1. CQC’s approach to inspection and regulation
Victoria Donner – PMS Inspection Manager
13 March 2018 1 1

2. 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
Register
Monitor and inspect
Use legal powers
Speak independently
Encourage improvement
Today I want to update you on 4 areas
State of care
Quality matters
Local system reviews
Next phase
Our purpose remains the same – our focus and drive behind all that we do.
People have a right to expect safe, good care from their health and social care services
Strategy Slides - 24 May MASTER

3. 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.

4. The landscape of care GP practices 58.9 m registered with a GP
Care homes
460,000 beds
223,000 Nursing home beds
237,000 Residential home beds
NHS hospitals
93.9 million outpatient appointments / year
12.6 million inpatient episodes / year
23.7 million A&E attendances / year
636,000 baby deliveries / year
England
55.3 m (45.2m adults)
Dentists
22 million adults seen by NHS every 2 years
6.8 million children per year
Ambulances
6.9m calls receiving a face to face response
10 NHS trusts
251 independent ambulance providers
Sources (ALL FIGURES ENGLAND ONLY updated on 20/2/18 by Lizzy Dobres)
Private hospitals
-1,200 private hospitals and clinics (CQC register at 1 February 2018)
General public
55.3m (45.2m adults) - (Source: ONS mid-2016 population estimates, published June 2017)
1,200 private hospitals and clinics – CQC Register 1 February 2017.
Dentists
There are c.22m adult patients seen by the NHS every two years, and about 6.8m children seen every year.
Source – NHS Digital, NHS Dental Statistics for England 2016/17.
Health and social care staff
1.2m  (source: NHS Digital – NHS Workforce Statistics October 2017, provisional statistics)
1.58m adult social care jobs in England, 2016
 (source: Skills for Care – The size and structure of the adult social care workforce in England, 2017)
Care homes
ASC end of programme report capacity to care for around 460,000 people (that’s beds in care homes).
GP practices
58.9m patients registered at practices. NB: that’s higher than the population of England. That’s because there are known to be loads of ‘ghost’ patients who have moved practices, left the country or died but are still registered. So it may not be a helpful figure but neither is 52m – you could say that there are 7,700 practices and 41,000 GPs by headcount (source for both: NHS Digital 1 January 2018 ). It’s actually very difficult to estimate the total number of consultations. The BMA quote NHS England saying 340m.  
Homecare
In our ASC end of programme report last year we said “more than half a million people”, but that’s at any one time rather than per year.
NHS Hospitals
93.9m outpatient attendances in 2016/17 (source: NHS Digital: Hospital Outpatient Activity, 2016/17)
12.6m admitted patient episodes in 2016/17 (source: NHS Digital: Hospital Admitted Patient Care activity 2016/17)
23.7m A&E attendances (source: NHS England – A&E attendances and emergency admission statistics, NHS and independent sector organisations in England. Feb 2017 to Jan 2018
5.9m emergency admissions (all types of A&E and other emergency, not via A&E). (Source – NHS England – A&E attendances and emergency admission statistics, Feb 2017 to Jan 2018
636,000 deliveries in NHS hospitals in 2016/17  (source: NHS Digital – NHS Maternity Statistics 2016/17)
Ambulances
10 NHS ambulance trusts
251 independent ambulance providers
Number of calls to ambulance trusts has risen by 20% from 2011/12 to 2016/17 (8.2m to 9.8m)
4.9m transported incidents [patients taken by ambulance to A&E] in 2016/17
6.9m calls receiving a face to face response from the ambulance service in 2016/17
Source:
Health & social care staff
1.2m NHS staff
1.58m in adult social care
Private hospitals
Over 1,200 private hospitals and clinics
Home-care 500,000 + people receiving home-care support at any one time

5. What do the overall ratings mean?
Outstanding The service is performing exceptionally well.
Good The service is performing well and meeting our expectations.
Requires improvement The service isn't performing as well as it should and we have told the service how it must improve.
Inadequate The service is performing badly and we've taken action against the person or organisation that runs it.

