The introduction of the Care Quality Commission arguably fixes that which was not broken. Editorial The Trials of Marriage, The Guardian, Wednesday 1st April 2009.
The CQC came into existence on 1st April 2009. Consider the intended role of the CQC and evaluate this statement in light of the experiences of the first full year of the CQC’s existence.
“We need to see tougher action by the commission on poor providers. The commission can impose or vary conditions where older people may be at risk. It can cancel the registration if that is the only way to ensure safety. Areas highlighted as needing urgent attention include record-keeping, medication, care plans and staff supervision.”
Operating as from April 1st 2009 the Care Quality Commission (CQC) takes over from the role of the former Commission for Social Care Inspection (CSCI) as the registration and regulation body for social care in England, as well as performing the functions of the former Healthcare Commission and the Mental Health Act Commission. The CQC requires all health and adult social care providers to register their regulated activities. Regulated activities that require registration are declared in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009, Pt II, s 3(1). The intended role of the CQC is to make the general standard of care better, however concerns have been raised about the poor quality of health care for the elderly as almost one quarter of homes for older people provide inadequate care. The CQC has done a lot of juggling in its first year of existence which confirms the statement that it “arguably fixes that which was not broken”. First, its staff have had to create an organisation from the merger of the Commission for Social Care Inspection, the Healthcare Commission and the Mental Health Act Commission. In addition, it has had to continue its predecessors’ functions in assessing adult social care provision, evaluating health services and monitoring the treatment of detained mental health patients.
There are several health care regulators namely the Care Quality Commission (CQG), the Health Protection Agency (HPA), the Human Tissue Authority (HTA), the Medicines and Healthcare products Regulatory Agency (MHRA), the Medical Research Council (MRC), the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA). The CQG regulates all the health and adult social care in England and also protects the interests of those detained under the Mental Health Act. The most recently devised health care regulator is the CQC which seems to be an attempt at encompassing the role and functions of the other bodies.
The CQC has made proposals for its approach to the assessments of quality in 2010/2011 for all institutions in England that provide healthcare and adult social care services, and for the National Health Service (commonly referred to as the NHS) and local authority organisations that commission those services. The proposals were set up in accordance with the Heath and Social Care Act 2008. From April 1st 2009 all organisations that are providers of healthcare and adult social care services in England will be required to be registered by October 1st 2010 with the CQC as stated by the Heath and Social Care Act 2008. Registration is not just about the initial registration. but includes initial registration, monitoring and assessment of ongoing compliance, inspection and implementation. The CQC has to undertake registration activities as well as to perform “periodic reviews, and special reviews and studies and to publish information on its findings.”
A new legal framework has been created to facilitate the new regulation system that is the Health and Social Care Act 2008 (Registration Requirement Regulations 2009). The Health and Social Care Act 2008 gives the CQC extended powers. It can issue enforcement notices, withdraw provider bodies rights to provide services entirely or can issue certain conditions of service/registration if it decides it is necessary to do so. Its enforcement options range from minor to very serious sanctions depending on the service affected degree of risk or service disruption. However the CQC stresses it wants the regulatory system to drive and support the healthcare and adult social services organisations to improve and raise standards and to be based on fairness and transparency.
On its official website the NHS describes the intended role of the CQC a regulator which “makes sure that the voices of people who use health and adult social care services are heard by asking people to share their experiences of care services. It makes sure that users’ views are at the heart of its reports and reviews. In some cases patients and their carers work alongside inspectors to provide a user’s view of services.” The reality and whether the CQC has successfully achieved the goals the NHS mentioned is arguable.
The CQC is responsible to make sure that essential common standards of quality are met everywhere health care is provided, from hospitals to private care homes and work towards improving health care services. The Commission promotes the rights and interests of people who use services and have a wide range of enforcement powers to take action on their behalf if services are unacceptably below standards The CQC brought together (for the first time) independent regulation of health, mental health and adult social care. Before April 1st 2009, these tasks were carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. The aim of the CQC is to ensure that better care is provided for everyone wherever it is provided. The Commission has greater powers and responsibilities to use and take account of people’s views and experiences of services, and this includes evidence from overview and scrutiny committees. In June 2009, a Statement of Involvement was published setting out the Commission’s approach to involving people in their mission.
