To ask CQC to take on responsibility for regulating all health and social care providers whilst losing 25% of the previous budget was always going to be a tall order. Moving to a homogenised compliance framework was in my view wrong and has created unnecessary bureaucracy in the re-registration of social care providers.

Now the political fallout from Winterbourne View has driven a more punitive approach and one which will not help the future users of social care to exercise informed choice in a more personalised marketplace. We need a return to some of the values and vision shown in CQC's forerunners - yes to risk-based regulation but married to a clear vision of what quality and excellence look like, and run by one body, not Heinz 57 varieties.

Thanks for your thoughtful comments David; the regulatory environment and overarching approach to quality improvement is becoming less and less coherent to my mind.

We have CQC’s standards; NICE is currently developing social care quality standards; local councils are duplicating inspection activity, sometimes against standards they’ve produced themselves because they don’t trust CQC; we have the DH’s ‘Transparency in Outcomes: A framework for quality in adult social care;’ Think Local Act Personal – Making it real markers of progress and all the while Monitor is waiting in the wings.

The elephant in the room is the abandoned excellence scheme. It’s not clear to me what’s going to replace the defunct scheme or even when it’s likely to emerge. But what is clear are the increased burdens and costs heaped on providers and in my view (a view supported by the NAO) the poor deal the public and taxpayers are getting. The DH designed CQC they should be held to account.

VODG and ECCA are to be commended for raising these serious concerns which are summed up for me by this "the regulator’s focus on providers failure to comply with essential standards needs to be balanced with recognising and publicising good practice".

Service users have no way of distinguishing those organisations who deliver high quality services from those who are merely compliant. Without information there can be no informed choice.

I would be intersted to hear how CQC meet their stated aim of celebrating and sharing good practise. The only practise which will be of interest to them in the future is poor practise.

I share the views above and the thanks to VODG for managing the dialogue between CQC and provider members which to be frank kept me sane when I thought our organisation was alone in our experiences.

I dont think any of us expected the chaos that the CQC experience has been and the subsequent loss of integrity this body has from providers, local authorities who utilised CQC for quality monitoring and safeguarding, and then the public themselves.

My fear is that the backlash will be an organisation that wants to see quick wins which show the public they are an assertive punitive organisation only. I fear that to achieve this will be through desktop administration exercises, not from local, knowledgeable, and skilled inspectors who I believe also mourn the loss of their role and the opportunities they had to recognise and reward great practice with a Star rating (as flawed and unhappy as we were with it at times), as well as the time to spend with people using our services. I groan at the thought of all those bodies and consultation groups and reports which John mentions and I am not prepared to invest in a quality mark which may be considered acceptable in one authority or not in another and not understood by our users.

In fact I almost miss CSCI.

Well done Martin and John- great stuff- I think you have struck a chord with the sensible moderates who are looking to do the right thing and want a regulator which will incentivise this.

Any system for ensuring quality and safety requires a set of agreed standards that are understood by all parties. The standards need to be clear enough so that any doubt about interpretation is avoided.

The policing and enforcement of the standards can take a number of different forms:

1. An independant external regulator ( such as CQC or HIQA) can be charged with the responsibility, this often fails due to lack of expertise and resources( as highlighted in mid staffs evidence from Amanda Pollard) Another problem can be a concentration on the functions of detection and enforcement whilst neglecting the role of direction. Providers are told what not to do and then let to find solutions for themselves.

2. Commissioners can be held responsible for the way they spend public funds - this can be effective but does not protect individuals who are funding their own care.

3. The process can be left entirely to market forces - but what will be the focus cost or quality?

4. The process can be left in the hands of the providers by way of self regulation. The problem here is do will trust the integrity and expertise of the providers. Would they be honest in reporting failures?

It seems that the system of regulation we have now is failing and that a total rethink is required. A start would be to revisit the standards and to build a model that was based on detection, enforcement and most importantly direction. The processes used in inspection and the skills required by inspectors need to be revisited, the focus on documentation needs to be shifted towards observation and interviewing of both staff and service users.

An system mustt be able to accurately capture what it is like for the person who experiences the service. The key questions must be " what is it like to live here?" and "are you happy here?".

When CQC was established I applauded the intention to focus on outcomes and to raise the bar in expected standards of good practice. I had some sympathy with the organisation for being given the extremely difficult task of 'super-regulator' whilst not being given sufficient resources. And I suspected that what would happen is that CQC would 'retrench' and there would be a backwards step as inspectors followed the letter rather than the spirit of the new system - because this is exactly what happened when NCSC and then CSCI were established - until it all settled down and inspectors gained confidence again.