6. Display of ratings
Why? Public able to see rating of service quickly and easily
Where? Providers should display in prominent area in public view and on website
CQC will send a template for completion and display
CQC will check this during inspections
A Provider
From 1 April 2015, if you have been awarded CQC ratings you must display them in each and every premises where a regulated activity is being delivered, in your main place of business and on your website(s) if you have any. This includes community premises and other premises which might not necessarily be registered with CQC (for example, premises from which you provide occasional clinics and therefore may not be registered with us as separate locations). You must always display your most up-to-date ratings.
Ratings must be displayed legibly and conspicuously to make sure the public, and in particular the people who use your services, can see them.
We also encourage you to raise awareness of your most recent ratings when communicating with people who use your services, by letter, or other means.
Generic ASC deck (June Final)

7. Ambition Our ambition for the next five years:
A more targeted, responsive and collaborative approach to regulation, so more people get high-quality care
We’re on the way to completing inspections of all the services we regulate, giving us a unique baseline understanding of quality.
When we’ve finished, the next step isn’t simply to start again, but to use what we’ve learned (and what people tell us) to target our inspections where poor care, or a change in quality, is more likely.
So the new strategy sets out the next stage of our journey - it sets out an ambitious vision for a more targeted, responsive and collaborative approach to regulation so more people get high quality care. It has been developed based on what thousands of people, providers, staff and partners have told us and what we have learned from over 22,000 inspections. 7

8. Four priorities to achieve our strategic ambition
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.

9. What will our strategy mean for primary care?
Reduce duplication for providers, agree actions jointly where there are risks of poor care
Extend inspection intervals for good or outstanding practices
Focus on understanding innovative models of care and areas where potential risks may emerge
Federations and other new care models: focus on well-led question, consider inspection of sample locations alongside, understanding potential risks using local data
For urgent and emergency care, including OoH and NHS 111:
inspect related services at the same time
Work with partners to reduce duplication for providers, agreeing jointly what action should be taken by whom where there may be risks of poor quality care
Example of above –
Agree a data request with the General Medical Council and NHS England so that GP practices only need to provide a single description of their quality based on the five key questions.
Move to a maximum interval of five years for inspecting practices rated good and outstanding – subject to general practices providing accurate and full data, and our confidence that quality has not changed significantly
Focus on areas of where there may be emerging risks, or where we need to understand more about innovative models of care, for example independent doctors, digital health providers
For federations and other new care models, focus on how well-led they are at corporate level, and consider inspecting a sample of locations, alongside looking at local area data to understand potential risks
For urgent and emergency care, including out of hours and NHS 111 services, inspect related services at the same time and strengthen how we work with our Hospital Directorate
• Continue our current approach to joint inspections, such as the multi-agency work with HMI Prisons, HMI Constabulary, Ofsted and HMI Probation for children’s services and in the criminal justice system, and look for opportunities to develop future joint inspection programmes
Strategy Slides - 24 May MASTER

10. Our challenge to the primary medical sector
Invest in strong governance and visible leadership, both clinical and managerial
Report all safety incidents both within the practice and externally, and embed a culture of learning among staff
Improve the consistency of quality improvement activity
Improve access to services
Consider how providers can integrate and work together to reduce variation in quality
Improve medicines optimisation through a culture of learning from medicines related safety incidents
Report all safety incidents both within the practice and externally, and embed a culture of learning among staff
Improve the consistency of quality improvement activity
Improve access to services
Consider how providers can integrate and work together to reduce variation in quality
Improve medicines optimisation through a culture of learning from medicines related safety incidents

11. Unique oversight of health and care
Full picture of the quality of health and social care in England, with ratings for all sectors
Now have a baseline from which to draw conclusions about quality and safety of care and what influences this
21,256 adult social care services
152 NHS acute hospital trusts
197 independent acute hospitals
18 NHS community health trusts
54 NHS mental health trusts
226 independent mental health locations
10 NHS ambulance trusts
7,028 primary medical care services
Increasingly, CQC will report on quality of areas and coordination across services – for care fit for the 21st century
Is it safe?
Is it effective?
Is it caring?
Is it responsive?
Is it well-led?
This report sets out the CQC’s assessment of the state of care in England in 2016/17. We use our inspections and ratings data, along with other information including that from people who use services, their families and carers, to inform our judgements of the quality of care. The report is based on 29,000 inspections.
Our inspections and ratings allow us to highlight those services that are delivering high-quality care, and recognise and act when we find poor care. When we inspect we ask the same five questions of every provider or service: Is it safe? Is it effective? Is it caring? Is it responsive? Is it well-led? We then award one of four ratings: outstanding, good, requires improvement or inadequate.
We have now established a full picture of the quality of health and social care in England. We have completed our first programmes of inspections with ratings for all the sectors that we regulate. We now have a baseline from which to draw conclusions about quality and safety of care and what influences this.
To present as contemporary a picture of quality as possible, the data on inspections and ratings in this report are for CQC ratings published as at 31 July 2017.
This covers:
21,256 adult social care services
152 NHS acute hospital trusts
197 independent acute hospitals
18 NHS community health trusts
54 NHS mental health trusts
226 independent mental health locations
10 NHS ambulance trusts
7,028 primary medical care services.
Any providers or locations that are not rated will have been recently registered with us or do not fall into categories for which we have the power to rate.