Overview and scrutiny committees working on health issues have been an important source of evidence of people’s views and experiences of health services for the Healthcare Commission. The Commission wants to build on this relationship and to encourage committees to develop an ongoing dialogue with them. Scrutiny committees have a fundamental role in bringing together and articulating the views of local people who use health and social care services in their area, and to check whether their needs and concerns are being addressed by service commissioners and providers. In many ways, scrutiny committees operate like a local regulator, holding services to account.
During its first year the CQC has faced many challenges which sheds a doubt of whether the Commission has really fixed a prevailing issue or has fixed that which was not broken. The CQC has had to proceed with the roles carried out by its predecessors as stated in the Health and Social Care Bill, Part II. The CQC has also introduced a new registration system for health and social care providers in English which is the first time the NHS has been regulated in that manner. The new core standards imposed by the CQC will replace the regulations and relative National Minimum Standards under the Care Standards Act 2000 which will be void as from September 30th 2010. The regulations introduced by the CQC will apply from October 1st 2010 (the date when the providers must be registered in the new system). Under the new system introduced by the CQC, instead of being individually registered for each service, providers will have to register according to their respective regulated activity.
In September 2009, the CQC had to face a serious allegation about manipulating survey findings. The head of the Development for Mental Health, Louis Appleby, accused the CQC of trying to attract the media’s attention by portraying a distorted flattering image of the Commission’s work hence undermining the intended role of the CQC which “is to be factual and balanced and inform the public and patients”. Professor Appleby expressed his concerns about the poor performance of the CQC which the Commission did not welcome.
In December 2009, Colin Angel, the head of policy and communication United Kingdom Homecare Association and the Registered Nursing Home Association criticised the Commission’s failure to communicate effectively over the system of registration: “We are extremely disappointed about the handling of the registration process. We fear that CQC isn’t adequately prepared for the enormous communication exercise facing them.” Colin Angel also identified the fact that the CQC was “missing the opportunity to use the extensive technical knowledge available from providers’ representative bodies” which the Registered Nursing Home Association chief executive Frank Ursell approved.
Some service providers have expressed their concerns about the fact that the Commission might have embarked on a mission which was too extensive and challenging to them as stated by the joint chair of the Association of Directors of Adult Social Services standards and resources network: “It has been stretched at senior management level and we’ve had quite short notice of a number of initiatives. It’s been a bit hand-to-mouth in terms of its ability to make decisions.”
She points to the fact that final guidance on how councils were to be assessed in 2009-10 was only published three-quarters of the way through the year.
Colin Angel, head of policy and communication at the UKHCA, says: “The CQC has lost valuable time restructuring, leaving insufficient time for over 24,000 social care providers to adapt to new standards before they are required to re-register.”
But Amanda Sherlock, head of operations at the CQC, says it has “been an outstanding achievement to pull together the three commissions, deliver business as usual as well as bring in a new regulatory model”, while building a new organisation.
She says that some things could have gone better, saying that the CQC has worked on how it handles national announcements, so councils and other bodies face “no surprises” when these happen.
Norman acknowledges the CQC has “shown itself willing to listen” and “accepted the concerns that we’ve had”.
On provider registration, Sherlock says: “We are keen to hear how we can do things better and how we can tailor our approach and communication.” She says the CQC has an “absolute focus” on making sure providers are “clear what is expected between April and October” when they must register.
National Care Forum executive director Des Kelly says for its part the provider sector needs to work with the CQC to ensure registration succeeds.
Sherlock admits the CQC has “put a lot of time” into organisational development but says this has paid off in establishing an organisation that has an “absolute commitment to driving up quality and safety across health and social care without defining any sector as special”.
