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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 1203-ii
House of COMMONS
TAKEN BEFORE the
Tuesday 28 June 2011
Dame Jo Williams DBE and Amanda Sherlock
Evidence heard in Public Questions 149 - 258
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Taken before the Health Committee
on Tuesday 28 June 2011
Mr Stephen Dorrell (Chair)
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Dame Jo Williams DBE, Chair, Care Quality Commission, and Amanda Sherlock, Director of Operations Delivery, Care Quality Commission, gave evidence.
Q149 Chair: Good morning. I apologise for keeping you waiting outside. We were dealing with some other unrelated issues. It was not that we were spending too long working out how we were going to crossquestion you. We had something else that we wanted to talk about.
Thank you for coming this morning. I would like, if I may, to open the meeting by referring back to the report we issued following your last appearance here, Jo, about nine months ago. It was fairly clear, in that session, that the CQC had quite a big internal agenda in terms of bringing together the predecessor organisations, creating a common culture, working out exactly how the new body was going to work internally and, ultimately-and, of course much more importantly-relate to providers in the system. I would like to begin by asking you to update the Committee on where you feel that process has got to.
Dame Jo Williams: Thank you very much, Chair. In the last nine months we have moved on a great deal, particularly since January this year. I would describe it as a step change. One of the things we addressed, during the January to Easter period, was making sure that our processing was improved. We had a backlog, so we worked on that. Also, from Easter this year through now, we have made another step change in terms of getting out and doing significantly more inspections. We have said to those we register that it will be, and is, an eightweek turnaround from them contacting us, which is half the time that was taken by the predecessor organisation, the Commission for Social Care Inspection. Internally we continue to train and develop our workforce and create a common culture but we also look at the regulatory framework and the way in which we are conducting our business.
Q150 Chair: That is a report of the atmospherics in the organisation, if you like, that you feel you are making progress.
Dame Jo Williams: Yes.
Q151 Chair: Are there key performance indicators reported to your board, which are available to the public and can be seen-
Dame Jo Williams: Absolutely.
Chair: -whereby you measure that progress?
Dame Jo Williams: Yes.
Q152 Chair: Do you discuss those with your registered providers in order to see where the genuine key performance indicators are and discuss the performance with them as well?
Dame Jo Williams: Overall, we have delivered our targets in terms of registering the sector. We have now registered about 23,000 organisations in 40,000 locations. Of course, we are challenged to make sure that we are doing proper risk analysis for each of those locations where services are being undertaken. Thus, in terms of our public board meetings, we have had regular reporting and we look at our performance in relation to activity as to inspections, as well as to our Mental Health Act duties and a whole raft of other things. Have we openly engaged in conversation with provider organisations about that? We have a Provider Advisory Group. Probably the conversations have centred on registration processes and glitches in that system rather than sharing with them, in full, the performance measures, but our meetings-when those performance measures are discussed-are in public.
Q153 Chair: Do you think it would be desirable for the CQC to engage beyond the registration process?
Dame Jo Williams: Of course.
Q154 Chair: That is merely preparing the ground. It is opening the way to allow you to do your job. It is not doing the job itself, is it?
Dame Jo Williams: No. That is right. Of course, we are having an ongoing dialogue with a range of provider organisations-the NHS Confederation, foundation trusts and the adult social care market-to talk about the issues that they are facing as well as the way in which we are carrying out our functions.
Q155 Chair: It would be useful to the Committee to understand what you see as being the key performance indicators, how your performance is moving against those objectives-indeed, where you think it needs to go in the future-and the extent to which those objectives are shared by the provider community. Is that something you can provide to the Committee?
Dame Jo Williams: We can. Certainly one of the key issues-not only for the provider community but, importantly, for the public-is an increased appetite for us to be seen on the ground carrying out inspections. For instance, we are now operating in the region of 600 inspections a month. That is a huge change from where we started at the beginning of the year. That is one of the key indicators which I think both the public and providers are critically interested in.
Q156 Chair: Do you have a view as to where you would like that to get to?
Dame Jo Williams: We would probably like to double that, at the very least. Of course, we operate a riskbased model. That means we look at information flowing into the organisation and each inspector then determines whether or not there are indicators suggesting an inspection should be carried out.
