardians albeit anonymous, it doesn’t really speak to the reporting of the Pulse Survey which that makes it quite difficult to try
and unpick. So, I think that is where the workshops that we are starting to run, to start and unpick into your point exactly, specific questions and giving colleagues the opportunity to speak in a secure environment, their experience or observations, thoughts, what they would like
to see. Because it is only by doing that and having those good conversations that we are going to be able to drill down. Because the survey, where so important, only goes so far, and for me it is about the start of that conversation, and
it is certainly not the end of it. That is the start and where we should be highlighting. The other thing with leadership is, I think there is a link to working from home and it is about the human touch. I think, you know all
of us, regardless of our position, have good days and bad days and actually, how do we check that, however our e-mail is landing to somebody who is again having a good day or a bad day. So, I think that fits into our leadership management
training that is already in hand, but actually needs to reflect some of the findings from the workshop, and also some of the content from this. Just being able to sort of go through what we are hearing, what we’re observing methodically, and locking it in
to what we have either already got in train, or what we are going to implement collectively. And taking ownership, because it doesn’t land on any one person’s shoulders, this is all of our responsibilities. Can I just come in on the home working point that
I think you made, Stephen. I think it is really important to acknowledge that up there with why people work at CQC, along with
Ms. Kate Terroni - 1:32:01
purpose, is the flexibility. So, something that really matters to our people, and I think any sort of hint that that is
not what is going to be on offer would not be a message we would want out there. However, when we talk about culture and we talk about how you create a good culture, I think it would be really important to have conversations with teams
about how do you ensure that you are coming together for good… You know, whether it is away days or shared learning, et cetera. So, might there be more we can do in terms of highlighting what best practice looks like in the organisation, about regularly
checking in, so you can have…, if you are needing to have difficult conversations, you are having them face-to-face, rather than e-mails that get interpreted. But I think, any sort of hint that the level of flexibility that we currently afford people is not, you know,
wouldn’t be continuing, wouldn’t be helpful. But also I don’t think a diktat that says this is how we should work, but I think we have got work to do in terms of having a conversation as the organisation about what does good look like when
it comes to team bonding, teams spending time together in person as
Mr Ian Dilks - 1:33:03
well. Just can I be clear on a couple of questions, but the suggestion from Stephen was doing some work about working from home and it is something we have talked about before, because
you know we never set out to design the model we have got, COVID made us switch one way and then we sort of drifted back a bit. So, I don’t have a good feel for whether, if we were to work out the ideal model,
what we have got is anywhere close to it. I think it must be close otherwise we would not have any positive results, but you know what I mean, intellectually, we haven’t looked at it. So, I do think it is worth capturing Stephen’s point as
to - going beyond what you are saying, I think, of looking at what works well and what doesn’t work well - but of taking stock, firstly, of how people find it. Are they spending the right amount of time at home versus the office. I
am not talking about a radical shift dragging people in, but I’m saying rather than spending all the time at home, you know how many physical interactions do you need with colleagues and which one? But then to the extent people are working from home, are
there any other things we could do to downplay some of these other problems, including, for example, use of e-mail? So, I’ll leave it with you to think about it, but I think it’s a very good point. I can see a number of people nodding.
I think it is worth looking at it both from a relevant and theoretical perspective, but also, of course, capture the good practice and totally where it exists, and obviously there may be evidence of what doesn’t work. There were a couple of other questions, sorry
a couple of other comments, I’ll come to those. Tyson, did you want to respond to that? I just wanted to respond to, yes, I think there are probably two issues here. Because I agree with Stephen and I remember when I started working from home
Mr Tyson Hepple - 1:34:42
for the first time at the start of COVID, it was a different experience, actually it could be quite lonely at times. I think doing some work with our people and I want what it feels like, it is absolutely right. But you would expect the
grizzled Ops Director to say this. I don’t think that people working from home is just about flexibility and their work-life balance, I also think it’s more productive in that quite a lot the people in this workforce are working out in local areas and I
think it’s much more efficient to be living in the local area you are inspecting in, rather than having to travel an hour and a half each way to get to Birmingham to take a desk in the office. So, I think we are in a
different situation when it comes to offices. Where I think where the Chair is right is about personal interactions and I think there are times when we should talk to our teams, about when do they come together, when do they come together as teams and
that should be done in person? But I think there are a number of things spinning here, but I definitely think doing some work into the working from home experience would be the right thing to do. So, I think it would be quite helpful if,
Mr Ian Dilks - 1:35:46
at some stage, we could come back to hear whether it has got the views of some… you know, we don’t want to mandate exact ways of working, but some guidance or maybe even some minimum standards. I mean, I really would struggle, I think, if
we employed somebody who had never met physically another member of staff for a certain period of time. I see lots of hands going up, so I apologise for not getting quite the right order. I think Drew if you want you go first, Mark, I
think David and then this Mark. Thank you. Tyson, very well-put, what
Drew Noble - 1:36:18
I was really going to say. But I just wanted to highlight the absolute benefits of working from home with that level of flexibility that that offers because (unintelligible) around colleague wellbeing, caring arrangements
and the flexibility that offers to many colleagues. particularly, but not limited to lone parents and the financial expense that people are encountering having to commute, and such as well. So, I would be really keen for us to be considering of the overwhelming benefits that
colleagues have found when we were able to move into a more flexible
Mr Tyson Hepple - 1:36:57
arrangement. Thank you. So, one ask and one potential suggestion. Starting with this, I think we have to remember this was done in May
Mark Chakravarty - 1:37:02
and actually this is a time of great change
and fast change, so we may not be in the same situation now as we were in May, but, you know, important to look at that. The one part of this is we are asking a lot of the organisation in terms of change. We are
putting them through a lot of change and change is difficult, and it also is not organisational change. It always comes back to personal change. I think there is a really critical message here for leadership, and that is the Board, as a totality, non-exec directors
and executive, and the executive team, to say there is a desire here from the organisation to see some personal change about how the leadership handles and the culture it creates. I know we’re starting that work, but it’s important to think about that at a
collective level for the Board and at an individual level, for each leader to say what am I going to do differently to foster the future culture that I want to see? That is one where people do feel free to speak up, where there is
not a view that challenging conversations are harassment, but they are constructive and supportive. So, I think there is that message. I think there is a degree of ownership we have to take and drive that through at an individual and collective level, so it needs
to be on the agenda. The suggestion was, and I think it is a build really on what Stephen sort of said, I think there may be a correlation between working from home, but what is really clear is that you need trust at the very
heart of this. And actually, things like working from home reduce the opportunity to build that trust. But this is also an organisation that has to be, by its nature, highly accountable and every individual has to be accountable. So, I think the other part in
this audit, or looking at what’s changed working from home, is how do we drive that supportive accountability? We can’t duck away from challenging and difficult conversations because they are essential to the job that we do, but you have to do it in a way
that comes across as supportive, not as harassment or bullying. I think there is probably a line there, where we need to support people’s ability to have those supportive accountability conversations. Sorry James, I might have skipped over you, and I said over there, so you
next and then you, David. Thanks very much. I wanted to welcome the report as well. I have welcomed the discussion that I have had in my
Mr James Bullion - 1:39:26
functional area to get underneath some of these issues there, but also the conversation here and I think it
is right that we are as transparent and as open and as respectful as we can be with these findings. As a relative newbie to CQC, I do recognise the enormous strain created by both the transformation and new ways of working. But I also wanted
to, I suppose, make the point about, as I look across other public services, many public services are under strain as a result of increased demand and of distress by the consequences of that demand that we are seeing, and we are an organisation that will
see that stuff coming through our doors. That is a consequence of the general health and social care state as it were, and then combined with an easy ability to get behind with work because of that demand and because of the ways of working can
create a very, toxic response and other public bodies are experiencing similar to ours. So, to state the obvious, a commitment from Executive level to support the initiatives that are underway and to try and make those as successful as possible. But I think even where
we can’t solve the problem of the demand or speed up the transformation because it’s too risky to speed up and we need to do it right, we can and should create that culture where people feel that they can speak out and speak up. So,
I think staff will really welcome the Board’s support for that, visible support in this meeting and further engagements actually at Board and Executive level to demonstrate that as you go along. Very much the point that Mark is making, we can be very visible with
our behaviour without solving a problem, and people understand that because we cannot control the whole of the problem. We can control the
Mr Ian Dilks - 1:41:25
way we behave with it. Thank you. David, sorry, do you want to go next? Saw some hands going up. Right. Thank you,
Mr David Croisdale-Appleby - 1:41:31
Jackie and Nadia. Mine is a question for you really about the workshops that that you have mentioned. One of the things that business schools around the world have come to realise quite recently is the problem of trying to give the opportunity for people to
demonstrate leadership. Firstly, when you are in a distributed organisation, but secondly, when a lot of people are now working from home, it is a sort of double whammy. A lot of people we are finding just don’t feel empowered to do that. Not my business,
not mine, I do my job, that kind of approach. One of the things that I would like to suggest is that - if I may, - is that when you run the workshops, you look at that sort of opportunity. Because once you get people
engaged in feeling that they can demonstrate leadership wherever they are in the organisation, then I think what we are finding from the published research is that that has a big effect upon the attitude towards the host organisation. A very positive one because they feel
they are included in that, because there is something they are actually doing that they weren’t necessarily doing before. So, I would just make that suggestion to you - if I may, - when you design the workshops with colleagues that you include consideration of that
in what you do. Thank you. Mark. Thank you. Really helpful to see this level of detail and transparency. I mean just an observation in terms
Mr Mark Chambers - 1:43:10
of process; it was May it’s now nearly October. I think we need to find a way of allowing the
Board to see this much quicker. If that involves putting more pressure on our provider to produce their product quicker, then we need to do that. Because the danger is we have lots of conversations about what has been done since and don’t focus on the
scores. With such a good proportion of our people spending the time to commit to this process, we need to give them full respect of seeing the scores without trying to rationalise that the world has changed since. Two things from me, like Stephen I was
quite struck by the chart on primary reason of continuing to work here. I was not particularly surprised by the element but was surprised by the order which was kind of almost upside down from other organisations that that I would have been more familiar with.
one of the things that struck me was the significant gap there between really strong buy-in and drive for our purpose and values, but a very low score for…, low on the list is our vision. Is that indicative of us, of opportunity to much better
integrate the two to get people more and more bought into what we are trying to do and why we are trying to do it? That was one question. Then my second question is about bullying and harassment and discrimination, where, you know, we should not
be seeing any red on this and this is at least the second time that I have seen survey scores here which raise questions and concerns around this area. You know, we have been previously told that we would be responding and dealing with this differently,
so again, you know, what is going to be different in terms of our response there? How are we going to eliminate red from this? Because you know, those are incredibly damaging indications of incredibly damaging events for people who deserve better protection. If I could
Mr Ian Dilks - 1:45:42
go first and then hand to Jackie for the second point? So, Mark, Slide
Ms. Kate Terroni - 1:45:46
39 where primary (unintelligible) is around work life balance and flexibility, second is purpose and values. The explanation as to why vision is so low. So, I think this is another example