What I didn't see coming was an organisation that has utterly wrapped itself up in meaningless bureaucracy, an administration that couldn't organise a bun fight in a bakery and a lack of strong and clear leadership - and I don't just mean the CEO/Chair who are understandably the focus of some of the reporting. VODG and ECCA are to be applauded for leading and coordinating the social care sector - and as Mandy Crowford has commented - keeping us sane! What I don't get any sense of, is that CQC can get itself out of this mess. The focus on non-compliance is taking us right back to the days when local authority registration units would write reports that were a long list of minor issues (the wonky toilet roll holder)and a line at the end to say the care was good. The balance is all wrong. The demise of the star rating system is of concern. Reports now are better than those bad old days of course, but the first thing you see is 'this service is not meeting one or more essential standards' and some newspapers are picking this up and sensationalising it. How does that help clients? How does that help carers? How does that focus on outcomes? How are they going to fix it?

Still so many questions to answer...

Wholly agree wtih you John and comments posted. In any service at any point in time there will be minor non-compliance if you look for it. That doesnt mean outcomes for people are poor. Focussing on non compliance is demoralising and does not give a rounded view of the service. Of course we all want to root out places like Winterbourne and once and for all stop bad practice before it becomes endemic. There is no collaborative working which i believe was a positive feature of CSCI. We have always been open and transparent in our approach and staff openly report when things go wrong. CQC are using this to come down hard on providers flexing their muscle when they themselves have missed opportunities to identify poor practice. The focus on form completion, new systems and blaming providers for getting it wrong is not helpful. They should look to their own guidance to determine why there are so many errors before publishing statistics to show why they have not achieved their targets.

Re the excellence scheme we have gone from more than 60% excellent remaining all good (no poor or satisfactory) to a mixture of compliant and 1 non compliant. How can that be?

I'm not going to give my views on regulation at this point but I do want to say that the comments so far on this discussion warm the cockles of my heart.

I say this as someone who receives mental health services and as a current (hopefully) board member of CQC.

Thank you to everyone for your hugely supportive comments and postings, particularly Kay.

We seem to have struck a chord and have it unofficially and off the record that some/many CQC grass-roots staff have been cheered by our views. We recognise the complexity of the task that CQC has been given and think those responsible at the DH for designing the current system now need to stand-up and be counted. The social care regulation & inspection system has never been allowed to stabilise. As soon as we begin to make progress in terms of driving-up quality the whole edifice is tipped upside down again by the DH and we’re all diverted from quality to form-filling. What we want is some genuine engagement on an excellence system. Not much to ask is it?

let's not forget that front line staff control daily safeguarding. any external monitoring is only that - a snapshot of one day in time. Possibly too much expectation of CQC, given their resources. New inspection prog is better now using people who know services inside-out. and emphasis is on slimming down processes, moving away from tick-boxes and getting "feel" of places.

So, let this process run its' course and if it THEN fails, have a go at them. there's loads more, but this will do for a start.

Thanks

I agree Terry, that external monitoring can only ever provide a brief snap-shot of what's going on. But for me that's the reason why greater account should be taken by CQC of the providers’ own systems, and quality assurance, including staff training.

Responsibility should be placed squarely on the Boards of these organisations, and in the case of serious failings criminal prosecutions should follow. That will focus minds. It was good hearing about the Winterbourne prosecutions, but what about the senior managers/directors and Board members? Too many Boards focus on financial results and not on the quality of outcomes for people.

Perhaps it is time to put the regulatory responsibility into the hands of people that understand regulation and work with providers to improve standards. The self assessment of CQC was incomprehensible. What providers want is competent regulators who can gather evidence to take action against providers that put residents at risk and encourage continuous improvement for the vast majority who provide good quality care.

What on earth do residents make of this shambles? The most vulnerable people don't know if they will be able to stay in what is supposed to be a home for life, where the funding is coming from and if they can trust providers or the regulators who are three to look out for them. It is time to redress the balance and make quality care a priority for vulnerable people.

I'm aware that there has been wide support for the way CQC is carrying out the Dignity and Nutrition Inspections and the Learning Disability inspections: that is with an inspector, an expert by experience and a professional expert. There is also much more probing and 'digging' which is throwing up lots of issues, good and bad, which had not previously been identified. This is great stuff.

However this is an approach for 'themed reviews' and is not the CQC 'business as usual' methodology. A common comment following large-scale one-off studies is what difference will they make in the longer term? Historically we have an initial big impact but then over time the problems return. Interestingly, CQC had decided that large scale studies were not the best way to make an impact and, maybe somewhat ironically, is getting lots of positive feedback about these large studies we have been asked to undertake.