12. The quality of care across England is mostly good
Much is encouraging – despite challenging circumstances, most people are still getting high quality care
NHS mental
health core services
68%
good
NHS acute hospital core services
55%
good
Adult
social
care %
good GP
practices
89%
good
The majority of the care that people receive is good, and there are providers and services that deliver outstanding care. Among the outstanding providers are 2% of adult social care services, 6% of NHS acute hospital and mental health core services, and 4% of GP practices.
But far too much care needs to improve. We rated 3% of NHS acute hospital core services, 2% of GP practices and 1% of adult social care and NHS mental health core services as inadequate at 31 July In addition, 37% of NHS acute core services were rated as requires improvement, as were 24% of NHS mental health core services, 19% of adult social care services and 6% of GP practices.

13. 100% 80% 80% Improvement Adult social care 82% Mental GP Health
Common factors leading to improvement:
Patient-centred care
Strong leadership
Positive culture
Shared vision
Outward looking approach
Involving people, communities, partners and collaborating
Of those services originally rated inadequate, most have improved
Adult social care 82%
Mental
Health
100% GP
practices
80%
Hospitals
80%
When re-inspected, services that were originally rated as inadequate have improved strongly: 82% of adult social care services originally rated as inadequate and re-inspected improved their rating, as did 80% of GP practices. Among NHS acute hospitals, 12 out of the 15 hospitals originally rated as inadequate and re-inspected improved. All of the nine NHS and independent mental health services originally rated as inadequate and re-inspected improved their rating. There was also positive movement, though not as strong, from requires improvement to good.
Throughout the year, CQC has shared examples of improvement in different parts of the system, identifying common factors among those that have succeeded. We often see patient-centred care at its best where there is strong leadership and a positive culture, but we have also pointed to where a shared vision and outward looking approach have been central to improvement. There were improvements for people when providers reached out to local communities and partners, involving patients and the public in shaping services, and collaborating with local groups.

14. 26% 18% 2% Deterioration Adult Mental social NHS acute hospitals GP
While recognising improvement, there is deterioration to be addressed
Where services rated good were re-inspected, some have fallen
Mental
health
26%
fallen
Adult
social
care %
fallen
NHS acute hospitals
18%
fallen GP
practices 2%
fallen
While there has been much improvement, some services have deteriorated in quality. Where we have re-inspected providers originally rated as good overall, the majority have remained good. But 26% of mental health services and 23% of adult social care services dropped at least one rating, as did 18% of acute hospitals. Only 2% of GP practices deteriorated.
Improvement is outpacing deterioration – for services overall 40% have improved vs. 10% have declined.
Deterioration of ratings suggests a fragility of care which points to our message of future care quality being precarious.
(Mental health figure refers to NHS mental health trusts and independent mental health locations)

15. Primary medical services
GP quality is good – 89% good and 4% outstanding – serving 52 million people
High-performing GP practices collaborating and using non traditional roles to support and reduce referrals
Safety is main concern for GPs - poor risk management, learning from incidents and poor leadership
Rising demand not matched by workforce growth in general practice
61% of urgent care and out-of-hours rated good and 8% outstanding
Online services improving people’s access to care – initial concerns around safety and safeguarding have improved on re-inspection
Improved access needed to speech and language, occupational therapies and diagnostics for children with autism
The quality of care in general practice overall is good, with 89% of GP practices rated as good and 4% rated as outstanding overall. This means that almost 49 million people are registered with practices that CQC has rated as good and nearly three million people have access to care rated as outstanding overall.
We have seen improvement in dental care in England in the last two years: after re-inspecting dental practices where we had taken enforcement action, most had improved.
High-performing GP practices are increasingly using non-traditional roles such as advanced nurse practitioners, care coordinators or healthcare assistants to support GPs and reduce referrals to secondary care or avoidable hospital admissions. These practices are also working collaboratively and using multidisciplinary working to improve patients’ experience.
Our main concern across all providers in primary care is the steps they take to ensure the safety of their services. The main issues we found included problems relating to poor governance systems and processes to manage risk and learn from incidents so that they are less likely to happen again, and poor leadership with unclear roles and responsibilities.
General practice continues to face pressures as the rising demand for GP services is not being matched by a growth in the workforce to meet needs, which means that people may find it harder to access an appointment with a GP.
61% of urgent care and out-of-hours services were rated as good and 8% as outstanding. Poor care was a result of challenges in managing patient demand and recruiting and retaining the workforce.
Online primary care services offering remote consultations over the internet, by text-based platforms or video link, are improving people’s access to care. We have taken action on initial concerns around safety measures and safeguarding patients, and have seen improvement on re-inspection.
There have been improvements in health care for children in the care of a local authority (looked after children), but local organisations need to improve access to speech and language and occupational therapies and a diagnostic pathway for children with autistic spectrum disorder.