We are also developing a different style of looking at the way in which organisations are performing, which we will continue to develop. We undertook 100 inspections of hospitals, looking at dignity and nutrition. We did it in conjunction with people we called "experts by experience", who have either experienced health care themselves or with someone they cared for, and also with professionals-nurses. That model, we believe, is something we will continue to grow. It certainly captures what we regard as critical information-listening to patients themselves and to people who experience services. Therefore, again, the way in which we engage with voluntary organisations and specific interest groups to help us carry out that work is very important.
Q157 Chris Skidmore: Dame Jo, in terms of being able to cope with the current situation, what is your current backlog of registrations with, for instance, organisations that wish to vary their existing registration? I believe you are receiving 155 applications a day and I know you have mentioned the eightweek waiting period. As of today, can you shed any light on how the current situation stands?
Dame Jo Williams: That is where we are now.
Q158 Chris Skidmore: On top of the registration period, you have obviously had episodes such as Winterbourne View. I must admit, as a constituency MP, it lies just outside my constituency in Kingswood, and I hope you don’t mind me asking a couple of questions about that particular case.
Dame Jo Williams: Not at all.
Q159 Chris Skidmore: Do you feel you can strike the right balance between this demand for registration-which may be constant, given that practices are always wanting to vary their current registrations-and, realistically, getting to that level of 1,200 inspections in a month?
Dame Jo Williams: It is important to say that the processing of variations to registration is something we have spent a great deal of time looking at and improving. Certainly, there is much more work to be done there. One of the issues for us-again this will need working with the sector-is the extent to which, in the future, we will look to them to send information electronically to us, and it will probably take two or three years for everyone to be able to communicate in that way. However, the processing is getting much slicker and that has enabled us to get to this eightweek turnaround. There will be occasions when there is a very complex situation which may take longer than that, but, apart from those exceptions, as I said, eight weeks is now the target we are largely hitting. That is the processing.
If it is a new registration, then, quite clearly, it requires the skills of someone who inspects services and will even engage in a site visit. The work of our inspectors is very much about looking at their caseload, doing a risk analysis and determining whether they need to make a visit. My aspiration for more inspections is largely based on us making sure that flow of information is effective to them and they have the tools to do their job, but also-there is no doubt-we are talking with the Department of Health about the extent to which we need to have additional resources to enable us to recruit more inspectors.
Q160 Chris Skidmore: Let us take that risk analysis and place it in the situation of Winterbourne View. I believe that on 6 December Terry Bryan, the whistleblower, contacted CQC directly.
Dame Jo Williams: Yes.
Q161 Chris Skidmore: Obviously, then, you have the local authority taking the safeguarding lead. You mentioned in your own account of events at Winterbourne View, "However, we recognise that had we contacted the whistleblower ourselves directly after we received the email we would have been alerted to the seriousness of the situation and moved swiftly to inspect the hospital." I want it to be clear on the record, if a whistleblower e-mails the CQC today, what process would be triggered and has that process been changed in light of the Winterbourne View situation?
Dame Jo Williams: The information would go to the inspector, as it did in relation to Winterbourne View. We now know that we need to follow that up and also make sure that their manager has that information as well. We have reviewed what has been happening and tightened up those procedures.
Q162 Chris Skidmore: In the situation with Winterbourne View, the contact was made on 6 December. The safeguarding meeting then did not take place till February 2011.
Dame Jo Williams: Absolutely.
Q163 Chris Skidmore: Once that email had been received by you, you passed it down to the local authority but left the situation as it was, depending on the local authority to have the safeguarding meeting.
Dame Jo Williams: It is fair to say-and I have said this on more than one occasion-that, regrettably, there was an error of judgment. The individual concerned wrongly made an assumption that, because it was resting with the safeguarding board, action was being taken. That should have been chased up. Indeed, she should also have made her own separate assessment of the risk. That did not happen.
Q164 Chris Skidmore: In terms of the culture of allowing people to become whistleblowers, to put that information across, in September you said, "We recognise there are some very real challenges about helping people speak out." You also mentioned that you all now actively follow up alerts. I saw, in your evidence to the Health Select Committee for today, you said: "We very aware of the danger of individual errors being made by those receiving the information", which I assume must be relating to Winterbourne View in particular.
Dame Jo Williams: Absolutely.
Q165 Chris Skidmore: "We are undertaking a hearts and minds exercise to ensure that our analysts and inspectors rigorously challenge provider organisations if we receive any negative or concerning information." Could you go into a bit more detail about what that hearts and minds exercise is currently involving?