So the issue for me is how to sustain improvement and, although it is obviously not just an issue for CQC, what does this mean for the regulator? A quick answer is make the DANI/LD methodology the BAU but of course this is very expensive...

Any thoughts?

Hi Kay, thanks for your comments and to get the ball rolling... Terry’s point above about external monitoring only ever being able to provide a snap-shot of service quality seems right to me. Which is why I believe much greater account should be given by the regulator to providers’ own QA mechanisms – the whole system I mean - from top-to-bottom. For example how does a Board level director of a large provider organisation actually know what’s happening at service level; what sort of feedback and monitoring arrangements do they have in place? What are their own risk management processes like?

Lots of providers put a lot of effort into doing this well and I believe it ought to count for something. It’s not the whole answer, but why not have one externally accredited QA system that CQC acknowledge as offering a robust framework that everyone can adopt.

Hi John. I certainly agree that providers should take responsibility for their own quality monitoring and assurance and that there needs to be a mechanism for assuring the assurance. This does relate to one of the Essential Standards but it is doubtful that inspectors, due to resource and maybe skill restraints, could do this justice at present. I wonder whether there is any evidence relating to accreditation schemes of any sort? I ask this because my anecdotal experience of accreditation schemes by professional bodies does not always inspire confidence from the service user perspective. An example: when I was a MH Act Commissioner I went to a ward and interviewed all the people detained there. Some themes came out particularly lack of information e.g. rights, medication, and lack of involvement in care planning. When I fed this back to the ward manager, the response was this couldn't be accurate because the ward had been accredited by the Royal College of Psychiatrists. Nevertheless I included these findings in my report and the response was a list of actions relating to information and involvement that the ward had undertaken as part of the accreditation. I couldn't help feeling the point had got lost along the way somewhere...

I guess I'm asking whether accreditation schemes could be a potential barrier - or smokescreen - for identifying & dealing with poor care even if only for a minority? And if so, are there ways round this?

No system is 100% safe of course Kay, so there should ideally be a range of approaches, for example more formalised systems (perhaps independently accredited) can be combined with other 'tools' as well – and the best providers are doing this.

United Response for example has a brilliant user-led peer review process (trained and properly supported service users who travel around carrying out inspections of other services). Brandon Trust has 'quality champions' at every level of the organisation and the whole management approach is about the pursuit of quality. MacIntyre are carrying out staff profiling of front-line support workers. They systematically asked service users, which staff they considered to be 'best' at the job and produced a personality profile based on the feedback – and now recruit to that profile. Some organisations are getting service users to deliver training. Some are heavily into co-production. I'm impressed at the lengths some of these providers go to. But it's almost as though all of this effort (and cost) counts for nothing, when you're being 'inspected' for non-compliance.

There needs to be a more mature dialogue between providers and inspectors, so that a 'critical friend' relationship is allowed to flourish and so that inspectors better understand which providers are serious about the pursuit of quality and which are paying it lip service. CQC should be helping to incentivise quality. We have a quality managers' network in the VODG and I'm struck at just how seriously these people approach their work. I'm not saying that all of these organisations are delivering high-quality all of the time. But we would do well to learn from the best.

This is an interesting article and thread. I work for an organisation (HSL) that is owned by a regulatory body (HSE) but that also works across the healthcare sector. Many times I see examples in healthcare where good practice is rarely shared with other wards in a hospital let alone other hospitals.

Kay - happy to discuss some of the work we are doing with HSE on inspection which might have some value for CQC.

Readers might also like to see the following blog from Mithran Samuel at Community Care: "David Cameron provides some respite for the CQC." (posted Dec 12) Seems like this story, or should that be CQC saga, is going to 'run-and-run.'

David Cameron provides some respite for the CQC

John and Martin, thanks for this thoughtful piece. CQC's predecessor CSCI did some excellent work with people, families, providers and commissioners working together to establish a shared understanding of person-centred services and what questions inspectors could ask in relation to them. This was dropped before full implementation by CQC despite assurances to the contrary.

We need this shared understanding of what people and families want; what providers need to provide; what commissioners need to commission; and what regulators should be looking for - and it needs to be based on personalisation.

As you might expect I am very keen on user-led peer review (I have taken part in user-focused monitoring myself). Thinking of regulation, one idea I had was that the CQC Acting Together project (aka experts by experience) could do some user-led monitoring of the mechanisms that care services have in place(which aligns with one of the Essential Standards), looking beyond the processes and talking to people who use and work in the service to find out how/if it all works. Of course this could be contracted out and/or interfaced with accreditation. We would not need to re-invent the wheel with so much expertise already out there.