16. The purpose of the consultations
How we propose to update our approach and our assessment framework to reflect the changing provider landscape
There are three consultations on these changes: one in Winter 2016/17, one in Summer 2017 and one in early 2018.
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 an ambitious vision for a more targeted, responsive and collaborative approach to regulation. We have four strategic priorities, which are to:
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.
The accompanying ‘sector by sector’ publication described how we would regulate and encourage improvement in each sector.
The first consultation looked at further detail about how we propose to update our approach and our assessment framework to reflect the changing provider landscape which was aimed at achieving;
A more integrated approach that enables us to be flexible and responsive to changes in care provision
A more targeted approach that focuses on areas of greatest concern, such as safety, and where there have been improvements in quality.
A 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 for:
how we will regulate new and complex types of providers 
changes to our assessment framework, including an updated well-led key question, which has been 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 the Spring 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.
When we publish our final assessment frameworks we will make them available as online information, as well as documents. This will mean you can find the information you need by searching or navigating our website on whichever devices you use, as well as printing or saving the information to share with colleagues. The information will be in sections of the website for each type of service we regulate. We will clearly show which information is generic to all services.

17. 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
Open now!!
26 January – 23 March 2018
Changes to Independent Acute inspection methodology
Last updated 16 February 2018
During these consultations, our aim was to listen to and hear from people 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 
As you can see, three of the four proposals listed here are now closed – with changes to the independent acute inspection methodology proposals now live and ready for you to submit your views until the 23 March.
The responses for all of the consultations can be found on our website [you can also add in slides that relate to the audience on timeline and what those changes are].
Closed
A joint consultation on Use of Resources with NHS Improvement is expected in Winter 2017

18. Primary medical services regulation
We will begin to implement changes in how we regulate primary medical services in phases.
Change
Timescale
Introducing our new Insight model
June 2017
New assessment framework introduced and inspection interval of up to five years for providers rated good or outstanding
Nov 2017
Refined approach to inspecting and rating population groups and introduction of shorter inspection reports
Apr 2018
Introducing the new system of provider information collections and annual regulatory reviews for good and outstanding services
Later in 2018
Shift to focused, rather than comprehensive inspections of good and outstanding services based on intelligence
Updated 16 February 2018
We will begin to implement changes in how we regulate primary medical services in phases.
We have already introduced our new Insight model. This uses nationally available data to help our inspectors monitor providers and plan what to inspect. We will use this information as part of the evidence in our inspection reports.
In November 2017, we will introduce an inspection interval of up to five years for providers rated good or outstanding. We will inspect a proportion of these providers every year in order for them all to be inspected within the period.
We will continue to inspect providers rated inadequate within six months and those rated requires improvement within 12 months. For these providers our inspections will be comprehensive; looking at all five key questions and all six population groups.
We intend to introduce a provider information collection in 2018 for practices rated as good and outstanding. This will enable providers to share with us any changes to the quality of care at their services. We will continue to use a provider information request as part of pre-inspection planning until the provider information collection is introduced.
From April 2018 most of our inspections of providers rated good or outstanding will be focused rather than comprehensive. The focus will be determined by what we know about each service – including data, information from the provider and other stakeholders, and the findings from our previous inspections.
As we already do, we may use short notice or unannounced inspections if we receive information of urgent concern, for example from whistleblowers.
We will continue to refine our approach to inspecting and rating population groups. We will introduce any changes in April 2018.

19. Testing our methodology
As part of developing our methodology on how we regulate primary medical services, we have been testing and piloting changes with GPs and urgent care providers
Four inspection teams – one in each region
Testing will be alongside our current methodology and with the permission of the provider
Will not affect rating
Opportunity for co-production
We are very keen to ensure that we are working in collaboration with GPs – so we have been testing our new approach with some volunteers. We are also work with organisations representing GPs to develop this process.

