Participant experience of a Care Quality Commission inspection

Transcription

1 Participant experience of a Care Quality Commission inspection Oates J (2015) Participant experience of a Care Quality Commission inspection. Nursing Standard. 29, 48, Date of submission: November ; date of acceptance: March Abstract The Care Quality Commission (CQC) is the regulator for health and social care in England. It sets and monitors standards of care and has legal powers to take action when those standards are not met. The CQC now regulates primary care as well as hospital, community and social care, with significant influence on nursing practice and the conduct of care. This article explains the role and function of the CQC and the circumstances in which its current model was devised. It discusses the commission s comprehensive inspection approach, with particular reference to mental health settings. The article aims to demystify the inspection process and put it into context, drawing on the experiences of a director of nursing, an expert by experience and a nursing specialist adviser who participated in a comprehensive inspection. Author Jennifer Oates Registered mental health nurse, PhD student and independent clinical member of the governing body, Brighton and Hove Clinical Commissioning Group, Brighton, England. Correspondence to: jenniferoates@nhs.net Keywords Care Quality Commission, comprehensive inspection, conduct of care, experts by experience, inspection policy, nursing care, regulation, specialist advisers, standards of care Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines THE CARE QUALITY Commission (CQC) announced a revised approach to the inspection of health and social care settings in England in spring 2013 (CQC 2013a). Since then, comprehensive inspections have been piloted in acute general, community, mental health and primary care trusts. The CQC chair and chief executive described 2013/14 as the year of considerable change at the CQC in terms of leadership, organisation and governance, as well as change to the inspection approach (CQC 2013b). Understanding and dealing with this revised approach is challenging for nurses, and the prospect of participating in a comprehensive inspection is daunting (Brown and Hilson 2014). Role of the Care Quality Commission The CQC is the regulator for health and social care in England. It monitors the quality of health and social care services and the care and treatment of people detained under the Mental Health Act. The CQC is a non-departmental public body, accountable to parliament and the secretary of state for health, as well as the public. It was established in 2009, taking on the remits of the former Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission (The King s Fund 2010). Monitor ( organisations/monitor) is the economic regulator for health services in England. Regulation is the legislative framework within which the NHS and independent providers should carry out their work (Maybin and Harrison 2008). The role of the CQC as a regulator is to set standards, to register services that meet those standards, to monitor and inspect registered services and to take action where standards are not met. The powers of the CQC are set out in the Health and Social Care Act Details of these powers are provided in the regulations that come under the act: the Care Quality Commission (Registration) Regulations 2009 and the Health and Social Care Act 2008 (Regulated Activities) Regulations Regulations on new fundamental standards (Box 1) became law from April 2015, replacing the 16 previous essential standards. Inspection and monitoring by the CQC measures services against these new standards. Changes in response to criticism of the CQC The CQC was subject to sustained criticism from the time it was established. This culminated 42 july 29 :: vol 29 no 48 :: 2015 NURSING STANDARD

2 in the Performance and Capability Review: Care Quality Commission, which included recommendations on how the CQC s model of regulation should be delivered and evaluated (Department of Health (DH) 2012a), as well as the resignations of the CQC s chief executive in February 2012 and the chair in September Failings in the CQC approach to identifying and responding to signs of potential harm to patients were noted in both the review of care at Winterbourne View Hospital, Transforming Care: A National Response to Winterbourne View Hospital (DH 2012b), and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2010a, 2010b, 2013). Both reports criticised the CQC for failing to act on information that suggested patients were at risk, for not responding to whistleblowers and for an organisational culture of bullying and lack of clear strategic oversight. As a result of these criticisms, the new fundamental standards, against which the CQC inspects, include regulation 20: Duty of candour and regulation 5: Fit and proper persons: directors (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). Francis (2013) observed that the CQC was not a mature organisation at the time of the Mid Staffordshire NHS Foundation Trust Public Inquiry, and that it was not sufficiently resourced to fulfil its remit. The inquiry found that there had been a focus on registering providers, rather than monitoring their compliance with standards through inspections. The inspectors were too generalist, with portfolios covering too many types of service for them to establish expertise. Furthermore, the full range of information available about health and care providers was not being analysed when profiling risk, and there was insufficient input from patents and clinicians in the regulatory process (Francis 2013). Following the Mid Staffordshire NHS Foundation Trust Public Inquiry, the secretary of state for health asked Don Berwick, an American health expert, to lead the National Advisory Group on the Safety of Patients in England (NAGSPE). The group reviewed the recommendations of the Francis report