CQC’s approach to inspection and regulation

1. CQC’s approach to inspection and regulation • Victoria Donner – PMS Inspection Manager • 13 March 2018 1

2. Our purpose and role • We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve • Register • Monitor and inspect • Use legal powers • Speak independently • Encourage improvement • People have a right to expect safe, good care from their health and social care services

3. Our current model of regulation Register Monitor, inspect and rate Enforce Independent voice We provide an independent voice on the state of health and adult social care in England on issues that matter to the public, providers and stakeholders We register those who apply to CQC to provide health and adult social care services Where we find poor care, we ask providers to improve and can enforce this if necessary We monitor services, carry out expert inspections, and judge each service, usually to give an overall rating,and conduct thematic reviews

4. The landscape of care • Care homes • 460,000 beds • 223,000 Nursing home beds • 237,000 Residential home beds • NHS hospitals • 93.9 million outpatient appointments / year • 12.6 million inpatient episodes / year • 23.7 million A&E attendances / year • 636,000 baby deliveries / year • Health & social care staff • 1.2m NHS staff • 1.58m in adult social care England 55.3 m (45.2m adults) • Ambulances • 6.9m calls receiving a face to face response • 10 NHS trusts • 251 independent ambulance providers • Dentists • 22 million adults seen by NHS every 2 years • 6.8 million children per year Home-care 500,000 + people receiving home-care support at any one time Private hospitals Over 1,200 private hospitals and clinics • GP practices • 58.9 m registered with a GP • 7,700 GP practices

5. What do the overall ratings mean? OutstandingThe service is performing exceptionally well. GoodThe service is performing well and meeting our expectations. Requires improvementThe service isn't performing as well as it should and we have told the service how it must improve. InadequateThe service is performing badly and we've taken action against the person or organisation that runs it.

6. Display of ratings • Why? Public able to see rating of service quickly and easily • Where? Providers should display in prominent area in public view and on website • CQC will send a template for completion and display • CQC will check this during inspections A Provider

7. Ambition Our ambition for the next five years: A more targeted, responsive and collaborative approach to regulation, so more people get high-quality care • 7

8. Four priorities to achieve our strategic ambition • Encourage improvement, innovation and sustainability in care • Deliver an intelligence-driven approach to regulation • Promote a single shared view of quality • Improve our efficiency and effectiveness

9. What will our strategy mean for primary care? • Reduce duplication for providers, agree actions jointly where there are risks of poor care • Extend inspection intervals for good or outstanding practices • Focus on understanding innovative models of care and areas where potential risks may emerge Federations and other new care models: focus on well-led question, consider inspection of sample locations alongside, understanding potential risks using local data For urgent and emergency care, including OoH and NHS 111: inspect related services at the same time

10. Our challenge to the primary medical sector • Invest in strong governance and visible leadership, both clinical and managerial • Report all safety incidents both within the practice and externally, and embed a culture of learning among staff • Improve the consistency of quality improvement activity • Improve access to services • Consider how providers can integrate and work together to reduce variation in quality • Improve medicines optimisation through a culture of learning from medicines related safety incidents

11. Unique oversight of health and care • Full picture of the quality of health and social care in England, with ratings for all sectors • Now have a baseline from which to draw conclusions about quality and safety of care and what influences this • 21,256 adult social care services • 152 NHS acute hospital trusts • 197 independent acute hospitals • 18 NHS community health trusts • 54 NHS mental health trusts • 226 independent mental health locations • 10 NHS ambulance trusts • 7,028 primary medical care services • Increasingly, CQC will report on quality of areas and coordination across services – for care fit for the 21st century • Is it safe? • Is it effective? • Is it caring? • Is it responsive? • Is it well-led?