20. Implementing changes to registration
Holding providers to account at the right level
Redefining the definition of a registered provider and asking all entities to meet that revised criteria
Making ownership relationships and links between providers clear to the public
Introducing digitalised provisions to collect information, having this information available to providers and allowing them to only take action when that information changes
Implementing in a phased by across different types of providers from 2018/19
Our changes to registration will allow us to hold people to account at the right level when regulating providers.
We will require all entities meeting our revised criteria for defining a provider to be registered with CQC. This requirement will be implemented in a phased way across different types of provider, with the first registrations of this nature in 2018/19. We will publish the schedule for these changes once detailed impact assessments have been completed.
By implementing these changes we will make ownership relationships and links between providers clear to the public on our register. For this reason, we will continue to inspect at location level.
We will implement the proposals to registration structure in a phased way through provider information collections and as providers make changes to their registration. The information will describe the provider and the services it provides. Providers will need to inform us when these details change. In some instances, they will need to apply to us and have the change agreed before changing their service provision.
In implementing this new approach, we will use a digital system that presents information we hold back to providers and requires them to take action only if the information changes. We are testing this digital system and will begin collecting this information from some providers in late 2017.

21. How do we monitor services?
Our monitoring helps us to identify possible changes in quality of care and target our operational activity effectively.
Refers to all practices, but especially important now as we move to longer inspection intervals for those rated as good and outstanding
Our intelligence comes from a number of sources:
Monitor
Local intelligence (CCG, Healthwatch, surveys)
National intelligence (GMC etc)
Relationship with provider
Provider information collection
CQC Insight
CQC Insight
Insight brings together existing national data on practices in one place combining quantitative and qualitative data. The indicators cover a range of GP activity and patient experience.
Relationship with provider
Developing relationships with providers allows us to better understand practices and their contexts and can help determine the significance of other information and intelligence.
Local stakeholders
We should communicate regularly and share information with local stakeholders including clinical commissioning groups and NHS England area teams. When these relationships work well they can be an invaluable in understanding quality and risk in an area. See joint framework for more information.
Local Healthwatch networks can provide us with links into local communities including information about people’s experiences of care. There are good practice examples in this briefing.
Stakeholder engagement (including with providers) should be recorded in CRM so it is reflected in the Insight dashboard.
Provider information collection (PIC)
For services rated good and outstanding the PIC’s purpose is to help us monitor changes in the quality of care at a practice. The PIC will help give context to the information available through other collections. To do this we will ask a series of questions that practices will be asked to complete on an annual basis.
The collection will be online and providers will be able access and update their information at any time. They will be reminded to update the information once each year, approximately six weeks before we plan to formally review the information.

22. Provider information collection (PIC)
For Good and Outstanding providers the provider information collection will underpin our monitoring of changes in the quality of care (both positive and negative):
An annual online information collection to replace the existing provider information return
We will ask providers for information every year through an online system, approximately six weeks before we plan to formally review the information we hold on a practice
Provider information collection will give practices an opportunity to champion the quality of care they are providing
One part of how we Monitor services is PIC – which is now being developed and which we will introduce during In line with our commitment to reduce the demand on GP practices CQC will not introduce this new process until our new digital systems are in place during We will also work with organisations representing GPs to develop this process
In a nutshell – PIC will ensure that every year we can formally review all of the information we have about a provider - and so decide whether to inspect.
We are determined to minimise the impact on practices, so we continue to work with providers and their representative bodies to refine how this will work. We will also continue to work with NHS England, the General Medical Council and other stakeholders through the Regulation of General Practice Programme Board to align our information requests and systems so that we reduce unnecessary duplication. (The Regulation of General Practice Programme Board was formed with the purpose of coordinating and improving the overall approach to the regulation of general practice ...)
What will PIC include?
It will give providers an opportunity to give us their view of the quality of care that they are providing
What has changed about quality of care provided since last year
What plans they have to improve
Examples of good practice
How they provide effective and responsive care to each population group.

23. Annual regulatory review (ARR) process
For Good and Outstanding providers we will introduce an annual regulatory review process to bring structure to our monitoring.
Every year inspectors will formally review the information they hold on each practice and consider whether there are any indications of substantial changes (good or bad) in the quality of care since our last inspection.
This process will inform the scheduling of inspections and defining their focus. If we decide not to take any action, we will tell the practice we have carried out the review and update our website.
Neither the PIC nor the ARR can change a practice rating, this can only happen following an inspection.

