1. Proposed changes to the way we inspect and regulate care services
Background
Strategy Raising standards, putting people first, published April 2013
June 2013 First of a series of consultations on significant changes –
Principles of new model for all care services
Detail of NHS intelligence model, inspection and ratings
Regulations underpinning the changes
Further consultation in October 2013 on further detail and guidance on NHS regulation, fundamentals of care
Co-development, engagement and further consultation throughout 1 1

2. Our purpose Our role 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
Our role
We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care
Thousands of people - members of the public, our staff, providers, professionals and others – have given their views during CQC’s consultation on its strategy for the next three years 2

3. A strong, independent, expert inspectorate, evidence-based judgements
Our direction
A strong, independent, expert inspectorate, evidence-based judgements
Always on the side of people who use services
Our purpose
We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve
Our role
We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care
Thousands of people - members of the public, our staff, providers, professionals and others – have given their views during CQC’s consultation on its strategy for the next three years
Direction
A strong, independent, expert inspectorate whose evidence-based judgements are welcomed and valued
Acknowledge and highlight excellent care
Expose services where people are receiving mediocre care
Have zero tolerance for services where people are not provided with fundamentals of care
Always on the side of people who use services
Independent but not distant from our partners in the health and social care system 3

4. Asking the right questions about quality and safety
Effective?
Caring?
Responsive to people’s needs?
Well-led?
Safe - People are protected from physical, psychological or emotional harm.
Effective - in line with nationally-recognised guidelines. Improving health or independence.
Caring - People are treated with compassion, respect and dignity and that care is tailored to their needs.
Well-led - effective leadership, governance and clinical involvement at all levels. Open, fair and transparent culture. Using people’s views to make improvements.
Responsive to people’s needs - treatment and care at the right time, without undue delay, and that they are listened to in a way that responds to their needs and concerns. 4

5. What will be different FROM TO Focus on Yes/No ‘compliance’
A low and unclear bar TO
Professional, intelligence-based judgements.
Ratings: Clear reports that talk about safe, effective, caring, well-led and responsive care
28 regulations, 16 outcomes
Five key questions
CQC as part of the system with responsibility for improvement
On the side of people who use services.
Providers and commissioners clearly responsible for improvement.
Generalist inspectors
Generic inspections
Specialist with teams of experts.
Longer, thorough and people-focussed inspections.
FROM
Yes/No statements of ‘compliance’ and unclear reports
A low and unclear bar
Compliance-based inspection reports
28 regulations, 16 outcomes
CQC as part of the system with responsibility for improvement TO
Professional, intelligence-based judgements about specialities, sites and Trusts
Clear quality bar and fundamentals of care to expose and drive out mediocrity and unacceptable care
Ratings to compare safety, effectiveness, caring, well-led and responsive
Inspection reports with a narrative, clear areas of excellence and for improvement
5 key questions about services
On the side of people who use services, independent from but not distant from the system
Providers and commissioners clearly responsible for improvement
Corporate body and registered manager held to account for the quality of care
Individuals at Board level also held to account for the quality of care. 5
FROM TO
Individuals at Board level also held to account for the quality of care.

6. Consultation launched June 2013
A New Start
Consultation launched June 2013
Safe - People are protected from physical, psychological or emotional harm.
Effective - in line with nationally-recognised guidelines. Improving health or independence.
Caring - People are treated with compassion, respect and dignity and that care is tailored to their needs.
Well-led - effective leadership, governance and clinical involvement at all levels. Open, fair and transparent culture. Using people’s views to make improvements.
Responsive to people’s needs - treatment and care at the right time, without undue delay, and that they are listened to in a way that responds to their needs and concerns. 6

7. New Operating Model
Surveillance

8. Named leaders held accountable
Registration
A more rigorous test to deliver safe, effective, compassionate, high- quality care
Legally binding
Named leaders held accountable
Surveillance
Registration
Making sure those we register make a commitment to deliver safe, effective, compassionate, high-quality care
Making sure that named directors or leaders of organisations are personally held to account for that commitment, and that they are suitable for the job
Making sure those we register show us that they have good plans for how they will provide care, including an effective system for spotting and dealing with problems
Building efficient digital services that will transform the way providers get involved and communicate with us
Using information
We will monitor information and evidence continuously to predict, identify and respond more quickly to services that are failing, or are likely to fail
We will continue to gather information from national and local data and intelligence sources, past inspections, Quality Surveillance Groups, Clinical Commissioning Groups, and from groups such as local Healthwatch, local overview and scrutiny committees and local voluntary groups
Information from people who use care services and from whistleblowers will be two of our most important sources of information to make sure we understand the reality of people’s care
Smaller number of more focused indicators that will trigger action by us when a certain level of concern is reached.
These ‘triggers’ will be different for different types of services 8