12. The quality of care across England is mostly good Much is encouraging – despite challenging circumstances, most people are still getting high quality care Adult social care 78% good NHS mental health core services 68% good NHS acute hospital core services 55% good GP practices 89% good

13. Improvement Adult social care 82% • Common factors leading to improvement: • Patient-centred care • Strong leadership • Positive culture • Shared vision • Outward looking approach • Involving people, communities, partners and collaborating Of those services originally rated inadequate, most have improved Mental Health 100% GP practices 80% Hospitals 80%

14. Deterioration While recognising improvement, there is deterioration to be addressed Where services rated good were re-inspected, some have fallen Adult social care 23% fallen Mental health 26% fallen NHS acute hospitals 18% fallen GP practices 2% fallen

15. Primary medical services • GP quality is good – 89% good and 4% outstanding – serving 52 million people • High-performing GP practices collaborating and using non- traditional roles to support and reduce referrals • Safety is main concern for GPs - poor risk management, learning from incidents and poor leadership • Rising demand not matched by workforce growth in general practice • 61% of urgent care and out-of-hours rated good and 8% outstanding • Online services improving people’s access to care – initial concerns around safety and safeguarding have improved on re-inspection • Improved access needed to speech and language, occupational therapies and diagnostics for children with autism

16. The purpose of the consultations • How we propose to update our approach and our assessment framework to reflect the changing provider landscape There are three consultations on these changes: one in Winter 2016/17, one in Summer 2017 and one in early 2018. more integrated approach that enables us to be flexible and responsive to changes in care provision more targeted approach that focuses on areas of greatest concern, and where there have been improvements in quality greater emphasis on leadership, including at the level of overall accountability for quality of care closer working and alignment with NHS Improvement and other partners so that providers experience less duplication

17. 26 January – 23 March 2018 Changes to Independent Acute inspection methodology Consultations on our proposed changes to inspections Closed Closed Open now!! Closed • A joint consultation on Use of Resources with NHS Improvement is expected in Winter 2017

18. Primary medical services regulation We will begin to implement changes in how we regulate primary medical services in phases.

19. Testing our methodology • As part of developing our methodology on how we regulate primary medical services, we have been testing and piloting changes with GPs and urgent care providers • Four inspection teams – one in each region • Testing will be alongside our current methodology and with the permission of the provider • Will not affect rating • Opportunity for co-production

20. Implementing changes to registration • Holding providers to account at the right level • Redefining the definition of a registered provider and asking all entities to meet that revised criteria • Making ownership relationships and links between providers clear to the public • Introducing digitalised provisions to collect information, having this information available to providers and allowing them to only take action when that information changes • Implementing in a phased by across different types of providers from 2018/19

21. How do we monitor services? • Our monitoring helps us to identify possible changes in quality of care and target our operational activity effectively. • Refers to all practices, but especially important now as we move to longer inspection intervals for those rated as good and outstanding • Our intelligence comes from a number of sources:

22. Provider information collection (PIC) • For Good and Outstanding providers the provider information collection will underpin our monitoring of changes in the quality of care (both positive and negative): • An annual online information collection to replace the existing provider information return • We will ask providers for information every year through an online system, approximately six weeks before we plan to formally review the information we hold on a practice • Provider information collection will give practices an opportunity to champion the quality of care they are providing

23. Annual regulatory review (ARR) process • For Good and Outstanding providers we will introduce an annual regulatory review process to bring structure to our monitoring. • Every year inspectors will formally review the information they hold on each practice and consider whether there are any indications of substantial changes (good or bad) in the quality of care since our last inspection. • This process will inform the scheduling of inspections and defining their focus. If we decide not to take any action, we will tell the practice we have carried out the review and update our website. • Neither the PIC nor the ARR can change a practice rating, this can only happen following an inspection.

24. How will our inspections change? • Frequency of inspection: • Practices rated Inadequate would be re-inspected after six months; • Requires Improvement within 12 months; • Good or Outstanding would move to an inspection interval of up to five years, although every year we will inspect a proportion. Scope: • Comprehensive inspections for providers rated Inadequate or those not inspected before • Providers rated Good and Outstanding most inspections will be focused – based on the intelligence we hold on a practice. These inspections will always look at effective and well-led as a minimum.