24. How will our inspections change?
Frequency of inspection:
Practices rated Inadequate would be re-inspected after six months;
Requires Improvement within 12 months;
Good or Outstanding would move to an inspection interval of up to five years, although every year we will inspect a proportion.
Scope:
Comprehensive inspections for providers rated Inadequate or those not inspected before
Providers rated Good and Outstanding most inspections will be focused – based on the intelligence we hold on a practice. These inspections will always look at effective and well-led as a minimum.
The GP Forward View committed CQC to move to a maximum interval of five yearly CQC inspections for good and outstanding practices, as outlined in our strategy for Inadequate would be re-inspected after six months; Requires Improvement within 12 months
Although Good or Outstanding would move to an inspection interval of up to five years (with a proportion inspected each year) this would also depend on an annual review of the information we hold on a provider.
We will introduced focused inspections

25. How will those inspections change? Continued
Inspection team:
Continue to use specialist advisors in our inspections
More efficient use of Experts by Experience (ExE)
For example – gathering evidence using telephone calls rather than on site visits
Notice periods
Increased flexibility including short notice and unannounced
Emphasis – more on the quality of care provided including population groups and conditions; less on policies and risk assessments
Scope – We will carry out comprehensive inspections for providers rated Inadequate or those that have not been inspected before
looking at all five key questions and all six population groups/
From April 2018 most of our inspections of providers rated good or outstanding will be focused rather than comprehensive. The focus will be determined by what we know about each service – including data, information from the provider and other stakeholders, and the findings from our previous inspections.
Inspection team – continue to use specialist advisors in the inspection process. We will use experts by experience more efficiently, for example by gathering evidence using telephone calls pre-inspection rather than on the site visit
Notice periods As we already do, we may use short notice or unannounced inspections if we receive information of urgent concern, for example from whistleblowers.
Emphasis – more on the quality of care provided including population groups and conditions; less on policies and risk assessments
For these providers our inspections will be comprehensive;.

26. Key changes to ratings and reporting
Content
Shorter summary report supported by an evidence table (from April 2018)
Publishing reports
Commitment to publishing 90% within 50 days of inspection
Updating ratings
Only changed on the basis of evidence from inspections
Six month limit for aggregating ratings dropped
Population groups
We will only rate the six population groups for effective, responsive and overall – more focus on evidence and the components of good quality care for these six groups
Shorter inspection report – We will redesign our inspection report, making it easier to read. The shortened report will still include a summary from the Chief Inspector, with more detail contained in an evidence table at the back of the report.
We currently inspect and rate the quality of care for each of the six population groups against each key question and provide aggregated ratings for each population group, each key question, and for the practice overall (42 ratings).
Population groups
April 2018 – revised approach to population groups, we will now only do this for effective and responsive (and overall). This is to ensure that we can improve how we look at the effectiveness and responsiveness of care and clinical outcomes for the six population groups. And to improve the extent to which we can reflect, through our ratings, the quality of care different GP practices provide to the six population groups.
We are doing this in two ways:
Changing our approach to rating the population groups
Improving how we gather evidence to support our ratings for the population groups for effective and responsive, considering the outcomes of care.

27. Population group ratings
To go into workshop on ratings

28. Deciding ratings (population group by key question ratings)
Evidence relating specifically to older people (eg identify those who are frail using an appropriate tool)
Evidence impacting everyone using the practice (eg the practice’s overall approach to quality improvement activity
Effective
Older People ??
Evidence relating specifically to vulnerable people (people with no fixed abode are able to register with the practice)
To go into workshop on ratings
Evidence impacting everyone using the practice (eg appointment availability & booking system)
Responsive
People in vulnerable circumstances ??

29. Evidence Tables – Effective example

30. Evidence Tables – Effective example

31. Types of inspection – a summary
Type of inspection
Scope of inspection
Reason for inspection
Impact on ratings
Comprehensive
All five key questions; all six population groups (where relevant)
New registrations, RI or Inadequate services; sometimes in response to emerging risk
Award new ratings for all key questions (and population groups) at all levels
Focused of a good and outstanding practice (from November 2018)
At least effective (Including all population groups) and well-led; other key questions depending on information we have about the service
Routine inspections of good and outstanding
Award new ratings for those key questions (and population groups) inspected; aggregate together with ratings from previous inspections
Follow up
Focused only on the concerns identified in previous inspections, often related to breaches of regulation or on emerging concerns.
Comprehensive inspections may also be used in response to concerns.
Follow up on concerns
Always consider resources and burden on provider, if a follow up inspection is completed, an additional comprehensive or new approach focussed inspection will be needed within the five years: so better use of resources may be to do focused inspection and include breach in focus.