Sharing good practice (particularly as defined/influence by people who use services & families) is clearly important. What should the regulator's role be in this, if any? The current direction of CQC, as people have highlighted, is around monitoring & enforcing compliance which is set to increase if the current proposals out for consultation are adopted. Interestingly 'Better Regulation' advocates the provision of advice/information to the 'regulated', incentivising good practice and using enforcement as a last resort. On the other hand resources are limited and the scale of regulation huge: does it make sense for the regulator to focus on poor care and leave wider improvement to others?

Better give the usual 'health warning': the views expressed above are mine and do not represent those of the organisation(!).

The dialogue that is developing in this blog is really helpful and I hope that some of the things that are coming out of it, will be seen as helpful to the process of refining and developing regulation in the future.

Kay Sheldon has raised some important issues and the dialogue so far should be seen in the context of identifying the issues of concern in the current regulatory process, and through this, finding a mutually agreed solution to the problems.

It is good to see at last understanding of the complexity of regulation in this very interesting exchange. Previous manifestations of the regulator for care seemed to think being an inspector is something you can hop in and out of. Physically going to homes to inspect them, at any time including, day or night, weekends and bank holidays, is the only way to protect vulnerable people. Desk exercises do not work - the first home to get BS5750 in the 1990s was closed down six months later for abusive practices. In those days we had managers and owners meetings to share good practice and strive for continuous improvement. But even good homes can deteriorate quickly when there is a change of manager.

In Ireland where I was Chief Inspector until I retired this year we gave each home a continuous improvement pack. This contained the latest research about key care topics then posed questions about how the home could make improvements according its particular circumstances. The managers were encouraged to work through the pack and discuss the topics with the staff and residents. In this way they owned the improvements rather than the inspectors telling them how to run their homes. Of course we inspected regularly, every three years there was a re-registration inspection so homes not meeting the requirements did not have their licences renewed, and I also closed homes that put residents at risk.

As far as the DH announcement about a rating site along the lines of Trip Advisor, we at CSRE have been working on developing www.ratemy-care.com for some months and are launching it in January.

Good point Helen (see comment above) I agree that the approach should be based on the principles of personalisation. But why was the good work developed by CSCI simply abandoned by CQC?? It’s all such a dreadful waste of effort and money and utterly demoralising.

Does anyone else remember the sense of progress under, 'Inspecting for Better Lives?' The 'star rating' system was brilliant in its own way because it incentivised providers to aspire to achieve a good or excellent rating so that outcomes for people improved and the provider knew the regulator was assured of their practice. The other rationale for the star rating system of course was to allow CSCI to focus resources on those services that were not providing good outcomes for people. However CSCI – as we all know - had little time to implement star ratings and no time to let it bed-down, or carry out the necessary review and make any adjustments to strengthen the model.

This constant change of direction, approved or led by the DH represents such a bad deal for people who use services and taxpayers. The DH should be ashamed of its policy failures – they share responsibility for Winterbourne View, for allowing this sort of facility to flourish.

Hi Marion, I read your comments about your experience in Ireland, where providers were given a 'continuous improvement pack' and had triennial re-registration with some envy. This to my mind is a great example of the regulator promoting/encouraging quality improvement, in other words a 'stick and carrot approach'. We seem to have lost the notion of regulatory encouragement here and service users are losing out. Thanks for telling us about this interesting alternative approach.

Thank you John. I should make it clear we inspected homes regularly between the re-registration inspection visits. The regulations and standards were outcome based which required the providers to be responsible and accountable for their services. We also provided comprehensive training for inspectors by specialist external trainers. Finally the standards for services for people with learning disabilities were developed and led by service users through discussion about what was important to them, with meetings held in their own settings or in comfortable rooms rather than formal meeting rooms. Thus the standards were written using the term 'individuals' as their preferred terminology. What emerged from the discussions was turned into standards by my staff.

Initially this method of developing standards was resisted by the great and good but gradually they came to appreciate the service users' involvement, so we made a film of the process to demonstrate the different approach. The service users launched the standards at Dublin Castle.

Incidentally the process helped the participants who had been institutionalised for most of their lives to gain confidence so much so that some people at the launch thought we had substituted residents with actors! One lifelong resident subsequently moved into independent living. It just shows what people with learning disabilities can achieve given some self determination.

There is a very interesting blog; 'Beware of the pitfalls of rating care homes,' from James Munro and Kate Ebbutt (Patient Opinion) who have experience of the Trip Advisor type rating model:

“Second, we found it difficult to stimulate useful volumes of feedback. Residents themselves were not able to place feedback online. Their relatives could do so – but why would they? In fact, we found that relatives were happy to place positive feedback online (as a one-off), but were far more wary about public criticism, perhaps because they were concerned about the continued welfare of their loved ones.”

Care homes review website pitfalls