Dame Jo Williams: I would make a couple of general points, if I might, before I answer the specific. One of the real challenges for both health and social care-the whole sector-is creating a culture whereby people feel confident about raising concerns within their organisation. For instance, in relation to the Health Service, the National Quality Board issued a publication which was about managing the system in transition. One of the key things there was a reminder that those working in health services have a duty to raise concerns. That is one aspect of it.
Again, I recently received a copy of a letter from a service provider in the care sector-a letter to all his workforce- saying, "We welcome you raising your voice. We want to hear from you if there are concerns." One of the issues for me is: what are other organisations doing in relation to encouraging their workforce to raise concerns? That is one of the ways in which we would look to make a judgment about whether or not an organisation was, itself, quality assuring what is happening. On the ground-day in, day out-providers need to know that their procedures and policies are being followed and, importantly, that people are getting safe care.
In terms of our own organisation, we appreciate that we can only do our job well if the general public, but also those working in the sector, have the confidence to come and tell us what is going on. In the last two months we have received significantly more phone calls of concern. Last year, we probably had less than 200. We have already had well over 100 in the last two and a half months. It is very important that we respond well. One of the things we do is say to people that there is an organisation called Public Concern at Work because we know that individuals are very nervous of putting their head above the parapet, if I can put it like that. We know there have been situations where whistleblowers have lost their jobs.
Q166 Chris Skidmore: I am very concerned that, in terms of the Winterbourne View situation, real lessons will be learned because that would mean a great deal for the patients and their families. Do you believe that is taking place and that, in terms of what happened at Winterbourne View, you have all learned those lessons?
Dame Jo Williams: It is fundamental to us. This is the critical thing for us. We must always learn from things. It was desperate to see Winterbourne View and know that, potentially, people had experienced some terrible things because we and other people had not taken action. Absolutely, we are very much examining what happened, how we can do better and, as I say, rebuild that confidence so people can come to us and let us know if there are things happening that are putting people at risk. Thank you very much.
Q167 Chair: One of the points we took up with the General Medical Council and the Nursing and Midwifery Council when they were here two or three weeks ago was the point you made about the obligation on all health care professionals to be responsible for care being provided around them in addition to their responsibility for the care that they themselves provide. Is that something the CQC engages with? If it finds an example of a health care professional that, in the view of CQC, should have reported what was going on and did not, is that an issue where the CQC engages either with the regulator or in its own right?
Dame Jo Williams: Absolutely.
Q168 Chair: How many professionals have been reported by CQC to their professional regulatory body?
Dame Jo Williams: I do not have that figure.
Amanda Sherlock: We can get them.
Q169 Chair: It would be interesting to know because the question in Winterbourne View, but much more generally, is: how many professionals either knew or should have known what was going on and did not observe their professional responsibility to report it?
Dame Jo Williams: Yes.
Q170 Chair: It is one thing to facilitate whistleblowing. It is another thing to ensure that people understand, if they are professionals, they have an obligation to report.
Dame Jo Williams: I agree with you.
Q171 Chair: Is it something the CQC has followed up as a theme with individual employers or individual providers, that either the culture or individual performance in an individual provider has not reflected that obligation?
Dame Jo Williams: I cannot answer that question with specific examples for you, Chair, but I will certainly look into that.
Q172 David Tredinnick: I want to go back to registration, but, on the whistleblowing, do you think the increase in the number of whistleblowers is because of improved practice or is it in fact that they were ignored in the past and you never picked them up?
Dame Jo Williams: From the point of view of CQC, I have no evidence at all that we previously ignored anyone ringing us with a concern at work.
Q173 David Tredinnick: There is a dramatic increase, isn’t there, in the numbers of whistleblowers who have come to you?
Dame Jo Williams: Yes.
Q174 David Tredinnick: Do you have any idea or thoughts about why?
Dame Jo Williams: Why do whistleblowers come to us?
David Tredinnick: Yes. Why has the number suddenly shot up?
Dame Jo Williams: This is speculative, but I imagine it was because of Winterbourne View and being in the public domain. It is true to say that we are still a relatively new organisation and it may well have been that, for the first time, people understood what the Care Quality Commission was, who we were and how to get hold of us.
Q175 David Tredinnick: Thank you very much. I have a couple of questions on registration. The British Dental Association described the process as "shambolic". Do you think that is fair?