where the this has given us headlines, but we don’t have the granular depth of the explanation under. So, I am using a degree of interpretation that my Exec colleagues may want to come in on. I think people believe in what we were about as
an organisation, are passionate about us getting out there and regulating so that people get safe health and social care. I think people…, different parts of the organisation are in different places with their views about how we are getting from where we are to where
we need to be. So, I think there is still really good buy-in for our strategy, regulating through the eyes of people with lived experiences, understanding quality and risks within a place. But actually, as Mark said, we are in quite a painful place at the
moment where our people are, you know, some of our new changes have switched on, some are still having to use old systems. That is one where I am very hopeful that in maybe nine to 12 months - I am giving ourselves longer than six
months because I think next six months is still going to be pretty difficult - I really would hope to see that come back out again. But, Nadia, that might be one where, when we do our workshops, we could try and tease out a bit
more. It almost feels like a contradiction, so you believe in our purpose and values, but you are not liking our vision. As I say, I am interpreting it, that people are finding this…, some people are finding this change really tough at the moment even
though they still believe in where we are trying to get to. Jackie, I don’t know whether you want to say anything about the bullying and harassment. Yes. I think with the bullying and harassment, I think we need to take a blended approach. Why are
everything together in terms of providing safe spaces? So, this is not exclusive to see managers speak up, working with the National Guardian’s office, using our staff networks who have, you know, good communication with trade union, colleagues if something is brought by membership to them.
I think it is about how we join that up and make sure that colleagues have as many avenues as we can possibly think of, so that if you feel as though you need to speak to somebody about something you have witnessed, or something you
are experiencing yourself, you can choose the avenue that best suits you. I’m not sure, I think we have got the avenues, I don’t know if we have done enough to publicise this, make them accessible and make people feel confident in their ability to use
whichever one fits their needs and meet them where they are. So, I think, with staff networks, that is something that we will need to look at in terms of what else can be done. And probably ask colleagues, and what next? Because I think a
lot of this, we can have conversations about what we think is the answer says, but actually is that hitting the spot? I think we need to get some endorsement that we are following the right path. I think this is the same with bullying and
harassment. I think we have got plenty of avenues, but are they the right ones, and how do we publicise them and make them make them secure, and a safe space? If I could follow up? One of my concerns is
Mr Mark Chambers - 1:49:10
that the scores around…, did
you raise it and were you satisfied with how it was dealt with? The second scores are bad as well, and the trouble is that very quickly gets into the culture that there is no point in using any of those channels because nothing will happen.
So, I agree with the response, but I think this is something that needs a huge amount of focus. Yes, and just to add I think as well, this is another one because if you were to have a look at some of the data that
you would normally go to endorse and substantiate that, that is not there. So, it is not questioning the validity of this, but again it is about how you unpick the data that you see in front of you to then do something more about. I
think that is one of the challenges we have got at the moment in terms of some of the back-up data. Yes, well, although this is our reality, because culture is what it feels like to be here, almost regardless of any data that is available.
We will need close the (unintelligible), but I think a few more hands
Mr Ian Dilks - 1:50:33
went up. Chris. Just to build in some conversations we are having with leaders as part of the transformation. We talked a little bit about
Chris Day - 1:50:40
what it is like to lead in the
organisation at the moment. I think there is a really interesting sort of link to the purpose of the organisation and the realities of action today. So, as we have talked about in other conversations, it is a fast-paced organisation with lots happening, both in terms
of transformation, but also in terms of operational delivery. I think this goes right back to; how do we encourage leaders of teams to have good conversations with their people? This started a conversation about what is the use of e-mail. Actually, there’s a really interesting
point about how do you have good conversations with people that are two-way? Because the problem with e-mail, essentially it is a one-way channel. You don’t actually know the intent of an e-mail that is sent, but you can infer intent from a conversation, either face-to-face
or indeed over Teams. But it is about giving people the sense that it is as important to have the right conversation as it is to get the message out. I think encouraging the conversations, particularly with frontline leaders, that the time taken to have a
conversation is well-spent against the other challenges that they have, and indeed there are many challenges that frontline leaders have. So, I think there is something about how we encourage that conversation because it builds trust. How do you, how do you, as a leader, choose
the right channel for the right type of conversations, and how do you take responsibility not just for having the conversations but to hearing the feedback and using that feedback back up the line? I think that often in the organisation there is a layer which
the information is communicated in a one-way process, and we don’t hear the feedback back up into the Executive. So, giving leaders not just the power to do that, but the encouragement to have those conversations two-way with their teams. I think it will be an
important part of our cultural journey that we talked about earlier. As has been mentioned, these are truly disappointing results and absolutely warrant very serious interventions that colleagues have
Drew Noble - 1:52:46
already mentioned. I do, however, want to highlight one area of positivity, in that our equality networks
are the second highest-scoring answer under the “What we’re doing well” section, and I think that is to be noted. We as an LGBT+ network have recently inherited leadership, so we can’t take all the credit by any means. But certainly, you know, it is credit
to the network leaders who have brought it to the point where we are at. We are working really well with Jackie, Nadia and team in regard to the likes of addressing some of the issues around bullying, harassment and discrimination. Ian, I know that we
have had some calls with you and Jackie recently and some things have already started. I do want to share a (unintelligible) or an off-air to our colleagues around the table in that we are here to support you in the work that you are doing
locally, in addition to the work that Nadia and Jackie are doing. We represent our sub-communities. We provide an awful lot of insight, lived experience and expertise in these areas, so please do use us in what you are doing at all levels within your respective
areas. We are more than here to help with that activity. Thanks Drew, both for the comment and giving us the positive feedback. Any more
Mr Ian Dilks - 1:54:02
questions? I really have to make it last two or three, otherwise we are going to be here until (unintelligible). Christine
and then Belinda. (unintelligible) did you want to speak about…? Yes,
Ms. Christine Asbury - 1:54:15
thanks. I would hope that that the amount of time we’ve given this as a Board will reassure people out there that we are genuinely taking this seriously, but I just felt that that the
pain is now. Most of the actions we are talking about are in the future, so what comfort can we give people that we are listening, and things are going to get better, now or soon? Kate I think the point I was going to make
Mr Ian Trenholm - 1:54:45
much more broadly was that if we look at the surveys over the last few years, the surveys in 2020-21 during COVID were significantly better than this despite a very similar working environment. So, I think we should…, we can also look at the fact that
in those surveys, the results in Mark’s group were relatively poor, the results in Mark’s group now are very good and one of the characteristics of this survey is the variability. (inaudible) who are particularly struggling at the moment under Tyson’s leadership to improve a range of
things. I think what we are seeing, we are starting to see those green shoots of recovery, we are starting to see people - with the small ad hoc surveys that we are doing - starting to report much more positively about how their experiences have
changed, their experiences of where they see us going and all of these things. So, I don’t think in saying all of that we should be wildly overconfident, but I think two things there. One is the speed with which this changes. It has gone, it’s
going very high, then it went down, and I am confident that it will come back up again. There are lots and lots of individual actions which are in place. And I think underpinned by the point you made, which is we are taking this incredibly
seriously. That gives me confidence that there is a road out of this. We’re not there now and there are things in this survey which we probably haven’t necessarily seen in detail in other surveys, age being one of those things that I think we have
not talked about a huge amount in the past. But I think working with a network, somewhat on the age dimension of the protected characteristics is important, but I do think there is a potential pathway out of this. But there’s lots and lots of individual
activities which have been going on for months now and will continue to go on. Just a similar point to Ian really, that when you break it down to the Executive directorate team, you know, we have got some really good results in the technology, data
Mrs Belinda Black - 1:57:04
and insight and the regulatory customer and corporate operations. So, I just wanted to stress that, you know, it’s not, yes, we have got to see it as an overall with some very bad results and it’s disappointing, but, you know, in some areas we have
been seeing good results from the team. OK. (unintelligible) dealt
Mr Ian Dilks - 1:57:26
with any questions. It would be impossible to summarise all that discussion, so a number of observations to try and pull it together, but also one last question for Kate. I mean personally, thanks very much
for the report, and despite the fact the results are poor, bad, whatever phrase we use, I will give some credit for the fact that as an organisation, I think the fact that, you know, we are showing this not just for the Board, but with
our people and public, the senior executives do deserve credit for that degree of openness. I can think of a lot of organisations that wouldn’t have done that, so I think that says something about culture at least, that, you know, it does hold everybody to
account now to deal with it because we have so open about it. There are a number of suggestions which, perhaps, I will ask you to take away, some really helpful observations. I think two or three people commenting on this, that Stephen’s comment about working
from home and just understanding the implications of that, whether it is looking at guidance elsewhere, experience elsewhere, so academia or other businesses and our own experience, that would be extremely helpful. So, really well done to all, even if we have got a very poor
position. And as you say, Christine, I mean, you know, we spent double the amount of time on it. I think that says something, I hope if any of our colleagues are listening, the Board really does want to see this as one of our top
three issues to address. So, you know, we’ve seen observations and comments from James and from Drew, and Mark, about the actions of this Board, so if there’s suggestions or comments along those lines of things we should be doing differently, then please let us know.
But I hope the message is getting across that, you know, we are throwing what resources are needed this time to get it right. Just one last question for you, Kate. One of the things that struck me when I joined this organisation was the number
of people commented about the values and they are clearly quite important to a lot of people. But equally, in my 18 months here, we have never had any discussion about values at the Board and it made me reflect on it, to be fair a
couple of other colleagues mentioned it. Most organisations would review or refresh their values every few years and I’m not sure that has been done for a best part of a decade here. So, when I say refresh, I’m not talking about changing them, people are
heavily committed to a lot of them. But would now be a good time for some sort of relook, refresh of the values, perhaps as part of the culture work which would come back to the Board.
Ms. Kate Terroni - 2:00:08
Yes. As you say, in the results we have just seen, it is the second most important thing for people about why they work here so values really matter to our people. So very briefly, the last values that were
co-produced extensively were 10 years ago and approximately only a quarter of our staff are people who were here when those values were originally established. But that’s not to say they don’t still have high resonance with people today. So, I think as part of the
conversation we’re going to have around culture, we want to start a conversation with our people, with our networks, with all the other fabulous forums we have got around, are they still the right values, do they need a refresh, do we need to make them
more action-orientated? Do we want to do something different with them? I think that needs to be the starting point for the conversation that then says, yes, it is either re-confirming or tweaking or changing the values, depending on what the view is in the organisation,
and obviously around this table. Then, what are the associated behaviours, behavioural expectations and how do we hold each other to account for the culture we want to have it in the organisation as well? So, in the coming weeks or months we are going to
hone down our thinking on that and then have a conversation in November with Board and be really keen to hear your thoughts also on
Mr Ian Dilks - 2:01:18
it. Thank you very much indeed. Just to reinforce that point, we want to do that very rapidly. We don’t want
Mr Ian Trenholm - 2:01:23
to turn this into a very long period…, long thing, that behaviours thing is something we want to do really, really quickly. I think that is right because the feedback I get is that most people think it is
Mr Ian Dilks - 2:01:33
good, so (unintelligible) rapid change. Kate, Jackie,
thank you so much for that. Can we just move on very quickly? We have one last fight, and we are running badly behind, but let’s try and stick to the agenda and take a late break. So, we have two documents here you want us

