CQC — outstanding / good / requires improvement / inadequate?
Another day in healthcare, another stone turned over revealing problems and inadequacies. Last week I wrote about the relative turmoil in the NMC, the organisation that regulates Nurses and Midwives in the UK. Today, it was the Care Quality Commission (CQC) has been found to be wanting.
As someone who works at a number of NHS Trusts during my career that have received a variety of inspection reports, I have seen first hand the immense pressure felt by senior Trust leaders when the CQC “are coming. I doubt they are actually like the Spanish Inquisition, but from the reactions to imminent and unannounced inspections — you might be mistaken.
For a number of reasons, there are a lot of watchdogs, arms-length bodies and tiers of governance aligned to healthcare. In no particular order, and by no means an exhaustive list includes
Then there are the professional bodies like the General Medical Council , , The Nursing and Midwifery Council who regulate the individuals as well as the profession. Not to mention the royal colleges who provide standards as well as providing a voice for subgroups of the professions. The Health and Care Professions Council
I think it is fair to say that it is pretty messy space. And bear in mind that the CQC was established with a merger of the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission. In doing so, it was intended to be a single and probably super-regulator for all of health and social care.
Some things in the recent report by Dr Penelope Dash are pretty uncomfortable reading. This includes inspectors whom had never encountered a patient with dementia or never inspected before, IT systems that weren’t fit for purpose, outdated and incomplete inspections. The list goes on.
Kate Terroni the interim Chief Executive at the CQC has given a frank response that is accepting of the findings and apparently “Many of these align with areas we have prioritised as part of our work to restore trust with the public and providers”.
I am pretty sure, that many in healthcare will be jumping on the bandwagon, sticking the boot in and talking about how dreadful the process was, how inept the inspections and inspectors are and at the very least, rolling their eyes and tutting.
I am going to stick my neck out and say that whilst they have been underperforming and found to be unfit for purpose, the CQC is — and has been — a force for good. Ultimately it was established to try and ensure patient safety. It tries to ensure the basic standards of quality and safety. Which let’s not forget, is incredibly difficult to do and very multi-faceted. Ultimately it will almost always be based upon surrogates and judgements.
Get Lawrie Kidd’s stories in your inbox
Join Medium for free to get updates from this writer.
I am going to share the experiences I have had in 3 Trusts.
The first, was talking to someone who was an inspector. She was amazing. She smashed through glass ceilings, has driven change in her profession and been an immense force for good and agent for change — but sat and held a patient’s hand in their final moments of life, waiting for the family to arrive. I asked her what it was like inspecting a hospital. The last place she had been was far from being an “Outstanding” Trust. This became evident in all kinds of metrics, processes and observations. One day on the ward, she saw a patient crying because they couldn’t reach their water on their bedside table. The patient was sick, frail and needed help. And for a variety of reasons, this patient was being left to suffer. She stepped in, gave the patient a drink, flagged this to the nurse in charge, and reported this and other incidents. And this CQC report was read and acted upon.
In another Trust, a door that always jammed and a tile that had been broken for months, that despite being reported for months, suddenly became fixed. A corridor that I used to wheel patients from the operating theatres into the Intensive Care had previously been piled high with stored equipment and boxes was cleared. And no longer did the perilously unwell patient’s bed crash into obstructions. No longer did my delicate invasive monitoring clatter in the wall or the infusion pumps giving inotropes and sedatives bump and alarm. This all occurred because the CQC were coming.
And in another Trust, the patients’ notes were systematically and religiously locked away on the wards. Which is frankly at times, a little bit annoying when I can’t remember the code. But also, entirely appropriate. Of course this immensely private and personal information should not be casually viewable by someone curious, nosy or nefarious strolling past.
At Gloucestershire Hospitals NHS Foundation Trust I frequently see colleagues measuring and documenting the temperature of fridges where some our drugs are kept. This was as a direct result of a CQC inspection. And yes, this is a tiny bit annoying because it is another job. But if I am going to have drugs that need to be kept cool, I would want them to have been kept cool.
Shortly after the formation of the CQC, it came under a volley of criticism about its processes, leadership and governance. It went on be roundly criticised in light of the Mid Staffs Enquiry with one former inspector accusing the CQC as lacking clarity of governance with a process that “seemed nothing more than a tick box exercise.”
The process of inspections changed in 2014 and then much more recently with the development of a single assessment framework (SAF). The SAF has come in for criticism in the Dash Report for lacking, amongst other things, transparency and consistency. Amongst other things, other major criticisms include a lack of clarity as to how inspection rating are made, a loss of credibility within the health and social care sector and an overall unacceptable performance.
Things changed over the years, but the challenge set out for the CQC was enormous. Was it too bold? Was it aiming too high? Was it doomed from the outset?
I would argue that aiming high in healthcare, especially when it comes to safety and care is never a bad thing. But — and this is really important — to do so requires that the governance, processes and resources are sufficient. The Dash Report has shone the light on the regulator and it has been found wanting. It has a huge task — and an immensely important one. And without sufficient resources to do what it has been tasked with, it was probably inevitable that is will have come up short. In her report, Dr Penelope Dash says, “all recognise the need for a strong, credible and effective regulator of health and social care services”. And I could not agree more.
As well as using this as a catalyst for change and improvement, we should also pause for thought and recognise that whilst being far from perfect — the mission and the impact the CQC has achieved over the years in striving to improve care standards should not be ignored.
Many years ago, I heard Sir Mike Richards talking about the challenges of evaluating care when you are using surrogates. Do my ridiculous examples of fridge temperatures and broken doors equate to safe and quality care? His feeling was that they do. The Special Air Service or SAS are revered worldwide. What is it about them that makes them the best? They stand by the fact that they do the simple things the best and the rest follows. Hospitals, are no different. Healthcare regulation is complicated, challenging and in a bit of a pickle. To use the CQC’s own ranking scale, their own performance is Inadequate and Requires Improvement. But I would argue that if nothing else at all it has been a driver for doing the simple things better and being a driver for change — perhaps it should be upgraded to Good. Maybe it should now aim for Outstanding.
Originally published at https://www.linkedin.com.