and accounts of the inquiry, and in August 2013 published A Promise to Learn A Commitment to Act: Improving the Safety of Patients in England (NAGSPE 2013). This report identified the main lessons learned from the Francis inquiry as poor priorities, lack of accountability and warning signs being ignored, and made ten recommendations for change. The emphasis was on improving patient safety through a commitment to organisational learning and a focus on quality and patient experience. The report also called for transparency and accessibility, with simple supervisory and regulatory processes (NAGSPE 2013). The secretary of state for health also asked Sir Bruce Keogh to review the quality of care and treatment in 14 acute trusts with persistently high mortality rates, to determine if the issues identified at Mid Staffordshire NHS Foundation Trust were apparent elsewhere. The Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England was guided by the principles of patient and public participation, listening to the views of staff, openness and transparency, and co-operation between organisations (Keogh 2013). A new start for the Care Quality Commission The new start for CQC inspection was launched in April 2013 and piloted from September that year. The three-stage review process used by Keogh (2013) informs the CQC comprehensive inspection methodology. It consists of three stages: 1. Data gathering and analysis. 2. A rapid response review visit from a team of inspectors, clinical experts and patient representatives. 3. A summit meeting to review the findings of the on-site review and agree an action plan. The new start CQC model was also informed by the approach used by schools regulator the Office BOX 1 The Care Quality Commission s fundamental standards Join our First Friday Twitter discussion on issues raised in this article on Friday August 7 from to 1.30 using #NurseJC Care and treatment must be appropriate and reflect service users needs and preferences. Service users must be treated with dignity and respect. Care and treatment must be provided only with consent. Care and treatment must be provided in a safe way. Service users must be protected from abuse and improper treatment. Service users nutritional and hydration needs must be met. All premises and equipment must be clean, secure, suitable and used properly. Complaints must be appropriately investigated and appropriate action taken in response. Systems and processes must be established to ensure compliance with the fundamental standards. Sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed. Persons employed must be of good character, have the necessary qualifications, skills and experience, and be able to perform the work for which they are employed (fit and proper persons requirement). Registered persons must be open and transparent with service users about their care and treatment (duty of candour). (Care Quality Commission 2015a) NURSING STANDARD july 29 :: vol 29 no 48 ::

3 BOX 2 for Standards in Education, Children s Services and Skills (OFSTED), in that a rating of outstanding, good, requires improvement or inadequate A specialist adviser s view of the comprehensive inspection process I am a nurse consultant in a large mental health and disability trust in the North of England. Until this year my experience was that of a senior nurse with almost no knowledge of Care Quality Commission (CQC) work. I was critical of the point-in-time aspect of inspections and somewhat resentful of inspection reports, which I saw as unhelpfully critical and not adding usefully to patient care. My perception was that they ran the risk of being too superficial. Having been seconded to act as a specialist adviser to the CQC, my views have altered somewhat. Being a member of inspection teams has allowed me privileged access to staff and users of services and I have learned a lot, which has enriched my own practice, as well as having benefits for my parent trust. I am sure the new style of inspection is an improvement on the previous approach and allows a deeper dive into the organisation being inspected. I am less critical, but still sceptical, about the point-in-time nature of such inspection, but I worry that the cost is prohibitive (most clinical teams I know are aghast at stories of large teams of CQC staff descending on a trust). I now have a much better understanding of regulation and its importance. I am more appreciative of the importance of good governance. Most significantly, while I am willing to cast a critical eye over my own services and trust, I am impressed by how the independence of a CQC inspection is powerful, and doubt that self-regulation can ever really be as thorough. Paul Veitch, nurse consultant at Northumberland, Tyne and Wear NHS Foundation Trust BOX 3 An expert by experience s view of the comprehensive inspection process I have been an expert by experience in Care Quality Commission (CQC) inspections primarily of mental health wards and services for nearly four years. My motivation for taking part in inspections was partly my own experiences of mental health services and also my continued desire to ensure that patients are treated as individuals and with the respect and dignity they deserve. I have found considerable advantages in working with a larger team of inspectors and specialist advisers. Inspections are now over a number of days and I am usually allocated to a smaller team of four or five. This has allowed for better planning of how we conduct inspections. I have found team working has helped me as an expert by experience to fulfil my part of the process and has given me greater clarity on individual team member s roles. My current concern is that healthcare providers are given notice of when CQC inspection will take place, and this allows them to prepare. In my experience, this has been fairly obvious and evidence of their preparations relatively clear (fresh paint, flower tubs and new noticeboards). However, patients