3.4 Workforce Race Equality Standard (WRES) and Workforce Disability Standard (WDES) Reports 2022/23 and action plans

to approve, which is the workforce race equality standard and the disability standards, so the reports. Kate I’ll hand to you in a second, but just one observation from me on behalf of NED colleagues – it might save some questions. You may have noticed comments
in there along the lines of the race or ethnicity status of the non-execs are unknown. You might have found that was a little bit surprising, the same on disability. To clarify why that is there, this data is drawn from our systems, since non-executives are
appointed by the Secretary of State. They hold that data, this organisation doesn’t, apparently, with the exception of myself, because I am logged into the system, so my details are in here, yours aren’t. I made two suggestions to take into account the approval. This is
as of a few months ago and the composition of the board has changed significantly since then, so I said zero point in going back and working out what it might have been six months ago. But I have asked for the words to be tweaked
a little bit, just to explain why it is that that is the case. We don’t hold the data because, and then I’d like to suggest that, looking forward, subject of course to the agreement of NEDs who would have to disclose the data, that we
do actually capture it internally, so next year we can have reflective of the lot. But to anyone listening, and particularly our colleagues in the organisation that may have found it very odd that the implication given that NEDS were not prepared to divulge that information.
So that deals with that, and so we are being asked to approve it subject to some tweaks about wording that I have already agreed. So, Kate over to you. Thank you. So, I will shortly hand over to Nadia. I think these are two pieces
Ms. Kate Terroni - 2:03:37
of work we can feel pretty proud of, I think, Nadia, (unintelligible) to say what you’ve done with the networks around this, and obviously two Exec colleagues as sponsors for the work. Two things that I want to point out that I think is really positive.
I think the honing down in each of the reports around three priority areas. As with everything, you could go after so many different things, but I think for both the WRES and DES, to nail down with real clarity the three priority areas they are
going to go after, I think, should really help us in our ambition of making this deliverable and measurable as well. But without further ado, over to Nadia. Thank you, Kate. There is quite a lot in the plan, so I wanted to draw out some
key priorities that are relevant to both plans. Firstly, recruitment, with respect to race we are focusing on recruitment in terms of improving our representation at Exec level and then the internal talent pipeline, so Grades A and B. For disability this is more focused on
the experience in terms of our reasonable adjustments offer. The second priority I would say that is relevant to both is inclusion. We have discussed a lot about bullying, harassment and discrimination and we will be working on that as a priority because it’s relevant to
both characteristics. Then, finally, inclusion from our workplace adjustments support perspective, and also our psychological safety that we are providing to colleagues that will be a key focus of the inclusion work that we will be doing. We are hoping that the conversations that we start
now, from September to November on the survey, should support that level of growth in psychological safety. Most organisations that welcome feedback, respond to feedback and keep people engaged with feedback, showed that they are safe to challenge and to speak up to leaders, and people
are more engaged with the organisation, and they also feel more of a sense of belonging. So, we are hoping that some of that work will support the activity that we have got planned within these within both plans. In terms of adjustments with disabilities, there
is a massive book of work in terms of improving our reasonable adjustments offer, including the implementation where I believe we probably have struggled historically. Wider to those adjustments, we are also working on other adjustments and support that people will need, and that will impact
both disabled colleagues and colleagues from an ethnic minority background. For example, caring responsibilities, gender identity, their general working styles. So, as we have discussed earlier in terms of what works for them, working virtually and how we connect with them. Hopefully, we will be working
to support our staff when it comes to widening our adjustments offer further than what we are offering for disabled colleagues. I’ll open the floor for any questions. Thank you. Questions or comments from colleagues? Tyson. I just wanted to make a comment from the point
Mr Ian Dilks - 2:06:49
of view of being the Executive Sponsor of the Race Equality Network.
Mr Tyson Hepple - 2:06:53
First of all, to pay tribute to the WREN, particularly their co-chairs who I think, do a fantastic job. I think there are some encouraging signs in the Race Equality Statement, I think particularly
around the number of ethnic minority colleagues now in Executive grades, although a number of those, particularly in my group, are still in interim positions. But I think that is a start, but I think two of the big priorities have got to be around recruitment
which is well captured in the plan. Because we are very good at attracting interest from people from ethnic minority backgrounds, less good at shortlisting and appointing them. I think also the data around discrimination, in particular, is worrying and I think as part of Workstream
3 when we are talking about psychological safety and inclusion, I would be keen for us also to particularly focus on the work we can do around discrimination. Thank you. (unintelligible). Ali, I think, was
Mr Ian Dilks - 2:07:51
first, then you, Mark. Thank you. It is a really clear
Mr Ali Hasan - 2:07:58
health report and I think the clarity of the actions, as well as the data is really useful to understand. I agree with what Tyson said about there are some areas which clearly show improvement, but they are also clearly some areas that are striking and
really draw a lot of attention to, such as the rates of bullying, harassment and abuse from colleagues with disabilities too. I think, similar to the previous report discussed, it will be helpful to continually analyse the level of data we have to understand actually how
do these characteristics intersect with other ones to understand whether specific nuclei have concerns or whether they spread more widely within groups of characteristics. And also, to keep making sure that as we undertake other pieces of work that impact on this, we are building a
more rounded comprehensive base to understand how we are doing in supporting and valuing our colleagues. Thank you. Do you want to go
Mr Ian Dilks - 2:08:49
first, or are you first? Mark. In a similar vein to Tyson, just huge thanks to the Disability Equality Network. We have had
Mr Mark Sutton - 2:09:03
recently the appointment of six new co-chairs, all working incredibly hard. The focus around reasonable adjustments, I think, is critical and thanks for your support, Jackie and Nadia on that work. I’m really excited about what that is going to deliver for us, because that is
going to make a significant improvement to the experience of colleagues with disabilities at CQC. But the Disability Equality Network are actually working on a huge draft of change and improvements which, I think, is equally exciting in itself and all supporting the aims with the
Workforce Disability Equality Standards. Ian. One of the things that doesn’t come particularly strongly through in terms of the numbers is the work over the last year around support for neurodiverse colleagues. I think one of the things that has always been quite striking is that
we have been able to offer direct support for people who need a different computer or a different or a different workspace to work in. But neurodiverse colleagues, I think, have a much more sophisticated set of needs to enable them to contribute, and I think
a lot of the work this year has been on deepening our understanding with that group of colleagues and I think we have made some progress in that area, but I think there is definitely more to go. The WDES doesn’t really bring that out super
strongly, but it is an area that we are very much focused on. Thank you. Thanks Ian, it is an area you feel very strongly about. Any other
Mr Ian Dilks - 2:10:30
comments? So, we are being asked to approve this. It is pretty factual, really so it is helpful
to have the interpretation, but as far as the document goes… Looks like we are approving that, so thanks very much. And thank you very much both of you for spending your time with us this afternoon, appreciate it. So, let’s take a well-earned comfort break.
Apologies for colleagues here and anyone listening in at this rate - we are running about half an hour behind schedule. We will see if we can catch some of that up, otherwise, I hope I’m not inconveniencing too much if we do run over. But

