The Care Quality Commission’s (CQC) report on The state of health and adult social care in England 2015/6 gives a rich but mixed picture.1 The introduction of the new inspection framework, with more rigorous inspections and tougher special measures processes, aims to identify poor providers of care immediately.
The CQC has a mandate to inspect all health and social care organisations in England that provide regulated activities. It is now close to completing these inspections. The programme is complete for all NHS Trusts (acute, community, mental health and ambulance). Inspections for all remaining services in adult social care, primary medical services and independent acute hospitals should be complete by March 2017. This gives the CQC a solid baseline for analysis of the quality and safety of care and its report this year makes good inroads into that.
David Behan, chief executive of the CQC, said that ‘the good news is that, despite challenging circumstances, most people are still getting high-quality care and there are encouraging levels of improvement taking place’.
He acknowledged that there is still a wide variation in quality and ‘providers are struggling to improve and there is emerging evidence of deterioration in quality.’
The picture may become richer still in time. The Department of Health is consulting on proposals to extend the CQC’s rating powers to some sectors not currently rated.
These include dentists cosmetic surgery, independent community health and ambulance services, substance misuse centres and pregnancy termination services.
What does the CQC inspect?
The regulator’s comprehensive inspection framework, introduced in April 2014, assesses providers against five key questions. Are services safe, effective, caring, responsive and well-led? When inspecting GP practices, inspectors also look into how well a practice meets the needs of the following population groups:
- Older people.
- People with long-term conditions.
- Families, children and young people.
- Working age people, including those recently retired, and students.
- People whose circumstances may make them vulnerable.
- People experiencing poor mental health, including people with dementia.
Inspectors conduct interviews, observations and reviews of documentation. Interviews are held with medical and administrative staff and people using the service. A wide range of documentation is reviewed and inspectors will ‘follow their nose’ on any issues that may emerge. Inspectors will check safety issues, such as medication – does it conform to requirements, is it in date and safely stored? They will be interested in how well managed the service is and will review audits carried out, looking to understand what changes have been made where these are indicated.
Feedback of key points is given at the end and breaches discussed. When the service later receives the detailed report they are able to comment on any factual inaccuracies. The report includes an overall rating, as well as a rating for each key question, and, for community services, a rating for each core service.
What did the CQC find?
Many GP practices are providing good quality care. 83% of the 4511 practices inspected were rated good and 4% outstanding.
This is encouraging, particularly in light of the difficult environment for GPs and practice nurses. They are facing greater demand which puts pressure on their ability to deliver effective services.
The majority of the just over 200 general practices that had been re-inspected had improved. Three quarters of the 68 originally rated ‘inadequate’ improved their rating and three quarters of the 135 practices originally rated ‘requires improvement’ also improved. It means, however, that a quarter of the re-inspected practices did not manage to improve and some deteriorated.
The CQC notes that around 800,000 people were registered with practices that were rated 'inadequate' for safety and around 3.3 million with practices rated inadequate for leadership.
‘It is important to have a strong and healthy primary care sector, as it is at the forefront of helping people to stay healthy, to keep out of hospital and to receive the care and support they need. Sustained support is needed to ensure that primary care can be an enabler of the service changes needed,’ the report stated.
Community health services
Overall, the quality of care in community services was good; around 70% were rated ‘good’ or ‘outstanding’.
The CQC reported a positive culture among staff working in community services. Most providers had taken time to create a culture of safety and had good processes for reporting and learning from incidents.
In Trusts which combined community services with acute and/or mental health services, we have yet to see truly integrated services and a number of professionals reported feeling distant from the central functions of their organisation.
The CQC identified safety as its biggest concern in all sectors. Within GP practices, there were common characteristics for those rated ‘good’ or ‘outstanding’ on safety. These included an open culture where continuous improvement is encouraged. These services proactively anticipate and manage risks to patients. They also share learning about problems, not only in the practice, but in the local health community too.
A lack of learning and management usually underpinned ratings of ‘inadequate’ in safety. Where safety was a problem, a number of issues were found such as:
- Health and safety incidents were not recorded or learnt from.
- Equipment and training for medical emergencies were often incomplete.
- Premises were unsuitable or poorly maintained.
- Safeguarding policies and training were not always in place.
- Equipment checks and servicing were not always carried out.