are remarkably honest and tell us what has been happening. I feel the new and longer inspection process has allowed me to contribute significantly more information to the outcome, as I now have the opportunity to discuss my own findings, views or concerns with the team, and because learning from their experience has helped me focus on specific areas using my particular skill set as a service user. The new wave inspections have given me greater opportunities to be a team member and feel my contributions are valid and valued by other members of the team. Nick Plumbridge, expert by experience at Choice Support ( is assigned to each service, hospital and trust. The rating focuses on five domains identified as markers of quality: safety, effectiveness, caring, responsiveness and being well led (DH 2008). During the consultation and pilot period in 2013 and 2014, there was considerable discussion about the meaning of the different ratings (what does good look like?), and the types of evidence that should be reviewed when considering the five domains: 1. Is it safe? 2. Is it effective? 3. Is it caring? 4. Is it responsive? 5. Is it well led? Important lines of enquiry have evolved for each domain, from lists of prompts to compendiums of numbered questions, with accompanying definitions of good (Walshe et al 2014). The comprehensive inspection team Each comprehensive inspection is led by a head of hospital inspection from the CQC and an independent chair and undertaken by a team of inspection managers and inspectors. These individuals lead sub-teams comprised of CQC staff, inspectors and, where relevant, mental health act reviewers, experts by experience and specialist advisers. They are supported by inspection planners and data analysts. Specialist advisers bring their experience of a professional role and knowledge of service provision (Box 2). Experts by experience bring their personal experience of services and skill at engaging peers (Box 3). These roles are intrinsic to the inspection team because they provide professional and service user advice on expected standards of practice in their area of expertise. Their integral roles in the process reflect the adoption of recommendations by Francis (2013), Berwick (NAGSPE 2013) and Keogh (2013) on patient and clinical involvement. The comprehensive inspection process In the weeks before an inspection, the core team, led by the head of hospital inspection, has regular contact with the organisation to be inspected. The aim is to gather data as part of intelligent monitoring and resolve the logistics of the on-site visit. Listening events, where individuals can express their views, share feedback and ask questions about the inspection, are held with service user representative groups and other partners. On the week of the visit, the inspection team is divided into sub-teams, each looking 44 july 29 :: vol 29 no 48 :: 2015 NURSING STANDARD

4 at a particular type of service or aspect of the organisation for example, a governance sub-team or a sub-team looking at older people s services. The team follows a schedule of planned visits throughout the inspection, with some scope for return visits or deviations from the schedule when follow up is required in important lines of enquiry. The visits incorporate: interviews; focus groups; observations of clinical practice, for example accompanying nurses on home visits; team meetings; reviews of patient records; and reviews of local policies and records of staff training and supervision. Visits also involve spending time in the care environment to get a sense of the safety and effectiveness of the care provided. At the end of each day of the inspection, sub-teams confirm their findings and review their priorities for inspections the following day, based on their evolving assessment of care quality. When the inspection visit is over, the core CQC team drafts reports based on the findings. In the two weeks after inspection the team may make unannounced returns to the site if there are particular concerns. This is followed by an intensive period of report writing and engagement with the inspected organisation regarding the content of the final inspection report and any regulatory action to be taken, for example, the issuing of warning notices and compliance actions. The final report is published on the day after a quality summit, a meeting between the inspected organisation, the CQC and other partners, such as the local clinical commissioning group and a local group from the Healthwatch network ( The overall findings of the inspection are discussed at this summit, where the aim is to identify next steps and broker a commitment to a plan of action to address what the organisation must or should do to raise the quality of its care. Box 4 provides a director of nursing s view of the comprehensive inspection process. Benefits of the comprehensive inspection approach Research on the revised inspection approach by The King s Fund and Manchester University Business School, commissioned by the CQC, found that it is credible and thorough and offers partners in care the opportunity to engage in service improvement. The involvement of specialist advisers is viewed as bringing much-needed content knowledge, subject expertise and managerial/clinical seniority (Walshe et al 2014). The development of the revised approach has increased scrutiny of the purpose of regulation and increased the sharing of information and experience between providers and clinicians. Risks and challenges of the comprehensive inspection approach The new approach is not without faults, since it is costly and labour intensive (Walshe et al 2014). The CQC has found it difficult to recruit sufficient inspectors to fulfil its commitments, and there has been a leaked report about inspectors experiencing an intolerable workload since the new inspections began (Calkin 2014). Therefore the process may not be sustainable in its current form. There is some