3.4 Workforce Race Equality Standard (WRES) and Workforce Disability Standard (WDES) Reports 2022/23 and action plans

let’s try and come back in 10 minutes, maybe a little under if that is at all possible. Thanks very much. Welcome back everybody. Sorry to
Mr Ian Dilks - 2:11:17
rush your tea break, but I hope you managed to suitably refresh. I will try to make up a little
bit of time, let’s see how we can do that. The next item on the agenda is the National Complaints Team Report. Kate Staples, I think I will just come straight to you on this, so over to you. Yes. Kates are interchangeable on this one.
I’m going to assume you have read the report, a couple of points to highlight, for emphasis. First of those, the increase in the number of
Ms. Kate Staples - 2:11:52
complaints received during the reporting year, coupled with a vacancy rate in the team meant that there were more people
complaining, but we were slower in responding to their complaints than we would like to be, so our performance has dipped in that regard. In terms of actions, we have already taken to respond to that, pleasingly, the team is back-up at full strength. What we
have also instituted is some monthly case management disciplines to make sure that we are pushing through on responding to complaints in a timely fashion, so hopefully the report for this year will show an improvement again in throughput. Looking ahead to what we can anticipate
in the complaints year 23-24, as a result of the transformation programme we are anticipating an uptick in the number of complaints that come through to us. So, we are trying to get ahead of that by ensuring that we have connections with colleagues across the
organisation on whom we can call should complaints come through specifically around the new transformation and new ways of working. Within my directorate what we are also looking at, is ways in which we can build more resilience in the team to ensure that, even if
there is more complaints activity in in this current complaints year, we are better able to handle it. And in terms of delivering a better outcome, essentially for those who are complaining, we are constantly trying to improve the way we forge connections and learn from
and share insight with colleagues across CQC. So, that the complaints exercise is never purely a process, or a mechanistic one. We do try to seek the learning from complaints that are upheld and feed that back into the CQC system to make sure that we
build on it for future reference. I will pause there and happily take any questions from colleagues. Thank you very much. Any questions? Christine. Yes. I note the analysis and also the supplementary paper that was in the reading room that I have had a look
Ms. Christine Asbury - 2:14:12
at. I wondered if there was any feedback from the people making the complaints about how satisfied they were with the way they were investigated and the outcomes. It is a mixed picture. Some are
Ms. Kate Staples - 2:14:31
satisfied with the service, albeit not necessarily with the answer or
the outcome. Some are dissatisfied with both, and in a sense that is to be expected. I think there is underlying issue to some extent, and I think we have picked up on it in this morning’s Board, about the extent to which there is a
mismatch between external stakeholders’ expectations as to what we can do, and our ability to do what they would like us to do. There tends to be a greater level of dissatisfaction from individual complainants who think we have the power to do something in response
to something bad that has happened, and that is not always the case. So, there is a mismatch and we do constantly try and think of ways of correcting that. Without overcomplicating this - he said - is there any way of pulling out those things
that misunderstand scope, because we do see quite a bit of that. I mean I sit on the stuff that comes across my desk and…, so there’s no
Mr Ian Dilks - 2:15:41
learning, maybe we should be better explaining our scope, but just in terms of understanding performance, clearly there’s
a big difference between something we are not doing as well as we should have done, but it’s in our scope, versus those things that are out of scope. If anything, it seems to me the out of scope concerns are growing, as people have worries

3.5 National Complaints Team Report 2022/23

about the system, and they turn to us to try to fix things. One of the interesting things to emerged from a series of one-to-one I had with
Ms. Kate Staples - 2:16:15
colleagues across the directorate was the extent to which human interaction at a very early stage could be
really helpful in heading off extended correspondence. That is something, I think, to bear in mind, making sure that we don’t simply rely on electronic means or relatively mechanistic processes, but think about that human interaction. Because some of the colleagues, they really are wonderful at
giving stakeholders a jolly good listening to which is really, really important at an early stage. So, it is something…, we will take your challenge away and see what we can come up with. The other related point to what you just said is the PHSO
Mr Ian Dilks - 2:17:04
and indeed my previous body, our Chair, put out some joint guidance on complaints handling. It was really aimed at the NHS, a year or so ago. I don’t know if we have looked at how our processes compare, but I mean one of the key
things there was that human interaction showing you have got the point at an early stage makes a huge difference. So, if we haven’t, perhaps we could make sure we have looked at that. We have started to do some benchmarking over the last two months
or so, precisely to understand the extent to which other organisations
Ms. Kate Staples - 2:17:33
do things slightly differently from us, and even more importantly, slightly better than us. So those sorts of things will certainly emerge. Thanks. David. Thank you. Thank you, Chair. Kate, I’m not sure whether I
Mr David Croisdale-Appleby - 2:17:51
may have missed this in the report, so forgive me. But in terms of complaints, do we have a formal “you said, we did, this happened” log? Because other organisations that I serve, we have instituted that, so that the complaint in a sense, although it
may well be resolved, the point is that it is also logged in that form. In other words, you said - so are clear about what you said, this is what we did and then there is an outcome to that. I don’t know. I couldn’t
see it in the report, but if it’s there, point it out to me, if not, perhaps you would consider it? We certainly seek to respond appropriately to each complainant to articulate… No, this is about…,
Ms. Kate Staples - 2:18:40
forgive me, but this is about our internal learning from
the process. I am quite sure that we communicate properly with the people who are complaining, that is not my point. Whether it is in log form, I don’t know, I will check. But we certainly do capture the points that are coming out of the
complaints and feed them back to colleagues to make sure that there is an opportunity to respond and reflect and adjust behaviours as a consequence. So yes, we do, whether it is as formal as a log, I will go and check. Because the, if I
may, the point about it being formal, is that it then can’t escape the system. If you see what I mean, it is a formal log and it can be
Mr David Croisdale-Appleby - 2:19:19
interrogated and looked at, etc., but it is a way in which you can add accountability
to the question of complaint handling. Let me take that one away and
Ms. Kate Staples - 2:19:34
Mr Ian Dilks - 2:19:37
we will get back. Thanks David. Any other comments or questions? No? OK. Well, Kate, thank you very much indeed for that. We have now got an interesting session on…, it is a policy position