32. To summarise Maximum five year inspection intervals for most
Closer working relationship with named inspector at CQC
More proportionate action - not only inspection
Increased emphasis on patient outcomes
A simpler process for low risk registration changes
More timely information about a provider’s performance
In summary
Our desire in this sector is to encourage improvement and see sustainability … which in turn will drive a less frequent inspection regime and a lighter regulatory burden
A lighter touch (Less frequent inspection) for the Good or Outstanding practices
CQC talking to other regulators to harmonise requests for information
More proportionate action - not only inspection (eg desktop review if appropriate)
Talking to the BMA and RCGP about our approach
Focus on patient experience: More on the quality of care provided including population groups and conditions; less on policies and risk assessments
PIC – will give us more timely information about a provider’s performance
And - we will phase in any changes gradually.

33. Examples of inadequate care
“We identified one locum staff member who had treated patients but couldn’t provide evidence that they were medically qualified to do so.”
“We found no evidence of criminal record checks for the two practice nurses, or any of the non-clinical staff.”
“Medicines were found to be out-of-date, and requests for prescriptions had not been processed in a timely manner to ensure patients had access to their medicines.”
“There was no mechanism for the practice to seek patient feedback about services, and complaints had not been used to improve the service.” 33

34. Outstanding characteristics
Easy to access appointments and services through several communication channels
Good and effective leadership extends beyond the manager and those values are cascaded to inspire staff
Staff training and support
Open culture – people who use services/ staff/ relatives shared views and issues
Strong links with local community
Working with multi-professional colleagues and from other organisations
Support patients and carers with emotional needs
Services empowering patients to self manage long-term conditions
LAs –
How can you commission for these outstanding qualities?
How can you manage existing contracts to reach and value services which demonstrate these qualities?
The better the relationship between LA and CQC, and the more a LA works proactively in partnership with local providers, the better the quality of care.

35. Inadequate characteristics
Weak leadership, Chaotic and disorganised environment
Isolated working, not involving other local providers to share learning and best practice
A lack of vision for the organisation and clarity around individuals’ roles and responsibilities
A poor culture of safety and learning ie. lack of learning from complaints/events analysis
Poor systems for quality improvement
Disregard for HR processes ie. DBS checks
Unsafe medicines management
Low/insufficient practice nurses or sessions
Weak leadership and a chaotic and disorganised environment
Isolated working – not working closely with other local providers to share learning
A lack of vision for the organisation and clarity around individuals’ roles and responsibilities
A poor culture of safety and learning (for example, lack of significant event analysis or learning from complaints)
Poor systems for quality improvement (including quality audit)
Limited examples of assurance of clinical care
Disregard for HR processes (for example, DBS checks)
Unsafe medicines management
Limited access to advice and treatment
Lack of practice nurses or very low numbers of practice nurse sessions

36. Outstanding case study: Holsworthy Doctors
Holsworthy doctors in Devon has the largest catchment area of any practice in England. The practice was rated outstanding in April 2015
Nearest hospital is 29 miles away
Practice hosts specialist clinics such as diabetic retinal screening
Nearest hospice is 26 miles away
Monthly meetings with all staff and local hospital palliative care team
Some patients live a distance from the practice
Enabled patient to request prescriptions and appointments online
Other examples: Comprehensive business plan progress is regularly discussed with staff and Patient Participation Group (PPG) members. The practice facilitated a virtual PPG to receive feedback and ideas to improve the service. 36

37. Safety: key themes in poor care
Safety issues often relate to poor systems and processes, examples include:
Insufficient evidence of risk management and learning from incidents
Poor responses to patient complaint letters and failure to act on issues raised
Lack of effective and timely safeguarding and training
Poor infection control procedures
The condition and storage of emergency equipment and the management of medicines
Fridges at the wrong temperature, insufficient emergency drugs and expired medicines
Poor recruitment processes, for example a lack of DBS checks 37

38. Effective: key themes in good care
We’ve found many examples of good, effective clinical practice, meeting the needs of local populations, for example:
Quality improvement programmes
Coordinated referral processes
Joined up care with other healthcare providers
Strong relationships with local schools, universities, fire and benefits advisory services
These relationships support practices to deliver enhances services
Joined up models of working, benefits observed include:
Appointments outside normal working hours
Wider range of services 38

39. Caring: key themes in good and poor care
Outstanding practices were able to demonstrate, for example:
Specific support for individual population groups
Innovative programmes for certain health conditions
Flexible access to services
Of the small (but still concerning) number of practices we found to be Inadequate for caring we found:
Staff to lack compassion and respect for patients
Poor concern for patients’ privacy and dignity at the reception desk/waiting area 39

40. Responsive: key themes in good care
Practices rated as outstanding had considered the needs of its population and subsequently implemented change.
For example:
Guaranteed same-day appointments
Extended practice opening hours
Language support for non-English speaking patients
Innovation in how primary care is provided is developing rapidly:
Recently registered new GP care model using technology to provide consultation
Social enterprises are leading the way in care provision models
Demonstrate a clear vision to improve health of vulnerable and excluded groups
Work closely with services across their locality 40

