An update from CQC and Quality Matters Nicky Nendick Head of Inspection 1 1

Our purpose The Care Quality Commission is the independent regulator of health and adult social care in England We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve Strategy Slides - 24 May 2016 - MASTER

Monitor, inspect and rate Our current model of regulation Register Monitor, inspect and rate Enforce Independent voice We register those who apply to CQC to provide health and adult social care services We monitor services, carry out expert inspections, and judge each service, usually to give an overall rating, and conduct thematic reviews Where we find poor care, we ask providers to improve and can enforce this if necessary 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 In 2013 we introduced fundamental changes to our model of regulation. We know we still have work to do to deliver this approach consistently and to a high standard. Over the next five years we will continue to focus on the aspects of our model that people have said make the greatest difference – taking action swiftly when we find poor care and publishing independent expert ratings of quality. Our core operating model will stay the same and we will ensure we continually improve how we deliver our four main functions.

The Mum (or anyone you love) Test Is it responsive to people’s needs? Is it good enough for my Mum? Is it effective? Is it safe? Is it well-led? Is it caring?

How good and outstanding providers meet The Mum Test

Outstanding: learn from the best People are at the centre and staff want to them to have a life not just a service Good leadership extends beyond the manager and values are shared to inspire staff Transparent, open culture with people who use services, staff, families, carers and partners Strong links with local community Creative and innovative A can do, will do attitude – staff dedication Safe care actively promoted Always looking to improve Focus is on people not the regulator! CQC Published reports – sampled for data on all inspections

Overall ratings…. Adult Social Care covers residential (care homes) and community social care. All hospices have been included under Hospitals. Source: CQC – 1 September 2017

…and by key question Source: CQC – 1 September 2017

Domiciliary care agencies …and by service type Community social care (1,618) Domiciliary care agencies (5,940) Residential homes (10,885) The above chart presents data we have for DCA locations that have been rated and the number of people using the service. There is a trend suggesting that locations providing care to a smaller number of people are performing better than larger services. This analysis is based upon 3,199 rated DCA locations. Nursing homes (3,546) Nursing homes (4,043) Source: CQC – 1 June 2017

Published 13 October 2016 State of Care 2016 The good news Many services are providing good quality care – over 70% More than three-quarters of re-inspected inadequate locations improved 84% of community social care locations, including 92% Shared Lives services, Good or Outstanding Caring achieves highest scores – 90% Good, 2% Outstanding The worrying news 26% services Require Improvement and 2% are Inadequate Poorer performance for safety and leadership Nearly a quarter of re-inspected inadequate services did not improve Half of services rated requires improvement did not improve on re-inspection – 8% became inadequate Services for older people fare worse than those for people with a learning disability Next one published 10 October 2017. 10 10

State of Care 2016: system failing the Mum Test Causes of delayed transfers of care April 2012 to July 2016 Home care package Nursing home Residential home Age UK estimated in 2015 over a million older people have unmet social care needs, up 800,000 from 2010 26% fewer older people receive LA funded care – 81% of councils reduced spending on social care Five-year increase in nursing home beds now stalled Improvements are becoming harder to make Some providers resigning contracts, councils warn of more

Good care The provider and staff supported people in a number of creative ways to lead a fulfilling life with a commitment and determination to promote people's quality of life. Innovative ways of involving people were used so people were at the heart of everything. People were listened to and their comments acted on. A person who liked heavy metal had a CD player and headphones. Another person liked birds – they had their own budgies and love birds to look after. But there is great care still out there. Relatives told us they were amazed and moved by the changes they saw in their family member when they used their iPads. 12 12

Shaping the future: CQC’s strategy 2016 to 2021 A changing environment Use and delivery of regulated services is changing CQC must deliver its purpose with fewer resources Adapt and improve We want to become more efficient and effective to stay relevant and sustainable for the future The public, and organisations that deliver care, have told us we have improved but we know there is more to do By 2020, it is expected that 50 per cent of the population will be receiving care in a range of new ways and from organisations that bring different elements of care together. We’ll have fewer resources to deliver our purpose - over the next four years we will reduce our budget by £32m. Our stakeholders tell us they support our model but there is more we can do to improve Strategy Slides - 24 May 2016 - MASTER