3.6 Policy Position - Reducing Restrictive Practices

that is being put to the board by the management on reducing restrictive practices. Joyce, I think you’re going to lead on this, but we are going to be joined by Rebecca Bauers and Jackie Wilson again, she has been in and out like a jack-in-the-box
today. I won’t say much more until they arrive. Thank you for joining us, so Joyce I will hand to you in just one second. This is really just down to hear what’s going on and discuss, but it is a policy position the management wish
to promote. It is very important. It is in line with our strategy, there is a video which you’ll explain in a moment. In terms of output, other than just noting what it is being proposed and discussing, we are proposing that a bit more detail
on this will come to the Regulatory Governance Committee of this Board at a future meeting. That is the forum in which we consider the way we practically go about handling our regulatory obligations, so we are not being asked to approve anything, but if people
want something looked at in more detail, let’s capture that and that can be added to the work of the RGC when they come to look at it. So, I just wanted to frame that, what we want to get out of the session, but Joyce,
over to you. Thank you, Ian. That is really helpful in terms of, it is really important to raise awareness about our policy positions. When a
Mrs Belinda Black - 2:21:28
regulator does a policy position, it is to provide clarity on the stance that we take on certain issues. In
reducing restrictive practices, we have highlighted these issues in two reports, two subsequent reports on Out of Sight, which has shown when it is inappropriate, in terms of restrictive practices including restriction, segregation, seclusion, the impact on individuals that this happens to. We have done this
policy position, largely because people have asked us to do so, because of the negative impact and the experiences. You will see a video later on from somebody with lived experience, Alexis Quinn, who will talk about what has happened to her and why this policy
position is so important. I’ll hand over to Rebecca and Jackie who will talk in more detail about the fact that we started this for people, as a priority for people with learning disabilities and autism, but actually this position applies to anyone where restrictive practices
may impact. So, it is any setting and any groups of people where this might have a bearing. So, I will hand over to Rebecca. Thank you, Joyce. It is good to be here today at public Board. thank you for inviting us. As you already
know, my name is Rebecca Bauers and I am the Director for People with Learning Disabilities and Autistic People, and I am joined by Jackie Wilson here, one of our policy managers. I wanted to give you a bit of context really to the cross-sector policy
position for reducing restrictive practice and why it is so important and how we arrived at this point. Reducing restrictive practice is everybody’s responsibility and we expect everyone in health and social care to be actively working towards reducing restrictive practice to the point where its
use is rare. It is considered a failure of care across the system. In its place, we expect to see regularly reviewed, person-centred, trauma-informed care plans that are tailored to each individual’s specific needs. It is our contribution to change practice and to reduce restrictive practice,
this is a call to action for us all. The policy position does build on the 2020 publication - Out of Sight, Who Cares? and the progress report that we published into 2022. The progress report showed that too many people with a learning disability and
autistic people were still experiencing restrictive practice, including restraint and segregation. We have set three ambitions for people with a learning disability and autistic people through our expert advisory group. One of those is about reducing restrictive practice, the other is about health and wellbeing to
reduce mortality by better GP access, and the third is around community provision to reduce admission into hospital. These ambitions, alongside our business plan objectives, will direct our work over the next two years and the policy position will set the direction for the sectors and
inform our reducing restrictive practices strategy and priorities going forward. Since the publication of Out of Sight, Who cares? our work in this area has very much focused on services for people who are autistic or people with a learning disability which Joyc has already mentioned.
However, we know that restrictive practice is used in many sectors and settings we regulate, including acute hospitals, GPs and dentists, patient transport and services for older people. Our expert advisory group told us that this policy is really important because restraint and restrictive practice is
a cause of harm and trauma to the person experiencing it. The policy position is developed in response to this request from people with lived experience and CQC. So, this is a cross sector policy that is applying to all health and social care services that
we regulate. We have a full engagement plan to include the notion of a campaign and a call to action for us all, and for external stakeholders. Chris Day, Director for Engagement, will give some indication of what that will look like a little later on,
after Jackie has given some key headlines around the policy. Internally our staff will be undertaking specific training, promoting the reduction of restrictive practice that has been commissioned through building a reduction restraint network. And helpfully, as Joyce has already mentioned, Alexis Quinn has recorded a
short video to share her own experience and to explain to you why this cross-sector policy position is so important for people. So, before we go any further, I’m going to hand over to Jackie who is going to give some key headlines to the policy.
Thanks very much Rebecca. So, to summarise policy, what is important to know about this. Firstly, we expect services to listen to and understand people and to use this understanding to reduce the need for restrictive practices. So, this policy is about prevention, where possible. We
recognise that organisational culture has a role to play in this. A positive culture will promote trust between people who use the service and staff, and that kind of culture and context is vital in helping people to live their best lives. However, we acknowledge that
sometimes restrictive practices are necessary to avoid people harming themselves or other people, but, having said this, restrictive practices should never be used to cause pain or as a punishment. So, what we are about is tailoring services to people to reduce restrictive practices. In cases
where restrictive practices, such as restraint or segregation, have to be used, we expect providers to analyse and learn from their use and to better tailor care to the individual in future, but also to learn from the incidents and report to the Board or equivalent
of the organisation. Part of this analysis should include whether there was a failure elsewhere in the system in the person’s pathway leading up to this stage. As an organisation in future, we are going to be looking at ICSs, so it is important we take
that big picture, and we ask people to carry out that analysis. So, importantly we are asking providers to support people after incidents of restrictive practice, because often people are traumatised, and they need some form of therapy or support afterwards. Finally, we highlight that the
regulations we will use to enforce this are Regulation 12 and 13, that is Safe Care and Safeguarding. So, there is clarity both for our staff and for providers in knowing how we will enforce this. Thank you. Thank you, Jackie. OK, before we do play
the video Curtis - thanks for waiting - Chris did you want to just give a little bit of background in terms of the campaign, please? Thanks. So, as colleagues have said, this piece of work stems right back to the Out of Sight, Who Cares?
Chris Day - 2:29:01
Report which talked for the first time about people’s experience of restrictive practice. What we wanted to try and do with the work now with the policy position is to offer clarity. Clarity about what we felt was acceptable for people using services, clarity for what
we expect from people delivering care at the front line of care, clarity for commissioners, clarity for providers. So, this piece of work is an effort to create that clarity that has been sought by a variety of colleagues. Just want to pay tribute to the
colleagues in in the room and the colleagues in CQC who have put this piece of work together, and also to Alexis Quinn who you will hear about shortly in the video. I think, a combination of her testimony to make that change possible and also
our determination to keep this issue alive from the first Out of Sight report is, I think, really important. So, we have already published a blog, but the idea is that we would use that blog and use the information in a statement to have ongoing
conversations, particularly with partner organisations who often are instrumental in beginning that change in the wider system, commissioners and providers, and also people at the front line of care. So, they really understand the implications of this, what we are seeking to change as a result
of this. We want to encourage a better way of working; we want to encourage a move away from areas of service that we feel are toxic to people’s needs. We know that some of this is (unintelligible) detriment, and often can prolong people’s use of
services. So, the video will be played shortly, but I think this will be an ongoing campaign for us as we go into this year. It will be mentioned in State of Care this year, and our aim is to continue conversations with DHS, with NHS
England, but also with other organisations that represent commissioners and providers, so that we can really embed this way of thinking into their work. Thanks Chris. I am going to ask Curtis now to play the video, please Curtis, and then after there will be an
opportunity to ask some questions. Thank you. HI, my name is Alexis Quinn, I’m an autistic person, and was previously detained in in-patient settings for four years. During that time, restraint, it was part of my life, I would have a sensory overload. I would be
restrained; I would be secluded. then I would wait for that overload to happen again. Not much proactive, trauma-informed care really was going on, and for me I think what was happening was staff were focusing on risk and management of the stress. And in doing
so, they were objectifying parts of me, pathologizing them and that led really to a response force. So, what’s really important about this policy document that the CQC are suggesting and setting out is that it insists on a proactive way of managing and caring, really
actually, caring for people in settings. So just if you don’t mind my indulging, you with a little anecdote? I was being transferred to secure services in the back of a caged ambulance. You know I was folded in half to get inside, I was sat
on a very sort of narrow, plastic bench, there was no seatbelt, my hands were handcuffed together, my legs were tied together with leg straps, I was in there for about four hours and there was surveillance inside the vehicle. There was no toilet, so you
know when I arrived, I was so soiled and quite stinking and understandably, very sort of upset and stressed. The staff opened the doors to the cage, there was two staff on one side, two staff on the other side. You know the idea, I guess
was that I was going to kick off or I was going to try and run away. Obviously, my legs were tied, I couldn’t go very far, but nevertheless, you know, there were four staff waiting for me There was also a nurse from the unit
I was being transferred to who I knew very well. She came up to the vehicle and I was stood there, as I say, soiled, handcuffed, leg strapped, and she said to the staff, take those handcuffs, those leg straps off Alexis – we were standing
outside. The staff sort of looked at each other, like are you for real? She said, take them off. You could see the staff was really perplexed, you know, like this woman is dangerous, like are you, you know? And she said, take them off now.
Anyway, the staff took them off, reluctantly, and she came up to me. She gave me a big hug and, you know, I think this is a really important story because what it does is it shows different perceptions. One member of staff saw the humanity,
the other, the risk. When we see humanity, we are much more likely to respond with compassion, with kindness, with love. So, I am really pleased to welcome this policy document from the CQC because what it does is it makes clear that, like that nurse,
everyone has to find the humanity in people. It is not OK just to see risk and just to respond with force. It is not OK to see otherness and difference, actually we need to support with compassion, we need to be proactive and, as the
statement also says, this requires working in a way which is you know proactive. It means not considering restrictive practices as the status quo, as part of the job, but rather something that, you know, is rare. Restrictive practice should be rare. It is a failure
to meet a person’s needs. Now, after I had been restrained, you know, I was often expected just to get on with it. But what is really needed is what this policy document does, and it is suggested that there has to be reassurance, there has
to be compassion, there has to be somebody that helps the person to feel safe again. And so, this statement might increase opportunities for post-incident support, and how wonderful if managers prioritised opportunities for post-incident learning so that staff could learn from what happened and break
Mr Ian Dilks - 2:35:44
those cycles of restraint, seclusion, repeat, and think about how we can minimise trauma by for staff and the person. Finally, this policy will send a clear message that we need to work relationally from the moment the person enters a service until they leave. This
policy, I know, would have made a massive difference to me, it would have made a massive difference to the staff supporting me. (inaudible). I am happy to open to questions, Ian. Thank you, Ian. So, any questions or observations or things you would like the
RGC to look at. James. It is not a question. I just wanted to…, well, first of all, I just wanted to publicly thank Alexis for her contribution to this whole process and the work she’s done nationally at building the right support programme. Board, actually,
she is a force for good, absolutely. I wanted to, you know, as Alexis
Mr James Bullion - 2:37:04
said, this is about liberty, and it is about dignity. Whilst this process will be about understanding with providers and staff and making sure that we undertake the work that we do
in a learning way and in a supportive way, it does mean, potentially, that we should send a very strong signal to the Boards of those organisations or the management teams, that it is their responsibility in this policy to review, not just their approach, but
also individually what is happening to people. I do think that is a strong leadership expectation that we should send, as well as operating the policy in an absolutely fair and supportive way, and recognising that, sometimes, it is appropriate the use of that kind of
restraint, but the rarity that is being suggested on the video needs to become the norm. Thank you. Thanks James. Belinda. So, yes, I
Mr Ian Dilks - 2:38:03
agree, you know, restrictive practice needs to be reduced, That has been in the Mental Health Guide since 2015 and NHS England
Ms. Joyce Frederick - 2:38:11
have been doing work on it since 2016-2018. They have done loads of projects and they have seen massive reductions in restrictive practice in areas where they have targeted. I think my concern is that, sometimes, restrictive practice is necessary, and we don’t want to demonise
the use of appropriate restrictive practice that should be used rarely and should be thoroughly reviewed when it has been used. I think a plea for that really is that we need a more balanced approach. You know such a practice ranges from locking the door
on a dementia unit to restricting people’s access to outside space. It is not all about restraint and seclusion, which are the sharper ends of restrictive practice. I think the plea really is that whatever practice health and social care staff use, it should always be
done with care and compassion. So, that is the right way that we are going to get the best care for people, not by saying we shouldn’t do this, we shouldn’t do that. All practice should be delivered with care and compassion which, I think, is
exactly what Alexis said. So, it is more of a comment really. (unintelligible) I was just going to say absolutely Belinda, that is what our policy position is trying to set out for, that balance and that whole person-centred approach, thinking about people’s best interests. You know
and just making sure we are doing the right thing at the right time across the health and social care sector for people to lead their best lives really. So, thanks for that. David. I thought that an excellent film if I may say so, it
really hit the point. Two things, questions for you really, are you familiar with Professor Joy Duxbury’s work at Manchester Metropolitan on reduction of restraint? Because she has done some really good papers on that and if you are not, may I recommend that you look
at them. And the second thing is Ben Higgins who is the Chief Executive of something called Restraint Reduction Network, is that part of…? Absolutely, he is a colleague of Alexis at… and we have worked closely with him and the Reduction Restraint Network to commission
our training for our staff internally. That would go quite a long way to answering Belinda’s point, I think, which is you know they have taken quite a grown-up view about it. It is necessary at times, it is about sorting out when it is necessary
Mr David Croisdale-Appleby - 2:40:43
and not lurching towards it as a sort of well, in case something goes wrong, we will be quite extreme about this. But his work, that network is informed by Joy Duxbury’s work, so do look at that. We will do, thank you. Thanks, David. Christine. Thank you.
I mean I was moved by Alexis’ experience as well. I think she
Mr Ian Dilks - 2:41:12
highlights very clearly the sort of extreme end of restrictive
Ms. Christine Asbury - 2:41:15
practice and restraint. I think one of my concerns is that restrictive practice, particularly for people with dementia in residential care, has become
the norm in many situations. You know, locking doors between floors, blocking access to external environments, and if I had my way you would have the model of the Hogeweyk – I don’t know if anybody has heard of it, in Amsterdam - where actually people
can move freely all around the campus. That is the ideal, that is what we would love to see, but the reality is that there are a lot of - particularly smaller providers, but sometimes you know the high-end providers in social care - where actually
doors are locked and sometimes that is because the premises don’t allow for safety. There are stairs that people will fall down or things like that. I think that locking doors and that restrictive practice was particularly an issue during COVID, where people were having to
be isolated for 14 days. That is very difficult for someone with dementia to be asked, to be forced to stay in their room, so there is a lot of issues, it’s complex. I think there needs to be some balance, although not too much balance,
and possibly some work looking at how we can help those who have got the least in the way of resources as providers to recognise that they can change their practice and do things differently. Because I think there will be some catch up with people
for whom the culture is restrictive before they actually recognise…, before they are able to implement change. So, I just think those are things - I don’t quite know what the solution is, - but those are things to take into account. Thanks. Any other questions?
I think, I did say it is one of the things we need to consider at the Regulatory Governance Committee, and you will remember anyway, Christine. So, it may be that particular point would be worth picking up when you have the discussion there. Because I
think what I’m hearing is violent agreement, we need to approach, following agreement, with generally what you are saying, but just a little bit of concern around the application of this at the margins and making sure there are unintended consequences. So, if, I don’t think
we need to report back on that particularly, but I think if you could pick it up on the RGC? What would also be helpful at some stage, as I am sure you will be reviewing the efficacy of this in practice, it would just be
useful to make sure we are doing that and we understand at the margins whether it has achieved its aims. I think you indicated that it is really combination of two things. One is providing guidance as to what is good, reminding providers of our obligations,
but also that consistency between our approach and their approach. I think having a document we can hang our hats on that achieves that would be really helpful. Joyce, sorry. I think you actually covered it, because it wasn’t about just we do an assessment and
then we tell providers what they are doing badly and then come down on them hard. But we have got a raft of different regulatory levers that we can use. One, would be providing guidance, two would be how do you support improvement in the sector?
How do you support learning and understanding? And that is what we intend to do, and that is part of the improvement campaign that Chris was talking about and the work that the policy is delivering. I think that what is at the centre of this
policy is to make sure that it’s person-centred. So, even if people can’t think, well, how do I do this, how do I cope? If they look at the person in front of them and think what’s right for this person in front of me and
how can we make it work for the person in front of me, bringing that humanity and compassion back into care, I think that would go a long way. Even though they may not have had the training or the understanding, but just that that understanding
from that individual perspective. Sorry, I haven’t got my microphone on, which is always, of course, very impressive, but thank you for
Mr Ian Dilks - 2:45:33
joining us. We…, I think I have James White joining us, so Nina, if you could bring James in? We have probably set our