9. Surveillance
Continuous monitoring to identify failures and risk of failure
“Smoke alarms” and “tin openers”
Use local and national information sources
Use qualitative information from people
Surveillance
Surveillance
Registration
Making sure those we register make a commitment to deliver safe, effective, compassionate, high-quality care
Making sure that named directors or leaders of organisations are personally held to account for that commitment, and that they are suitable for the job
Making sure those we register show us that they have good plans for how they will provide care, including an effective system for spotting and dealing with problems
Building efficient digital services that will transform the way providers get involved and communicate with us
Using information
We will monitor information and evidence continuously to predict, identify and respond more quickly to services that are failing, or are likely to fail
We will continue to gather information from national and local data and intelligence sources, past inspections, Quality Surveillance Groups, Clinical Commissioning Groups, and from groups such as local Healthwatch, local overview and scrutiny committees and local voluntary groups
Information from people who use care services and from whistleblowers will be two of our most important sources of information to make sure we understand the reality of people’s care
Smaller number of more focused indicators that will trigger action by us when a certain level of concern is reached.
These ‘triggers’ will be different for different types of services 9

10. Inspection
Chief Inspectors of Hospitals, Social Care, and General Practice
Expert inspection teams
Longer inspections, more time talking to people
Intelligence used to decide when, where and what to inspect
Inspectors using professional judgement
Surveillance
Clear standards to judge quality and Safety
These standards will help us to judge whether or not services are safe, effective, caring, well-led and responsive to people’s needs.
However, we will use them to support our professional judgements about these five key areas rather than to record ‘compliance’ or ‘non-compliance’ with standards. We will not tick the box, but miss the point.
These standards will have three levels:
Fundamentals of care
Expected standards of care
High quality care.
All services will be required by law to meet the fundamentals of care and the expected standards.
Less guidance, some examples to avoid box ticking
Senior inspectors will use data and evidence, including information from the public and care staff, and from our partners such as NHS England, Monitor and the NHS Trust Development Authority, to help them decide where, when and what to inspect
Inspectors will use professional judgement, supported by objective measures, to assess the quality and safety of care
In large hospitals, this will include a judgement and rating of the different services they provide, for example maternity and accident and emergency services
We will improve the links between our work under the Mental Health Act and how we regulate mental health services
Expert inspection teams led by the Chief Inspectors and including independent clinical experts
How often we inspect, how long we spend on an inspection, and the size and membership of the inspection team will be based on the ‘risk’ of the service - the type of care being offered, the vulnerability of people who use it, the information we have about a service, and its current rating 10

11. Services must meet fundamentals of care and the expected standards
Clear standards
Services must meet fundamentals of care and the expected standards
Three levels
Fundamentals of care
Expected standards of care
High quality care.
Surveillance
Clear standards to judge quality and Safety
These standards will help us to judge whether or not services are safe, effective, caring, well-led and responsive to people’s needs.
However, we will use them to support our professional judgements about these five key areas rather than to record ‘compliance’ or ‘non-compliance’ with standards. We will not tick the box, but miss the point.
These standards will have three levels:
Fundamentals of care
Expected standards of care
High quality care.
All services will be required by law to meet the fundamentals of care and the expected standards.
Less guidance, some examples to avoid box ticking
Senior inspectors will use data and evidence, including information from the public and care staff, and from our partners such as NHS England, Monitor and the NHS Trust Development Authority, to help them decide where, when and what to inspect
Inspectors will use professional judgement, supported by objective measures, to assess the quality and safety of care
In large hospitals, this will include a judgement and rating of the different services they provide, for example maternity and accident and emergency services
We will improve the links between our work under the Mental Health Act and how we regulate mental health services
Expert inspection teams led by the Chief Inspectors and including independent clinical experts
How often we inspect, how long we spend on an inspection, and the size and membership of the inspection team will be based on the ‘risk’ of the service - the type of care being offered, the vulnerability of people who use it, the information we have about a service, and its current rating 11