Four priorities to achieve our strategic ambition Our ambition for the next five years: A more targeted, responsive and collaborative approach to regulation, so more people get high-quality care 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 1. Encourage improvement, innovation and sustainability in care – we will work with others to support improvement, adapt our approach as new care models develop, and publish new ratings of NHS trusts’ and foundation trusts’ use of resources. 2. Deliver an intelligence-driven approach to regulation – we will use our information more effectively to target our resources where the risk to the quality of care provided is greatest and to check where quality is improving, and we will introduce a more proportionate approach to registration. 3. Promote a single shared view of quality – we will work with others to agree a consistent approach to defining and measuring quality, collecting information from providers, and working together towards a single vision of high-quality care. 4. Improve our efficiency and effectiveness – we will work more efficiently, achieving savings each year, and improving how we work with the public and providers. Strategy Slides - 24 May 2016 - MASTER

What will drive the next phase inspections? What will this mean for adult social care? The 3Rs: Registration Risk Rating Draft content from condoc2 (unpublished) MONITOR: We want to improve our monitor function through better use of information and develop a more sophisticated, nuanced set of regulatory responses. INSPECT AND RATE: We want to adopt a more targeted and focused approach to inspection, driving improvement through more effective use of rating and reporting without raising current expectations of what good and outstanding care look like. RATING: We want to be able to change an overall rating on the basis of a focussed inspection, removing the ‘6 month limit’ which we currently apply. We will define when services rated RI for extended periods are seen as ‘persistently requiring improvement’, and develop guidance designed to promote a consistent CQC response. REPORTING: Our inspection reports will be much more explicit in relation to the inspection history of both the individual service and of the quality of all the services which the provider operates and we will be exploring the best ways to achieve this. Building on our work to improve how we report good and outstanding ratings, all inspection reports may be shorter, clearer and more informative. CARE IN PEOPLE’S OWN HOME: We are developing a more extensive ‘toolkit’  for inspectors including the option of announcing inspection or of having a longer period after the inspection in which to gather information from people who use the service, staff and others. The main aim is to enable us to develop a better understanding of people’s experiences of care at home services. ENFORCEMENT: We want to improve the effectiveness and consistency with which we use our enforcement powers. 15

Our next phase of regulation We plan to update our approach and assessment framework to reflect the changing provider landscape Three consultations on these changes: Winter 2016/17 (now closed), Summer 2017 and Winter 2017 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 Our strategy for 2016 to 2021, published in May 2016, set out a vision for a targeted, responsive and collaborative approach to regulation. We have four strategic priorities: 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. In this consultation, we set out detail on updating our approach and assessment framework to reflect the changing provider landscape: more integrated approach to enable us to be flexible and responsive to changes in care provision more targeted approach that focuses on areas of greatest concern, such as safety, 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  This consultation sought views on specific proposals: how we will regulate new and complex types of providers  changes to our assessment framework, including an updated well-led key question, developed jointly with NHS Improvement how we will regulate NHS trusts from April 2017 how we will aggregate ratings for complex providers, including NHS trusts.   A further consultation in May 2017 will focus on how we will regulate adult social care and primary medical services, and will include further detail on the changes we want to make to how we register providers. 16

Consultations on our proposed changes to inspections 20 December 2016 – 14 February 2017 New care models and complex providers Cross sector changes to assessment frameworks Updated guidance for registration of learning disability services Changes to Hospitals inspection methodology 12 June – 8 August 2017 Changes to Adult Social Care regulation Changes to Primary Medical Services regulation Clarifying how we define registered providers and improving the structure of registration Updating guidance on Fit and Proper Person Requirements Closed Closed Winter 2017 Changes to Independent Acute inspection methodology We want to hear your views on these proposals, which are aimed at achieving 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, such as safety, 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  There will be three consultations on these changes: one in Winter 2016/17, another in Spring 2017, and a third in Winter 2017 The first consultation is now closed, which included the joint consultation with NHS improvement on use of resources and well-led. We will be reporting on responses to our consultation mid year. NHS Improvement are leading on the joint consultation response. We will also be issuing our updated guidance for registration of learning disability services. A further joint consultation is expected with NHS Improvement on our approach to assessing Use of Resources, in Winter 2017. A joint consultation on Use of Resources with NHS Improvement is expected in Winter 2017 17