3.7 Market Oversight Update

presenters the impossible task of delivering a lot of insights in a very short space of time. James, welcome. I don’t think most of the NEDs on the board will have met James, I mean he can introduce himself, but just say he is the Interim
Head of Market Oversight. Apart from the ask, I think it was an excellent opportunity for him to meet you and you to meet him. We have only allowed 10 minutes for this. James, we are actually running about half an hour behind, so use the
10 minutes, but if we could ask you not to run over. In his deck he has given an introductory slide which shows, sort of highlights key elements of our process. Very aware that some of the newer NEDs may not be familiar with that, so
you will, if you haven’t covered it yet as part of your induction programme you will in due course. If you have got any more immediate questions on the process we go through, perhaps you would take that offline with James. What I would like James
to do is focus on some of the learnings from what we are doing. James, over to you. Thanks, Ian. Given I have only got five minutes, I will probably jump straight in. In terms of my background, I have been with CQC five years, formally
at Head Off. before this role. So, I’m going to provide some further details with regards to actions available to Market Oversight when we identify a provider at Stage 5 within the six-stage operating model. When a provider is at Stage 5, we have identified significant
risks to financial sustainability, so our action is all around trying to de-escalate risk and attempting to further our understanding around likely business failure and likely service cessation, which is really our statutory role So, one of the options available to us, which is in the
paper, we can instruct an independent business review of a provider’s business. That would normally be carried out by an external accountant with a restructuring and turnaround background, and that IBR - independent business review - would really be focusing on any aspect of the provider’s
business which we have serious concerns around. So, for example, if we are concerned around the short-term financial projections and cashflow, the IBR would focus on that and provide feedback and advice to us. Another example would be if the provider was looking at having to
refinance its bank borrowings, and we had concerns around that, the IBR would also comment on that. A second option available to us when a provider is at Stage 5 in the operating model is, we can ask the senior management team of the provider to
give us a risk mitigation plan. A risk mitigation plan is really we are asking senior management to tell us what they are going to do in regard to risks we have identified in relation to the provider’s business. So, an example would be if that
provider’s business turnaround is really predicated upon raising additional monies from shareholders. If we are seriously concerned about that, we want to know what their plan B and what their plan C is, should they not be able to raise those monies from those shareholders. So,
as I said, it is all about mitigating the risks we have identified. I will now move on to look at the financial performance of the MO providers which is in the slides for the period to 31st of March 2023. I think my general comment
is it continues to be a challenging time for the MO providers during that period. We have seen further compression of EBITDA margins, and EBITDAM is probably our best proxy we have for our Market oversight providers in terms of profitability. Look that is really down
to probably two key factors interacting, staffing challenges remain in terms of recruitment and retention has made it difficult for those providers, and the general inflationary environment has also contributed. In terms of that inflationary environment, probably one of the key drivers there has been that
spike in utilities during those winter months. I will now look at the, I suppose, the sub-sectors we look at within ASEMO providers. Firstly, care homes for older people, it has been pleasing to see staff costs have been moving in the right direction. But unfortunately,
those staff savings which providers have been able to make, have really been outweighed again by those general inflationary environments and in particularly those utilities.. In terms of domiciliary home-care providers, the continuing trend which we have seen over the last two years, and it has
been decreasing recently, is hours have continued to reduce. That is really a deliberate decision by the management teams of those providers to try and protect their profit margins as best they can. The key driver of their revenue is LA work and what they had
been doing there with that LA work is certainly looking at it, contract-by-contract in terms of profitability, and if they are not satisfied with the profitability, they are taking actions such as refusing additional hours, letting contracts run to the end of their term or not
re-tendering on work. The final sub-sector is specialist providers within market oversight providers. Look, it has been pleasing to see agency has declined for the last two quarters through to that March quarter, but for some providers, it is at some really elevated levels, and the
problem that has for specialist providers is that because of the high-acuity nature of specialist providers, a lot of that care is one-on-one. So, it really does bite into the profit margins when you have got a nurse there, delivering one-on-one care, and it can take
it from a profitable care provision to a loss-making provision just from the use of that agency use. I will now move on to the final part of the pack which was around the outlook through the MO providers. Look, we have had some more recent
data since that 31st of March quarter, and we are obviously in constant engagement with our providers. Look, I think I can say it remains a challenging time for our providers it will remain challenging, but there are some green shoots of recovery there. Occupancy for
older people’s care homes as at the 1st of September is slowly and steadily increasing, and it’s reached 86.8% which is pleasing to see – that is past our estimate of break-even for those care home operators. In terms of staffing and recruitment, again, there seems
to be improvement there in terms of providers are telling us that vacancy levels are down and there is a general improvement in the labour market, but it remains a difficult time to recruit and retain staff. Further to that, agency for certain providers is still
moving in the right direction, but, as I mentioned earlier, for some providers it has really got quite embedded in their businesses. I think when agency gets embedded in certain levels in businesses, it is a long, hard fight to reduce that and try to bring
that down to levels that the providers want them to reach. Finally, in terms of LA fee uplifts, we have kind of seen, broadly, a kind of 8 to 10% increase for the 2023-24 financial year. Look, that is a material increase, but it needs to
be given the inflationary environment these providers have been operating in, particularly with the national living wage increase of, I think, you know, close to 10%. That is really my summary of that pack. I’m just wondering if anyone has any questions. Thanks very much indeed,
James. I think we have only just instituted the idea of Head of Market
Mrs Belinda Black - 2:53:37
Oversight coming to talk to this Board the year, although it is of
Mr Ian Dilks - 2:53:40
real concern to governance and usually important part of our work. But also, I think it is quite useful
just to put out in the public domain some of the learnings. What James has brought out, which perhaps we didn’t cover last time, is in addition to the early warning of the system, if you like, is actually the fact that we go in. And
in some of these cases this is itself a contributor to avoiding failure. We can’t ever claim that, we can never talk about examples, but, you know, I think there is a real value-add had from this organisation dysfunction in that area. Questions from anyone? James,
a comment, and the Stephen, a question. Yes, you anticipated me there. So, I just wanted to echo the point that you made, we are not supposed to be a deterrent, but we are meant to be a beacon as it were. I wanted to point
out that it is a really important function for local authorities, it is not just a function up to government to give them, as it were,
Mr James Bullion - 2:54:40
assurance or risk, but local authorities work with us on the potential consequences of, if we have to get to
a Stage 6, it is really, really critical for working with those people who would end up with the duty to provide the care that results from the failure. So, it is a really valued actually dysfunction of CQC. Stephen. Really helpful, thank you very much
indeed. A couple of questions it raises for me. One is kind of extrapolating these trends, where is this possibly taking us? Because there has been a decline in profitability. I think from some other
Mr Stephen Marston - 2:55:28
papers we’ve seen recently, there is an overall shrinkage in supply.
And there are increasing imbalances across the country where providers can keep going if they can access the self-funded market, but it’s a lot harder if you’re reliant on the local authority-funded market because the rates aren’t going up. So, where do we go with this?
We can monitor it, we can watch it, we can alert people, but is there something more we could and should be doing that creates insight for local authorities, for ICSs, for whoever about the long-term supply trends and the market exit trends that you’re seeing?
I think it is the 64-billion-dollar question. But James, do you want to comment, and then, Ian, maybe should as well because, you know, it is something that we do talk to people about. Yes. Look, I will certainly have a stab at answering that. I suppose, overall, as I
said, that the market does remain fragile. You know recent government support has helped in terms of the (unintelligible) funding and we are entering into…, coming into the winter months. So, who knows exactly what that might mean? In terms of, you know, that 64-million-dollar question,
it is probably not really Market Oversight’s place to, I suppose, answer that, other than… I note your comment about the self-funded point in terms of, you know, we have certainly seen that in terms of care homes where they’ve got that greater focus on self-funding,
it can assist, that certainly is duly noted. But as I said, it is probably not really a question I can ask in terms of Market Oversight’s statutory function is to basically identify financial sustainability concerns for potentially difficult-to-replace providers. Ian. Thanks Ian. I think it
is a really good question Stephen, and it is something we constantly talk about when we are looking at specific providers. I think a couple of things. One is what you are in essence describing is, do we want to
Mr Ian Trenholm - 2:57:43
step into the market management space?
Can we be more proactive in managing the market and the short answer to that is no, we can’t, because we don’t really have the legal powers to do it. I guess, ultimately, it is the responsibility of government, and it is a conversation in the
live conversation we have with government around who is the provider of last resort in the event of a large care home group goes bust or multiple large care home groups go bust? And it is a conversation that James and colleagues have in a very
sophisticated way with government, with named providers and talk to banks, and so forth. I think the opportunity for us, though, because I think it is always important we think about the (unintelligible)of opportunity. The opportunity for us is in our ICS work because I think,
in our local authority anyway, we are building relationships with local authorities and ICS organisations in their many and various forms where I think we can use those relationships to start to have conversations around whether the right amount of money is being paid locally, and
so on. And whether the right types of service are being delivered. Because I think we had…, earlier on in the pack, there was the point about increases in volumes in registration applications. Some of that is driven by this in the sense of providers looking
for specialty, ways of delivering services, changing their registration in order to find more profitable ways to exist. To being in a position, to explain that and then work collaboratively with local authority partners is probably a space we could probably do more in over the
course of time. But then in terms of tangibility, provider of last resort type or operator of last resort, as you would see it if it was a railway franchise, then we are not in that position and I don’t think government wants to be in
that position either, to be to be frank. But maybe it is a conversation that that needs to be had at some stage. Thank you. Christine. I think this links a little bit to the previous topic about restrictive practice because one of the most dangerous
Ms. Christine Asbury - 2:59:53
areas that I understand is specialist providers, so autism, severe learning, disability, challenging behaviour. Also, I don’t quite know how the market oversight works, but it may well be that at national level a provider, a specialist provider like that is doing OK, but actually in
certain areas they are about to hand back a contract. I heard of one area, I think, they are getting a 2.2% fee increase, and then it is really about viability. So, you could have just a local area rather than an overall provider about to