25. How will those inspections change? Continued Inspection team: • Continue to use specialist advisors in our inspections • More efficient use of Experts by Experience (ExE) • For example – gathering evidence using telephone calls rather than on site visits Notice periods • Increased flexibility including short notice and unannounced • Emphasis – more on the quality of care provided including population groups and conditions; less on policies and risk assessments

26. Key changes to ratings and reporting Content • Shorter summary report supported by an evidence table (from April 2018) Publishing reports • Commitment to publishing 90% within 50 days of inspection Updating ratings • Only changed on the basis of evidence from inspections • Six month limit for aggregating ratings dropped Population groups • We will only rate the six population groups for effective, responsive and overall – more focus on evidence and the components of good quality care for these six groups

27. Population group ratings

28. Deciding ratings (population group by key question ratings) Evidence relating specifically to older people (eg identify those who are frail using an appropriate tool) Evidence impacting everyone using the practice (eg the practice’s overall approach to quality improvement activity Evidence relating specifically to vulnerable people (people with no fixed abode are able to register with the practice) Evidence impacting everyone using the practice (egappointment availability & booking system)

29. Evidence Tables – Effective example

30. Evidence Tables – Effective example

31. Types of inspection – a summary

32. To summarise • Maximum five year inspection intervals for most • Closer working relationship with named inspector at CQC • More proportionate action - not only inspection • Increased emphasis on patient outcomes • A simpler process for low risk registration changes • More timely information about a provider’s performance

33. Examples of inadequate care “We identified one locum staff member who had treated patients but couldn’t provide evidence that they were medically qualified to do so.” “We found no evidence of criminal record checks for the two practice nurses, or any of the non-clinical staff.” • “Medicines were found to be out-of-date, and requests for prescriptions had not been processed in a timely manner to ensure patients had access to their medicines.” “There was no mechanism for the practice to seek patient feedback about services, and complaints had not been used to improve the service.” 33

34. Outstanding characteristics • Easy to access appointments and services through several communication channels • Good and effective leadership extends beyond the manager and those values are cascaded to inspire staff • Staff training and support • Open culture – people who use services/ staff/ relatives shared views and issues • Strong links with local community • Working with multi-professional colleagues and from other organisations • Support patients and carers with emotional needs • Services empowering patients to self manage long-term conditions

35. Inadequate characteristics • Weak leadership, Chaotic and disorganised environment • Isolated working, not involving other local providers to share learning and best practice • A lack of vision for the organisation and clarity around individuals’ roles and responsibilities • A poor culture of safety and learning ie. lack of learning from complaints/events analysis • Poor systems for quality improvement • Disregard for HR processes ie. DBS checks • Unsafe medicines management • Low/insufficient practice nurses or sessions

36. Outstanding case study: Holsworthy Doctors Holsworthy doctors in Devon has the largest catchment area of any practice in England. The practice was rated outstanding in April 2015 Nearest hospital is 29 miles away Practice hosts specialist clinics such as diabetic retinal screening Nearest hospice is 26 miles away Monthly meetings with all staff and local hospital palliative care team Some patients live a distance from the practice Enabled patient to request prescriptions and appointments online Other examples: Comprehensive business plan progress is regularly discussed with staff and Patient Participation Group (PPG) members. The practice facilitated a virtual PPG to receive feedback and ideas to improve the service. 36

37. Safety: key themes in poor care • Safety issues often relate to poor systems and processes, examples include: • Insufficient evidence of risk management and learning from incidents • Poor responses to patient complaintletters and failure to act on issuesraised • Lack of effective and timely safeguarding and training • Poor infection control procedures • The condition and storage of emergency equipment and the management of medicines • Fridges at the wrong temperature, insufficient emergency drugs and expired medicines • Poor recruitment processes, for example a lack of DBS checks 37

38. Effective: key themes in good care • We’ve found many examples of good, effective clinical practice, meeting the needs of local populations, for example: • Quality improvement programmes • Coordinated referral processes • Joined up care with other healthcare providers • Strong relationships with local schools, universities, fire and benefits advisory services • These relationships support practices to deliver enhances services • Joined up models of working, benefits observed include: • Appointments outside normal working hours • Wider range of services 38

39. Caring: key themes in good and poor care • Outstanding practices were able to demonstrate, for example: • Specific support for individual population groups • Innovative programmes for certain health conditions • Flexible access to services • Of the small (but still concerning) number of practices we found to be Inadequate for caring we found: • Staff to lack compassion and respect for patients • Poor concern for patients’ privacy and dignity at the reception desk/waiting area 39