- Checks on medicines, including storage and audits were not managed appropriately.
- Within hospital inspections, which included community services, inspectors highlighted what they had seen when they found poor safety cultures:
- Support for reporting and learning from incidents varied.
- Safety audits were incomplete.
- Essential and mandatory staff training was not always undertaken.
- Medicines management was inadequate.
- Record-keeping and systems were not fit for purpose, leading to unsafe workarounds.
- Data was not always shared, leading to incomplete care plans and unnecessarily repeated tests.
- Management of patients at risk of deteriorating was poor.
Services can and do improve their ratings when they address these issues. They can also learn from common characteristics identified by inspectors of practices rated ‘good’ or ‘outstanding’ for safety. These include, for example, having an open and proactive approach to learning, and to managing risks.
While most GP practices performed well in leadership, 12% were rated ‘inadequate’ or ‘requires improvement’. These issues took the form of poor governance or lack of support for staff. The types of issues found by inspectors included:
- Staff training, supervision and development was not adequate or evidenced.
- Referrals were not always monitored effectively.
- Complaints and concerns were not always acted on, or systems in place.
- The needs of the local population were not always known.
In poorly led organisations, staff were not actively reporting concerns or learning from incidents. Often a culture was found where leaders took false assurance from inadequate information and a lack of challenge from the board.
Examples were provided by the hospital and community health inspections, which showed that effective leadership is central to providing good and safe care. This leads to embedded values, engaged staff who listen to patients, and the use of incidents to learn and improve.
‘When Ursula Gallagher, the CQC deputy chief inspector for primary care, spoke at the Queen’s Nursing Institute (QNI) conference in September, she mentioned that there was an emerging correlation between practices with strong nurse leadership and a good inspection outcome,’ said Crystal Oldman, the chief executive of the QNI.
‘This indicates that we need to ensure nurses are appropriately skilled clinically and in leadership and management. The QNI is currently working to enhance the existing Nursing and Midwifery Council (NMC) specialist practice standards for practice nursing to reflect more accurately the leadership and management role of the nurse in general practice,’ she added.
People were found to be working towards the same goal and felt confident about raising issues and concerns. Trusts with good leadership had:
- Embedded values, engaged staff, shared information, and learning from incidents.
- A visible and approachable leadership team.
- Active engagement with staff by boards, a no blame culture and transparency when things went wrong.
Where leadership was poor, inspectors noted how important an open culture was. This in itself could enable improvements to surface and be addressed. An open culture could therefore help to drive improvements, along with a clear strategy and values that are known and shared by staff.
The report said that ‘good, stable leadership is a critical factor in maintaining quality and achieving financial control. If it is in place, there is a greater chance of success’.
With the introduction of the new comprehensive inspection framework came the CQC’s new approach to enforcement. This includes special measures, against which there is no right of appeal.
Services must show improvement when a further inspection is undertaken, sometime within six months of the date of the inspection report. If there is no improvement, the CQC will begin the process, within six months of the re-inspection, to prevent the provider from operating the service.2 They will cancel or vary the terms of the registration and a variation can lead to cancellation if there is no improvement.
Urgent action can be taken at any time. This means that services are not usually expected to be in special measures for more than
12 months. Poor and unimproved performance will not result in yet another poor inspection report and unlimited time to improve. Inspectors remain the arbiters of survival.
Ms Oldman says that there is an ‘emerging correlation between nursing leadership and good CQC inspection outcomes’.
‘I would anticipate that nurses will, as they always do, rise to the challenge of more rigorous inspections and ensure good outcomes for their patients, families, carers and communities,’ she added.
The CQC’s mandate provides a unique overview of England’s entire health economy and its annual report clearly shows the impact of their new, tough regime. While we can be assured that most services out there are performing well, we can also see that poor performance is not tolerated.
The introduction of the new inspection style has weeded out the poorest providers. The tougher approach to enforcement has led to some services leaving the market entirely, and the close monitoring of others for a finite period that can, and does, lead to cancellation of registrations.
The State of Care report clearly demonstrates that the introduction of specialised, comprehensive inspections has been effective in providing assurance and improvements for all of us.
Helena Frankova, health and social care writer
1. Care Quality Commission. 2016. The state of health and adult social care in England 2015/6.
2. Guide to special measures – GP practices, CQC