exit the market, but they are exiting the market in one area, and because it is specialist, you need the sort of specialist skills, it’s more likely that you are going to end up with more restrictive practices and more difficulties. So, I just wonder how
we deal with that and how we reflect that. Yes, that’s a really good point. In terms of parameters for entry into market oversight, it has been set up under the regulations so that it captures large national providers, but also regional providers of scale. So,
it may well be those providers, where you are talking about a regional presence, they could well be in market oversight because of those parameters. And in terms of contract hand back, so it’s something we have ongoing engagement with providers in market oversight to understand,
one, is that occurring, two, what does that mean around the financial sustainability? But it also helps us understand the wider market, and that is something in terms of market oversight. We do act as something, I suppose, almost an honest broker in terms of…, a
bit like a sponge, we get a lot of data and information and engagement with providers, and we do filter that back to wider government so that you know it informs them in their decision-making and understanding of the market. Your point is well made around,
you know, you could have it at a very local level where that is the sole provider of that specialist service. But, as I have said, market oversight is really set-up with those parameters to catch large regional or large national providers which are potentially difficult
to replace. (inaudible), sorry, David. James, some of the some of the comments I get from local authorities or from the integrated care
Mr David Croisdale-Appleby - 3:02:14
boards is their worry over in the care market, the highly leveraged large organisations who they fear could just suddenly walk away from
it because of purely financial considerations, in a sense beyond the capability of their own management to deal with because they are highly-leveraged. So, an instruction might come down, get out of this, just as it did with Circle in the NHS. Can you look at
that or not, is that out of scope for you? It is, it is out of scope. We look at market exit if it is due to business failure and essentially service cessation, but if a provider with market oversight, might well be private equity-based, decides
it can deploy its capital elsewhere, it may be another sector and get a better economic return, we’re not in a position as regulator to stop them exiting the market. It might well be their business may prosper in the hands of another operator, in terms
of assets it could go to an operator with maybe a stronger balance sheet, or it could be split up, and some assets end up with a not for public, not-for-profit charitable operator. So, yes, to answer your question, we are not in the position to
stop a provider exiting the market. Can you take account of the fact that we know that some of these organisations are heavily-leveraged because you know their accounts demonstrate that, does that allow you to sort of have a word early on about what kind of
alternative provision might be around, etc? Or is that…, do you have to wait for it to be triggered? Yes, look, unfortunately, with a provider, whether it’s highly leveraged or not, we look at a lot of, I suppose, factors in terms of assessing their financial
sustainability and high leverage would be one of those factors. But in terms of alerting LAs in terms of their duties under Section 48 of the Care Act to ensure no cessation of care as a result of business failure, we can only inform them of
that when we make a Stage 6 notification. We can’t act as, I suppose, a de-facto credit rating agency either. James, you have answered the question, thanks very much. I was going to say, I think he can probably explain more to you later, but just
to be clear, James, correct me if you disagree with this, but, you
Mr Ian Dilks - 3:04:45
know, there are limits to what we can do when looking at financial structures of groups, but of course, if a group is highly-leveraged and that is visible, let’s say within the UK,
certainly if it is big enough to go on to the scheme, then it is the sort of thing that we do look at. We would probably bring a real structure, struggle to have any sight in the UK, but could be much more profitable somewhere
else delivering business and just decided to shut down to re-deploy the capital, that would be difficult. The more likely scenario is that before you got there, the UK operation or an entity, as a result of being highly-leveraged and other things, was starting to look
dodgy. In which case, yes, I would think James would be (unintelligible) up under market oversight. I think that is the…, if you look at examples where we have had to report things in the past and that it does cover that. So, I wouldn’t want
the message to get out that we are oblivious to high-leverage, where it is visible and available to us, it is looked at and steps can be taken. James and colleagues, I mean there’s a reasonable-sized team, they do go in and talk to people and
have a pretty good understanding of the other structures, which is why James and his colleagues come from things like insolvency and restructuring backgrounds, but James can explain in more detail when you get to that stage. If there are no other comments, James, sorry, we
didn’t give enough time to really display your wares, but, thank you very much a. for covering that so succinctly, and also we should thank you for stepping in as the Interim Head of this area at very short notice. I mean it seems to have
been seamless from my perspective, so thank you very much indeed for that. Thank you. A few last items. There is one item to approve which
Mr Ian Dilks - 3:06:32
is the 2023 Performance Summary. I think we are being asked to approve the principle rather than a specific document.
So, perhaps Kate or Chris, I think we have mentioned this plan before, but if I could ask you to very briefly mention what’s being proposed, I might ask Jeremy to comment because this was on the Audit Committee agenda the other day. And then we
will take any questions, see whether people have any before we agree. I can do that, Ian. I’ll keep it brief because I am keen to get a train home tonight. Well, I forgot to welcome Stephanie, welcome
Chris Usher - 3:07:10
there. Steph is also keen to get a train home. So, every year we produce an annual
report and accounts that will include a summary of our performance for the year in question. That will outline how we have delivered, how we made progress against our strategy, et cetera. The challenge we have got is the last two financial years, our annual report
and accounts have been severely delayed due to issues with local government pension schemes, the auditing of that which is completely out of our control, and it is affecting organisations other than us. But it has meant in the example we have just been through that,
it has 15 months after the end of the financial year before we published our annual report and accounts. What we have been keen to do to bridge the gap is to create a standalone document around our performance for the financial year 22-23 that we
can publish and detach ourselves from the annual report and accounts, which will obviously be…, we will be published in in future in due course. So, that is what this summary document is. We would look to publish it onto our website in due course and
offer any comments or questions on that. Thanks Chris. Jeremy, do you want to add a couple of words about the role of the ARAC? Yes, definitely. I think the first point to note is that this is a plan. It isn’t something we are doing
accidentally because we knew that the council were going to be late again. And the other point to make is that, as we sit at the moment, this is consistent with the draft annual report and accounts, albeit that that won’t be formally audited and covered
Mr David Croisdale-Appleby - 3:08:36
Mr Jeremy Boss - 3:08:37
until later on,, but it is consistent with it and we can give that assurance from ARAC that we have gone through the same process as we would have done for the annual accounts. OK, so as you say it is a plan we are proposing.
I think the reason it comes here is we don’t have to do this, so we’re
Mr Ian Dilks - 3:08:56
taking out a few risks, at least in theory, not least that the document could have numbers in it when we finish the audit change. It is a) probably unlikely
that it wouldn’t be…, I would say the risk is pretty small because this is unaudited, we are not claiming it is. But I think the concept of being able to explain to the world something about our performance of what we are doing six or
nine months earlier than audit regulations will allow us to do is, personally, very sensible. So, not subject to audit, but we will do our very best through Jeremy’s ARAC to make sure that it is factually accurate, so we have a process for doing that.
So, this is really more about the principle, if you think that something should be radically different, raise it, but that then increases the risk that we have got a problem when the audit of the accounts is published later. So, are we happy with the
broad proposal? Mark. Just a question, I think it’s a very sensible idea, given the reality that we face in terms of when the audited accounts will be available. Once the accounts are published, is this
Mark Chakravarty - 3:09:58
going to be sunset and removed, is it something that
is a temporary document, that is transient and then disappears, or would they both exist in parallel? That is a good question, Mark. One I hadn’t really considered. Chris, you look like you want to come… Sorry, thank you, yes. My view would be that it
should be sun-setted and be replaced by, so you wouldn’t have effectively two narratives on one year, but as Chris said, the fact that it takes 15 months to get the last bit of the account signed off means that this should there should be a
precursor to what will be the full accounts. There may be an ask there which, I think is a sensible approach. Just to sort of say this, this
Chris Day - 3:10:41
would be then sunset, replaced by audited accounts. The only thing I
Mark Chakravarty - 3:10:45
think we need a plan for
is if there were a delta, at what threshold do we need to publish any kind of explanation of the delta that existed between a previous document that was in the public domain and a future document? So just understanding what the sort of intolerance is.
I think it is difficult to pre-agree a threshold because we said the probability is that there won’t be differences. But it is a good
Mr Ian Dilks - 3:11:07
question, we need to think about it, but I think it’s difficult to make decisions now. I mean there is one
bit of logic of leaving it out there as a parallel document which is that most people, with due respect to the accountants in the room, which I suppose my heritage is one, but most people don’t get beyond the performance report with the reading of
the document. So, there is actually some logic in having a separate performance report and then leaving the other 100 pages for those who are interested in and understand government accounting. I apologise if I have in any way offended you, Jeremy, but you wanted to
comment. I think it is just worth making the point that the performance report even in the annual accounts is not formally audited
Mr Jeremy Boss - 3:11:46
in that sense, but it is checked to make sure that it is consistent with the accounts. So, I guess if we did
have some sort of inconsistency that we found, then I think we would need to explain that in some way, either in the accounts or as an addendum to the document. I am not in favour of sunsetting reports because you can’t take them away, they’re
out there, aren’t they? People don’t un-download them, do they? But that we have, to some extent, we have to explain and be transparent is probably the right approach. Ian. Yes. I mean, I think what we did this last year was we wrote the annual
report and accounts, it took a long time to be finished off, and then
Mr Ian Trenholm - 3:12:23
we just did a refresh of the forward and the summary because we realised that it was kind of dated because it was from the COVID period, so did it really make
sense in the context? So, there was a sort of…, there was almost a check there before final publication, and I suspect we will do some version of that this time round. OK. So, I think we are approving the principle as at some stage where
we have reports back on progress of the ARAC, we can re-address and consider what we’re doing here. Thank you very much indeed Chris, and for your input, Jeremy. Board Effectiveness Review was down for me for an oral report to note, this is very quick.
All I would say to colleagues, just for confirmation, we did a Board Effectiveness Review, very limited in scope this year in the sense it
Mr Ian Dilks - 3:13:11
was purely internal. There were not that many recommendations coming out of it. I sat down with Sasha, we either have
addressed or are in the process of addressing the things in there, some of which you have seen. The only other bit I would flag is that, combining also with the results of the sort of review of the school set of the Board, there will
probably be some training programmes or development programmes for the Board as a whole, with a particular focus on the NEDs, to the extent that the Executive may have seen some of this earlier. But the timing of that will depend on the speed at which
we can get the final appointment of the Board. We asked for recruiting for a new full-time ARAC Chair or permanent ARAC Chair to replace Jeremy. So, I will take a view on when is a good time to run it Ideally, I would like to