12. The fundamentals of care – suggestions to promote debate
I will be cared for in a clean environment
I will be protected from abuse and discrimination
I will be protected from harm during my care and treatment
I will be given pain relief or other prescribed medication when I need it
When I am discharged my ongoing care will have been organised properly first
I will be helped to use the toilet and to wash when I need it
I will be given enough food and drink and helped to eat and drink if I need it
If I complain about my care, I will be listened to and not victimised as a result
I will not be held against my will, coerced or denied care and treatment without my consent or the proper legal authority
Clear standards to judge quality and Safety
These standards will help us to judge whether or not services are safe, effective, caring, well-led and responsive to people’s needs.
However, we will use them to support our professional judgements about these five key areas rather than to record ‘compliance’ or ‘non-compliance’ with standards. We will not tick the box, but miss the point.
These standards will have three levels:
Fundamentals of care
Expected standards of care
High quality care.
All services will be required by law to meet the fundamentals of care and the expected standards.
Less guidance, some examples to avoid box ticking
Senior inspectors will use data and evidence, including information from the public and care staff, and from our partners such as NHS England, Monitor and the NHS Trust Development Authority, to help them decide where, when and what to inspect
Inspectors will use professional judgement, supported by objective measures, to assess the quality and safety of care
In large hospitals, this will include a judgement and rating of the different services they provide, for example maternity and accident and emergency services
We will improve the links between our work under the Mental Health Act and how we regulate mental health services
Expert inspection teams led by the Chief Inspectors and including independent clinical experts
How often we inspect, how long we spend on an inspection, and the size and membership of the inspection team will be based on the ‘risk’ of the service - the type of care being offered, the vulnerability of people who use it, the information we have about a service, and its current rating 12

13. Ratings Ratings for services as well as provider eg Maternity services
Ratings to help people choose between services and to encourage improvement.
Ratings for each?
Safe
Effective
Caring
Responsive to people’s needs
Well-led
Surveillance
Ratings
Ratings will be a dynamic process. They will be updated in real time as a result of inspections by our expert teams.
We will make clear on our website when a service is being inspected so that the public understands that our judgement and rating might change.
We will publish the information on which the rating is based.
We will provide ratings for individual services (e.g., emergency services, maternity) as well as at hospital level and for the overall trust.
In all cases we will also provide ratings for each of our key questions: is the service safe, effective, caring, well-led and responsive to people’s needs?
Better information for public
Our Our reports of our inspections will explain the reason for the inspection and describe our findings, assessment and judgments on whether a service is safe, effective, caring, well-led, and responsive to people’s needs.
They will include a simple summary of the main points so that people can quickly understand the quality and safety of the service, together with more detail. 13

14. Taking action
Providers of care to be open and honest about issues affecting care – a duty of candour
New powers to:
Hold individuals accountable for poor care
Prosecute before issue of a formal warning first
Action in the NHS – phases:
Chief Inspector of Hospitals identifies failures and requires improvement
Special measures – programme for action by Monitor or NHS TDA to protect people and deal with the failure
Monitor or NHS TDA can dismiss the Board, and, if necessary, a special administrator appointed. In rare cases, the service may be closed
We will expect and encourage those who provide care to be open and honest about issues and problems that are affecting the quality and safety of people’s care.
We will follow up on all of our inspections and judgements to make sure that a service has improved or remains high quality care
In future we will also have new powers to:
Hold individuals, including leaders of a service and Board members, to account for failing to honour their commitments to provide safe, high quality care.
Prosecute a service or organisation as a corporate body for failing to provide fundamental levels of care without having to issue a formal warning first
Make sure the service is open and honest with the public about things that have gone wrong and why they happened
Action in the NHS
Phase 1: Chief Inspector of hospitals identifies failures of care and requires board of Trust to improve
Phase 2: If they don’t improve, Chief Inspector introduces special measures – a clear programme that makes sure action is taken by Monitor or NHS TDA to protect people and deal with the failure eg clinical support
Phase 3: If care still fails to improve, Chief Inspector requires Monitor or NHS TDA to dismiss the Board, and, if necessary, that a special administrator is appointed. In rare cases, the service may be closed
If closure is needed, provider, Monitor, NHS TDA, NHS England and local CCGs make sure local people have alternative care
In all these cases, Monitor and NHS TDA decide what action is needed to improve services. CQC decides if the action has improved care 14

15. NEXT STEPS Comment on our consultation by Monday 12 August
via our website at:
By at
Timescales
June
Named individuals at Board level held to account for the quality and safety of care of people with learning disabilities
Consultation on principles of new operating model, ratings system and detail of, fundamentals and expected standards of care, detailed proposals for NHS monitoring and inspection.
October
New way of monitoring and inspecting NHS acute hospitals begins
Clear programme for failing NHS trusts begins
Ratings of NHS acute hospitals begins
Named individuals at Board level held to account for quality and safety of care of people in all new care services
Consultation on regulations underpinning fundamental expected standards
December
First ratings of NHS acute hospitals begin 15