40. Responsive: key themes in good care • Practices rated as outstanding had considered the needs of its populationand subsequently implemented change. • For example: • Guaranteed same-day appointments • Extended practice opening hours • Language support for non-English speaking patients • Innovation in how primary care is provided is developing rapidly: • Recently registered new GP care model using technology to provide consultation • Social enterprises are leading the way in care provision models • Demonstrate a clear vision to improve health of vulnerable and excluded groups • Work closely with services across their locality 40

41. Well led: key themes in good care • GP practices are generally well-led, with 85% rated good or outstanding • Our inspection findings show good leadership is the foundation of an outstanding organisation. Examples include: • Patients at the centre of their developments, with effective patient participation groups involved in multiple aspects of the practice’s business • Excellent staff development and support, with the development of special programmes to aid staff development or support staff in their role • The role and capability of the practice manager has an important influence, and the level of training and support for practice managers is key 41

42. Population groups • GPs typically provide good services to their population groups • Common examples of where GPs had done more to adapt their services to specific needs include: 42

43. Enforcement policy • The enforcement policy, that was introduced and took effect from 1 April 2015, explains CQC’s approach to taking action where we identify poor care, or where registered providers and managers do not meet the standards required in the new regulations. • The Decision Tree supports and complements the policy • Specific serious incident guidance details how incidents may trigger civil and/or criminal enforcement actions • All can be found on our website and are reviewed regularly

44. Enforcement policy: Purpose and principles Purpose: Protect people who use regulated services from harm and the risk of harm, and to ensure they receive health and social care services of an appropriate standard Hold registered providers and managers to account for failures in how the service is provided Principles: Being on the side of people who use regulated services Integrating enforcement into our regulatory model Proportionality Consistency Transparency

45. An overview of CQC’s civil and criminal enforcement powers • Requirements (formerly known as compliance actions) • Warning notices • S.29 warning notices • Civil enforcement powers • Impose, vary or remove conditions of registration • Suspension of registration • Cancellation of registration • Urgent procedures • Failing services • Immediate action to protect from harm • Time-limited ‘final chance’ • Coordination with other oversight bodies • Criminal powers • Penalty notices • Simple cautions • Prosecutions • Holding individuals to account • Fit and proper person requirement • Prosecution of individuals Protect people who use services by requiring improvement Hold providers to account for failure Severity Protect people who use services by requiring improvement

46. Civil enforcement powers • Purpose: • Protect people who use regulated services from harm and the risk of harm • Powers: • Impose, vary or remove conditions of registration • Suspension of registration • Cancellation of Registration • Urgent procedures under sections 30 and 31 HSCA 2008 • Failing services • Immediate action to protect from harm or time-limited ‘final chance’ • Requires Coordination with other oversight bodies

47. Criminal enforcement powers • Purpose: • Holding providers and individuals to account for failure • Powers: • Simple cautions • Penalty Notices • Prosecution • Note: Criminal enforcement action may run parallel to civil enforcement action • Regulation 22 specifies the offences we can prosecute

48. Find out more • Read the monthly bulletin for primary care providers • Sent to all providers and registered managers, or sign up through our website • Join our provider and public online communities • Visit our new guidance page for GP practices www.cqc.org.uk/gpintroguide • Find all of the above and more at: www.cqc.org.uk/GPProvider

49. Helpful resources for practices • Make sure you’ve read our provider handbook, and understand the key lines of enquiry our inspectors will focus on • Read our mythbusters for tips and further guidance • Read our outstanding practice web tool kit and consider what would make care for people who use your services outstanding • Read our ‘What to expect from an inspection’ and case studies to understand what an inspection looks and feels like • We’ve signposted all of these resources and more in our provider toolkit. Simply visit: www.cqc.org.uk/GPProvider 49

50. Support for poor performing practices • What happens when a practice enters special measures? • We will inform the NHS clinical commissioning group, and NHS area team • The Royal College of GPs provides peer support to practices, using a local turnaround team • The RCGP helps practices identify and deliver an improvement plan 50