41. Well led: key themes in good care
GP practices are generally well-led, with 85% rated good or outstanding
Our inspection findings show good leadership is the foundation of an outstanding organisation. Examples include:
Patients at the centre of their developments, with effective patient participation groups involved in multiple aspects of the practice’s business
Excellent staff development and support, with the development of special programmes to aid staff development or support staff in their role
The role and capability of the practice manager has an important influence, and the level of training and support for practice managers is key 41

42. Population groups
GPs typically provide good services to their population groups
Common examples of where GPs had done more to adapt their services to specific needs include:
Population group
Example
Working age people
Offering appointments outside of usual working hours (9am-5pm) and at weekends.
People with long-term conditions
Educating patients to self-manage their long-term conditions more effectively.
People whose circumstances may make them vulnerable
Being flexible in their approach to vulnerable people by offering longer appointments and allowing homeless patients to register their home address at the practice.
People experiencing poor mental health
Working collaboratively with local mental health services and improving access to psychological therapies and substance misuse services.
Older people
More than what is in the standard NHS contract. Managing beds in a care home that led to demonstrable reduction in admission to hospital and reduced days spent in hospital for elderly patients.
Families, children and young people
Offering information in age appropriate formats for young people and ensuring staff were well trained on local safeguarding processes. 42

43. Enforcement policy
The enforcement policy, that was introduced and took effect from 1 April 2015, explains CQC’s approach to taking action where we identify poor care, or where registered providers and managers do not meet the standards required in the new regulations.
The Decision Tree supports and complements the policy
Specific serious incident guidance details how incidents may trigger civil and/or criminal enforcement actions
All can be found on our website and are reviewed regularly

44. Enforcement policy: Purpose and principles
Protect people who use regulated services from harm and the risk of harm, and to ensure they receive health and social care services of an appropriate standard
Hold registered providers and managers to account for failures in how the service is provided
Principles:
Being on the side of people who use regulated services
Integrating enforcement into our regulatory model
Proportionality
Consistency
Transparency

45. An overview of CQC’s civil and criminal enforcement powers
Requirements (formerly known as compliance actions)
Warning notices
S.29 warning notices
Civil enforcement powers
Impose, vary or remove conditions of registration
Suspension of registration
Cancellation of registration
Urgent procedures
Failing services
Immediate action to protect from harm
Time-limited ‘final chance’
Coordination with other oversight bodies
Criminal powers
Penalty notices
Simple cautions
Prosecutions
Holding individuals to account
Fit and proper person requirement
Prosecution of individuals
Protect people who use services by requiring improvement
Hold providers to account for failure
Severity
Protect people who use services by requiring improvement
Generic ASC deck (June Final)

46. Civil enforcement powers
Purpose:
Protect people who use regulated services from harm and the risk of harm
Powers:
Impose, vary or remove conditions of registration
Suspension of registration
Cancellation of Registration
Urgent procedures under sections 30 and 31 HSCA 2008
Failing services
Immediate action to protect from harm or time-limited ‘final chance’
Requires Coordination with other oversight bodies

47. Criminal enforcement powers
Purpose:
Holding providers and individuals to account for failure
Powers:
Simple cautions
Penalty Notices
Prosecution
Note: Criminal enforcement action may run parallel to civil enforcement action
Regulation 22 specifies the offences we can prosecute

48. Find all of the above and more at: www.cqc.org.uk/GPProvider
Find out more
Read the monthly bulletin for primary care providers
Sent to all providers and registered managers, or sign up through our website
Join our provider and public online communities
Visit our new guidance page for GP practices
Find all of the above and more at:

49. Helpful resources for practices
Make sure you’ve read our provider handbook, and understand the key lines of enquiry our inspectors will focus on
Read our mythbusters for tips and further guidance
Read our outstanding practice web tool kit and consider what would make care for people who use your services outstanding
Read our ‘What to expect from an inspection’ and case studies to understand what an inspection looks and feels like
We’ve signposted all of these resources and more in our provider toolkit. Simply visit: 49

50. Support for poor performing practices
What happens when a practice enters special measures?
We will inform the NHS clinical commissioning group, and NHS area team
The Royal College of GPs provides peer support to practices, using a local turnaround team
The RCGP helps practices identify and deliver an improvement plan 50

51. Thank you www.cqc.org.uk enquiries@cqc.org.uk @CareQualityComm
Generic Acute Deck - October 2015