4.0 Matters for Board Approval

wait until we have a full board, but we can’t wait forever, and we are in the hands of government for that. The minutes of the Board meeting were circulated in advance, I don’t think we got any comments, so are we happy to take those

5.3 Minutes of the previous Public Board meeting held on 19 July 2023

5.4 Review of the matters arising and the action log

as approved? Thank you very much. The action log has only got one item on it that is shown as green because it is due in November, so that’s fine. Any other business from anybody before I close the meeting? OK. Well, we will close the

6.0 Any Other Business

7.0 The next meeting is scheduled for 29 November

meeting at that stage. Apologies to those of you listening in who may be inconvenienced and apologise to my colleagues for running over, but it was such an important topic we discussed earlier on people. I think that had to be the right thing to do.
So, thank you very much for bearing with us. I will close the formal bit of the meeting down, but as usual we do have one or two questions from the public that we have said we will take. There is actually four today. The first
is actually a rather unusual one. I mean it is from a commercial organisation who clearly wants to do more business with the health and care system, but it was asked, so I think it’s only right we should give them an answer. Chris, I think
you’re going to deal with this. So, from a Claire Giantzides, the Chief Product Development Officer of Tendable and the question was, what is the correct channel for a software provider working with the NHS organisations to monitor and improve quality of care to engage in
the ongoing CQC transformation programme? So, I think the answer to the question, we engaged many commercial enterprises who have innovative solutions for both the health and the care sector and we regularly work with them. In fact, we recently published an article which focused on
a number of areas of innovation. So, we’re always interested to hear innovation that comes from organisations in different areas, and we are usually used to forming an idea of about what we think about that and sometimes use them as case studies. So, you’ll see,
for example, in State of Care which will come out in a couple of weeks, there’s a few examples of innovation that we’ve seen, both in technology and also in terms of how services are delivered that we will use. So, if you have got good
insight, I think my e-mail address is certainly available through the Board and other colleagues. We are always interested in good ideas around case studies. What we are really interested as well is how it is adopted in an area, so good idea with an idea
about how it has been adopted in one or a number of organisations. But we are very really keen, so please get in touch. OK, thank you very much, Chris. Then, we have three from Mr. Robin Pike. Nicola, I think in Sean’s absence you’re taking
the first which was how does CQC regulate the performance of hospitals in their management with two-week cancer referrals? Thank you. The first thing I would say is that NHS England monitor the performance of hospitals in regard to the two-week wait standard. Inspectors and inspection

6.0 Any Other Business

Mr Jeremy Boss - 3:17:15
teams do review the whole suite of cancer waiting time standards
Nicola Wise - 3:17:19
alongside other metrics as part of ongoing monitoring of providers and that informs both our engagement approach, but also does inform inspection. Within our inspection framework, we do have specific prompts around timely access to
diagnosis and access to care, and of course, if particular issues or concerns are identified, we would be raising and following that up with providers, with ICBs and, of course, with NHS England partners as
Mr Ian Dilks - 3:17:59
appropriate. This picks up a really important point about the relationship
between organisations and people’s experience of care through a
Chris Day - 3:18:08
pathway. So, we have a number of ways in which we do that. Probably the most obvious is through the use of Give Feedback on Care. When people describe their care journey to us, they don’t talk
about individual organisations. They often talk about the relationship between primary care and adult social care and secondary care, so we use…, we get a lot of information through that route and that helps inform our view. Secondly, we will work with local partners, so they
may be groups who represent people locally or they may be organisations that are part of the delivery in an area and we will use both to form a view of how discharge arrangements, how referrals, how transitions between different groups are working. We have used
it in the past to form a view of a good practice between primary care and secondary care, in particular, and also where we need to see change and improvement. I think this will be helpful not only for our regulation of providers, but also for
our regulation of ICSs moving forward. Thanks very much and then the third, last question. How will CQC regulate the performance of ICSs in
Mr Ian Dilks - 3:19:21
respect of their engagement with the public and patients? Again, a really important point and a really important question. We, as I
think we described earlier in the conversation, are currently testing
Chris Day - 3:19:27
our approach to both ICS and Local Authority assessments. Part of that assessment will be, most, in fact all ICSs and all local authorities have a view about how they intend to engage or how they
do engage people to use services in their area. I guess part of our approach is looking at what’s the theory and practice of that in an area, and how do people who work for, people who represent people using services, how do they feel about
that, that engagement that they’re having? We are setting out, under a number of different areas of our work, to look at the relativity of that in different areas, so what is working well, where are local authorities or ICSs challenged? We want to use an
understanding of that to really guide both ICSs and local authorities in terms of what good practice looks like, but critically for me, the work of ICSs and the work of a local authority in this area starts with their understanding of people in their area.
We have said in other places that ICSs, they start in different places, but understanding where people who use their services start, that is the start point to how they address the issues in their area. OK, very comprehensive answer, thanks very much indeed, Chris. So,

7.0 The next meeting is scheduled for 29 November

that also deals with all of the questions from the public, so for
Mr Ian Dilks - 3:20:50
those listening in, thank you for bearing with us and we looked forward to seeing you at the next meeting in November.