Strengthening and simplifying our assessment framework Our proposals are an evolution of our framework, not a re-design Strengthen Based on learning over the past three years and changes in the sectors Not ‘raising the bar’ for providers Providers to be able to demonstrate how they are developing and adapting Simplify Aligning the questions we ask of different sectors Promote a single shared view of quality A simpler process to reduce regulatory burden on providers Our proposals are intended to strengthen our assessment by incorporating what we have learned over the past three years, and reflecting changes in the sectors, new best practice guidance and the future context, as well as the feedback from internal and external stakeholders. Our proposed changes are not intended to ‘raise the bar’ or make it more difficult for providers to achieve a good or outstanding rating. The majority of content is very similar to the frameworks we introduced in 2014. However, CQC’s role in encouraging improvement means that we expect providers to be able to demonstrate how they are developing and adapting to new evidence of good practice as well as the changing landscape to improve the quality of care.   The proposals are also intended to simplify the process by more closely aligning the questions we ask of different sectors and the characteristics that reflect a rating. A simpler process will reduce the regulatory burden on providers that deliver care across traditional health and social care boundaries (‘combined providers’) by working better with shared governance systems, and by making it more straightforward for providers to respond to our regulatory requests and for statutory and local groups to collect evidence to support our work. Our assessments of combined providers and new care models, and thematic or place-based inspections will also be made simpler, and our internal systems and processes will be more efficient. The proposed changes will also support our strategic priority, shared by our stakeholders, to promote a single shared view of quality – ie, a consistent approach to defining and measuring quality and to collecting information. Through greater alignment, we will move closer to agreeing a definition of quality based around our five key questions, which means we can be clear and consistent about how we assess the quality of care across different types of service. 18

Consultation 2: Adult social care regulation – proposed changes Focus on how we will encourage improvement in services that are repeatedly rated as Requires Improvement Improved processes for inspecting services providing care to people in their own homes Our effectiveness and consistency of how we use our enforcement powers Promoting a single shared view of quality by developing our PIR requests MONITOR: We want to improve our monitor function through better use of information and develop a more sophisticated, nuanced set of regulatory responses. INSPECT AND RATE: We want to adopt a more targeted and focused approach to inspection, driving improvement through more effective use of rating and reporting without raising current expectations of what good and outstanding care look like. RATING: We want to be able to change an overall rating on the basis of a focussed inspection, removing the ‘6 month limit’ which we currently apply. We will define when services rated RI for extended periods are seen as ‘persistently requiring improvement’, and develop guidance designed to promote a consistent CQC response. REPORTING: Our inspection reports will be much more explicit in relation to the inspection history of both the individual service and of the quality of all the services which the provider operates and we will be exploring the best ways to achieve this. Building on our work to improve how we report good and outstanding ratings, all inspection reports may be shorter, clearer and more informative. CARE IN PEOPLE’S OWN HOME: We are developing a more extensive ‘toolkit’  for inspectors including the option of announcing inspection or of having a longer period after the inspection in which to gather information from people who use the service, staff and others. The main aim is to enable us to develop a better understanding of people’s experiences of care at home services. ENFORCEMENT: We want to improve the effectiveness and consistency with which we use our enforcement powers. 19

Consultation 2: Registration Outlines the principles for registering providers at the level of greatest accountability Provider-level assessments for all sectors to help encourage improvement Changes to how the register will record the services that providers are registered to deliver Describes what this means for new models and complex providers We will also be consulting on our proposed changes to primary medical service inspections, ratings, combined providers, quality in a place and FPPR Registration proposals: Bring about improvement through holding those ultimately responsible for quality to account and ensuring they drive up quality across their range of services. Enable us to be targeted and responsive to risk and improvement across large complex organisations. Constitute a register which properly informs the public about links between organisations, what services provided, to whom and where these services can be found. Respond to existing and new complex organisational forms and innovation in services. Support the regulatory functions of monitor, inspect and rate by providing up to date, more accurate information about organisations and their services and aligning the classification used at registration and inspection. Consultation response should be publishing end of October. Start of new methodology – 1 Nov. 20