Dame Jo Williams: We had a lot of conversations and did a lot of planning with the British Dental Association. They helped us with the processes. It is true to say that we had a single process, which we applied both to health, adult social care, and dentistry. We have recognised it is a cumbersome process-the regulations are cumbersome-and that there is some learning there for us. I know it has been painful.
Q176 David Tredinnick: As to this cumbersome process, presumably you are hoping it will be, perhaps, the key issue raised in the Government’s review-is that right-of the registration system? What changes do you think should be made, please?
Dame Jo Williams: Internally, we are reviewing that as well. We obviously need to work with the regulations and we are constrained by the regulations, but if there are things we can do to make that process of application simplified, we are aiming to do that. For instance, it strikes me that, when we fill in a tax application, we are used to saying, "This is not applicable"-one of the things dentists were saying was that particular areas weren’t applicable-making it easier to process in that way.
Q177 David Tredinnick: It is not suitable for small practice registrations at the moment, is it, say, for one or two? It is a very cumbersome system for that, isn’t it?
Dame Jo Williams: The regulations, which contain the essential standards, are applied universally to health, social care, dentists and, in the future, primary care. With those regulations, obviously, we need to be proportionate. Some of those regulations will apply less to someone operating as a dentist as opposed to an NHS hospital. Nevertheless, we have had to work within the regulations.
Q178 David Tredinnick: I put it to you the situation is, in fact, so bad that it is the reason the registration of doctors is going to be delayed until 2014. What exactly are you going to do with the breathing space that you will be given because of the delay in this other important registration of doctors?
Dame Jo Williams: At the beginning of this year-and again it was a very considered decision, recognising that we did have a backlog of work and were still a relatively new organisation that needed to mature-I went to the Secretary of State and said that I thought it was important we had more time to review our processes before registering general practice, primary care. That has been agreed. We have been working with the Royal College for some considerable time-and we will continue to do so-to ensure that process is more streamlined and appropriate. Next year we will be looking at outofhours medical services, so we will be doing that on time.
David Tredinnick: Thank you very much.
Q179 Dr Wollaston: Can I return, briefly, to Winterbourne View? How confident can the public be, if you received another email such as the one you received on 6 December, that an inspection would take place and it would be followed up in a timely manner? Also, what do you consider to be the time frame for that?
Dame Jo Williams: I want to reassure you we are now sighted on making sure not only that the individual inspector receives the information by email and by phone call but also that their manager has it too. That is putting in an extra, if you like, assurance in the system. Each inspector will make a judgment about the information they have received alongside the rest of the information they have in relation to a particular service or activity. We are now at the point where, with almost all our reviews of that nature or if we receive a series of concerns or complaints from the public about a service, we would go out and do an unannounced inspection.
Q180 Dr Wollaston: Had you had an email such as the one on 6 December, within what sort of time frame would you aim for that inspection to take place?
Dame Jo Williams: I don’t think we would set a-
Dr Wollaston: You wouldn’t.
Dame Jo Williams: We do not have a target of 24 or 48 hours, but we would expect it to be proportionate to the seriousness of the information we are receiving. An inspector would also want to talk to others that may be involved, for instance commissioners of services, so that the picture is drawn. If it was felt that individuals were at risk, my expectation would be that we went out immediately.
Q181 Dr Wollaston: We would not be waiting eight weeks for that kind of thing.
Dame Jo Williams: No, absolutely not.
Q182 Dr Wollaston: That is very important. One of the other issues that brings me on to is your budget. Your budget is £60 million less than your predecessor organisation. You told us in September that the CQC was struggling. How realistic do you think this is within your current budget and the extra responsibilities you are taking on?
Dame Jo Williams: I have said already this morning that I believe we do need more resources. I know that is difficult in the world within which we are working at the moment, where money is very difficult and the expectation is that we are a lighttouch, proportionate regulator. However, it does seem to me that there is considerable appetite among the public, and indeed those who are providers of service, for us to be more visible and to be carrying out more inspections. Unless we had a complete army of inspectors, of course, or other people were working with us, those who experience services and their families as well as providers-fundamentally, providers-we would not be able to say to the public that services were meeting those essential standards. It is about pulling that information together.
Q183 Dr Wollaston: Following on from that, of course, is the information available to commissioners?
Dame Jo Williams: Absolutely.
Q184 Dr Wollaston: Are you currently contacted regularly by commissioners in helping them to make decisions about care?