concern that the focus on week-long inspections is detracting from risk-based and unannounced work, as described by the contributors to this article (Boxes 2, 3 and 4). The CQC responded to this concern by stating that the planned, announced on-site inspection is only one part of an ongoing systematic approach and that intelligent monitoring allows for prioritisation of focus based on risk profiling (CQC 2015b). BOX 4 A director of nursing s view of the comprehensive inspection process I found the experience had much to commend it, though I appreciate this is not necessarily a universal view. We have certainly changed as an organisation as a result. Front line teams and their managers worked exceptionally hard in the run up to the inspection. We already knew we had great nurses and support staff, so we just said to them be proud of what you do every day for service users; think of three things you are doing that show compassion as well as skill in delivering safe, quality care, and tell the inspectors what they are. And they did. My advice to colleagues would be: don t underestimate the importance of the focus groups in your inspection outcome. The commission takes seriously the views of staff, and the collective revelations of a group of core trainees or support workers will be powerfully heard. Do not be tempted to big things up about your trust, as up to 100 professional inspectors, just as experienced as you, will see through it. On the other hand, there was complete respect and positive reflection shown by the inspectors for what we were doing right for service users, many of whom they talked to directly. Also, no one talks about the cost to a trust of an inspection, but it is not cheap. You will spend money on mobilisation, project management and communications, as well as needing to find resources to focus intensively on any fundamentals of quality and safety where your own internal assessments and benchmarking are wanting. For us, the quality summit was a challenge to organise in mid-august holiday season, but it was a hugely positive event. Our summit produced meaningful, shared plans for areas identified for improvement. It is not easy to accept the criticisms written in the thorough and meticulously prepared service reports produced by the CQC, but because we had no surprises and had worked with partners closely throughout, the mutual support and pledges of help or resources that emerged have made a genuine difference. Claire Johnston, director of nursing and people, Camden and Islington NHS Foundation Trust NURSING STANDARD july 29 :: vol 29 no 48 ::

5 Conclusion For front line staff, a CQC comprehensive inspection can present an opportunity to demonstrate good practice and emphasise some of the challenges encountered in providing good quality care. Participating in a CQC inspection as part of the inspection team has also given some nurses and service users the chance to influence the quality of care in their own areas and the services they have visited under the auspices of the CQC, as well as to influence the regulatory outcomes. Now that the fundamental standards have been enshrined in law and the comprehensive approach to inspection established, it is hoped that the enthusiasm for and critical engagement with this approach continues from providers, service users and the regulator NS Declaration of interest The author has acted as a specialist adviser and Mental Health Act commissioner and reviewer for the CQC. The views in this article do not necessarily reflect those of the CQC. References Brown D, Hilson N (2014) What to do to prepare for a CQC inspection. Practice Nursing. 25, 8, Calkin S (2014) Exhausted inspectors raise concerns about unsustainable CQC regime. Health Service Journal. (Last accessed: May ) Care Quality Commission (2013a) Raising Standards, Putting People First: Our Strategy for 2013 to CQC, Newcastle upon Tyne. Care Quality Commission (2013b) A New Start: Consultation on Changes to the Way CQC Regulates, Inspects and Monitors Care. CQC, Newcastle upon Tyne. Care Quality Commission (2015a) Guidance for Providers on Meeting the Regulations. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) (as amended). Care Quality Commission (Registration) Regulations 2009 (Part 4) (as amended). CQC, Newcastle upon Tyne. Care Quality Commission (2015b) Intelligent Monitoring. NHS Acute Hospitals. Frequently Asked Questions. tinyurl.com/pd5bruf (Last accessed: June ) Department of Health (2008) High Quality Care for All: NHS Next Stage Review Final Report. The Stationery Office, London. Department of Health (2012a) Performance and Capability Review: Care Quality Commission. The Stationery Office, London. Department of Health (2012b) Transforming Care: A National Response to Winterbourne View Hospital. tinyurl.com/kpwrver (Last accessed: June ) Francis R (2010a) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust. January 2005 March Volume 1. The Stationery Office, London. Francis R (2010b) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust. January 2005 March Volume 2. The Stationery Office, London. Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. inquiry.com/report (Last accessed: May ) Keogh B (2013) Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. NHS England, London. Maybin J, Harrison T (2008) Briefing: Regulation of Health Care Provision in England. The King s Fund, London. National Advisory Group on the Safety of Patients in England (2013) A Promise to Learn A Commitment to Act. Improving the Safety of Patients in England. tinyurl.com/k9peqrf (Last accessed: May ) The King s Fund (2010) The Regulation of Health Care in England. tinyurl.com/q3y7nfj (Last accessed: June ) Walshe K, Addicott R, Boyd A, Robertson R, Ross S (2014) Evaluating the Care Quality Commission s Acute Hospital Regulatory Model: Final Report. The King s Fund, London and Manchester University Business School, Manchester. 46 july 29 :: vol 29 no 48 :: 2015 NURSING STANDARD