Quality matters: a shared commitment to high quality, person-centred adult social care 21

A Shared Commitment: The Quality Matters initiative is co-led by partners from across the adult social care sector. Adult Social Care: Quality Matters sets out a single view of quality and a commitment to improvement. The summary action plan sets out 6 priority areas to make progress on improving quality in the first year.

What people told us they wanted www.penmendonca.com 23

Quality matters: a collective effort People who use services, families, carers – giving feedback Staff – capable, confident and supported Providers – culture, organisation, expectations Commissioners and funders – expectations of quality Regulators – monitor, inspect, rate, take action, celebrate 24

Promote quality through everything we do Our principles Promote quality through everything we do Support and encourage improvement Coordinate action 25

Our action plan priorities Acting on feedback, concerns and compliments Measuring, collecting and using data more effectively Commissioning for better outcomes Better support for improvement Shared focus areas for improvement Improving the profile of adult social care In order to ensure we are clear about how we will achieve concrete action to improve quality, our shared priorities are set out in an action plan. This lists the six things that we want to do first in order to make our commitment a reality, and each of these six things is supported by different organisations working in collaboration. The action plan is a ‘live’ document and will be updated as actions are achieved and as new priorities emerge – remaining in the spirit of the principles set out in the central Quality matters document. As we embark on our journey to improve the quality of adult social care, we will focus on these six priorities for action. These initial priorities have been identified by people who use services, their families and carers, providers, commissioners, and organisations that support and oversee adult social care services. Priority 1 – Acting on feedback, concerns and complaints Ensure that people who use services, their families and carers receive information that is clear and standardised, and that complaints are handled quickly and effectively. Ensure that there is a strong approach to the duty of candour so there is a culture of being open and honest when something goes wrong. Measuring, collecting and using data more effectively Review quantitative and qualitative data across the system and develop a common approach to measuring key quality metrics to ensure consistency. Collect and share the common metrics among commissioners, regulators and providers as suitable and proportionate. Agree and make available suitable and relevant information for the needs of the public. Commissioning for better outcomes Identify opportunities and risks from this approach and embed in commissioning practice. Don’t commission new services that are failing. Review guidelines for quality in commissioning and ensure these are co-produced. Explore how information about people’s experience of care can be used to improve the commissioning process. Better support for improvement Review sector-level improvement initiatives to support all organisations to improve. Describe clearly the role of national organisations within social care and how they work together to encourage improvement. Shared focus areas for improvement Ensure that adult social care is considered across health and social care initiatives (such as Sustainability and Transformation Plans) and that people work collaboratively across sectors. Improving the profile of adult social care Champion everything that is great about adult social care so more people understand, support and celebrate the fantastic difference care and support makes to people’s lives. Attract even more talented people to a career in adult social care. 26

Quality Matters: a shared view of quality for health and social care The document (launching 12 July) sets out a shared commitment to high-quality, person-centred adult social care. It has been produced to make a difference in care services by working across the sector with people who use these services and their carers. It has been developed so that: The public – people who use services, families and carers – know what high-quality care looks like and what they have the right to expect. Staff working within adult social care understand what high-quality care looks like and how they can contribute to delivering it. Providers of adult social care share a clear vision and commitment to providing high-quality care. Commissioners and funders of adult social care support the commissioning of high-quality care and high-quality integrated care. National bodies (including regulators and improvement agencies) support integrated working across the system to champion high-quality care. The purpose of the document is to bring the adult social care sector together in support of the agreed principles that underpin good quality adult social care. It builds on the partnerships and commitments that we have made before, and sets out clear action plans that support the delivery of priorities for improving quality. Crucially, it highlights that quality is everybody’s business.

Thank you www.cqc.org.uk enquiries@cqc.org.uk @CareQualityComm 28