A year ago, many in social care, including former CSCI chair Dame Denise Platt, feared the health service’s high political and public profile would make it “special”.
And since Johnstone’s departure last autumn, there has been no one with a social care background on CQC’s executive team below chief executive Cynthia Bower, who left social services in 1995.
Sherlock insists such fears have proved unfounded, but says the CQC has been helped by adult care’s rising profile.
Sherlock, who worked for the CSCI and its predecessor, the National Care Standards Commission, points to her own centrality to CQC’s strategic direction, despite not being on the executive team. She also reveals that the CQC will soon appoint a national social care adviser, to provide “external challenge” and strengthen links with the sector.
Kelly says the issue of social care’s priority has “gone better than I would have predicted 12 months ago”.
Concerns have also been raised that the CQC would not maintain the CSCI’s focus on user involvement. Sue Bott, director of the National Centre for Independent Living, which provides users to act as “experts by experience” on inspection teams, says involvement is “nowhere near as prevalent” as it was in the CSCI.
The CQC produced a statement on user involvement last June, pledging to conduct surveys and set up consultative panels.
Sherlock agrees there is more to do but says the statement has been implemented and the CQC’s user involvement team, led by Frances Hasler, who performed the same role for the CSCI, “actively challenges all parts of the organisation”.
One of the key objectives of the CQC is to support the integration of health and social care. Kelly says he has not seen “a great deal of evidence as yet” of progress on this front. But Sherlock points to the special reviews that the CQC has been doing on issues that cross the divide, including the quality of healthcare for care home residents, which she says will identify good practice and any gaps.
These will report in 2010-11, alongside the roll out of registration for adult care providers and a reformed performance assessment for councils. It will be another busy year.
ONE YEAR OF THE CQC
The Care Quality Commission starts work. Outgoing Commission for Social Care Inspection chair Dame Denise Platt raises concerns over its potential to sufficiently prioritise social care and involve service users.
Former Association of Directors of Adults Social Services standards lead David Johnstone appointed director of operations at the CQC. He leaves the organisation after only a few months.
Statement on service user involvement published. The CQC announces series of special reviews for 2009-10, including of healthcare needs of care home residents and impact of recession on services.
The CQC says NHS trusts are failing to comply with child protection requirements in areas such as staff training in report sparked by Baby Peter case.
DH mental health director Louis Appleby says the CQCHYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”‘HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”s portrayal of results of an in-patient survey was HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”deliberately distortingHYPERLINK “http://www.communitycare.co.uk/Articles/2009/09/29/112717/appleby-accuses-care-quality-commission-of-seeking-headlines.htm”” and simply highlighted negative findings. The CQC says many survey results were poor.
The CQC publishes draft standards for health and social care providers, and holds meeting with mental health leaders over its presentation of the results of its in-patient survey.
Adass criticises the CQC for its treatment of eight councils labelled HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm”priority for improvementHYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm””HYPERLINK “http://www.communitycare.co.uk/Articles/2009/12/04/113366/adasss-owen-attacks-cqc-over-treatment-of-eight-councils.htm” following annual performance assessment (APA). Councils improve for seventh year running.
The CQC says £2bn could be saved a year from reduced hospital admissions if joint working improves between health and social care in first HYPERLINK “http://www.communitycare.co.uk/Articles/2010/02/10/113768/cqc-health-and-socal-care-integration-can-save-2bn-a-year.htm”State of CareHYPERLINK “http://www.communitycare.co.uk/Articles/2010/02/10/113768/cqc-health-and-socal-care-integration-can-save-2bn-a-year.htm” report. It promises 2010-11 APA for councils will be tougher.
Care provider bodies slam the CQC for an alleged lack of communication of the process for registration under its new system. The CQC claims it has engaged extensively.
The CQC is one year old. It starts process of registering adult care providers under new system. National social care adviser appointed.