Dame Jo Williams: We have a flow of information. In relation to the Health Service, we have something called a Quality and Risk Profile where we draw down well over 250 pieces of information about an individual service. It is analysed. That is the hard data. In addition to that, we receive information from patients’ groups-LINks-which we are evaluating. That information goes to our staff, but also to commissioners. We are working with local government in relation to adult social care, looking at how we can exchange information. At the moment, we are working with 16 local authorities on pilot sites to ensure that flow of information. It is absolutely crucial that we do that and, frankly, with the Health Bill going through with those new changes, it will be crucial that our information is made available to commissioners and the NHS Commissioning Board.
Q185 Dr Wollaston: I know that other colleagues want to touch on Quality and Risk Profiles and the adequacy of that, but, before I finish, do you anticipate yourself having any role in regulating the quality of commissioners themselves, or merely in providing them information?
Dame Jo Williams: As things are at the moment, we no longer have a responsibility for looking at commissioning and regulating commissioning. However, first of all, it is vital we get that information to them, but it is also true to say we are about to embark on-following on from Winterbourne View-a significant series of inspections looking at health services for people with a learning disability. One of the things, almost inevitably, that will emerge from that is a commentary on what is happening in terms of commissioning. We will put that into the public domain. Although we are not regulating it, I know, through those inspections, that information flow will happen.
Q186 Chris Skidmore: Specifically on those inspections, there is a real issue of confidence in the system at the moment, as I mentioned in my earlier section.
Dame Jo Williams: Indeed.
Q187 Chris Skidmore: Those people who want to provide information need the confidence that it is going to be followed up. Obviously, you have now put in place systems and you will take those measures so that the situation of Terry Bryan never occurs again. First, to be clear, constituents contact me and are now copying me into emails to CQC, so I follow them through as well.
Dame Jo Williams: Good.
Q188 Chris Skidmore: But I do not know yet, for instance, if the CQC receives that contact by email, whether contact will be made by email or by phone or there will there be an active way of chasing up that complaint. I know you cannot give a time frame, but is there a guarantee that that will be done?
Dame Jo Williams: If one of your constituents is sending information to us, absolutely, we are following that up, yes.
Q189 Chris Skidmore: Secondly, in terms of inspections for homes dealing with people with learning disabilities, will those inspections be unannounced?
Dame Jo Williams: They will indeed, yes.
Q190 Rosie Cooper: I want to address another comment you made this morning. As to your workforce, how do you see the percentage of the work being done with regard to registrations and inspections currently-a short answer to that? Would you see them as both part of the same thing?
Dame Jo Williams: Registration is a process. It is managed.
Q191 Rosie Cooper: I understand the process. What I am asking you is this. How much time does your organisation spend currently on registration and inspection? I know you will say that inspection is part of the registration process, but I am talking about a revisit, a recheck. What is the balance?
Amanda Sherlock: Might I add some information here? Now that we are into a "business as usual" way of working-the bringing of these huge changes and services into registration is by and large completed-approximately 20% of our time is spent on registration and 80% on compliance, enforcement and followup, post registration and being brought into the regulatory system.
Q192 Rosie Cooper: How many vacancies do you have in your organisation currently?
Amanda Sherlock: For frontline inspectors?
Rosie Cooper: Throughout the organisation.
Amanda Sherlock: It is approximately 350 across the organisation.
Q193 Rosie Cooper: You have 350 vacancies. How many of those are inspectors?
Amanda Sherlock: 121.
Q194 Rosie Cooper: You are now telling us that you are getting more complaints through the system than ever. You have all these vacancies. I know you have given evidence to various inquiries, and the Mid Staffordshire inquiry for one. Did you disclose the number of vacancies you had? What are you doing about getting them filled? Dame Jo has talked about conversations with Government about resources-and somebody like me would say you were absolutely stretched and underresourced-but if you have 350 vacancies and 121 inspector vacancies, there is a problem here, isn’t there?
Dame Jo Williams: Can I pick up a couple of points? In terms of the inspectors, we have recruited and offered jobs to 70 people.
Amanda Sherlock: That is in the last few weeks.
Dame Jo Williams: Recruitment is going ahead now.
Q195 Rosie Cooper: How long have these 121 vacancies existed? This is not short term.
Dame Jo Williams: No.
Q196 Rosie Cooper: Why have you not interviewed and appointed before now? I am told that this is a longterm vacancy problem. If it is, why is it?
Dame Jo Williams: We have had to work within guidance to ensure that, when we were changing our systems internally, people being displaced from one job had to be given the opportunity to come into other jobs. It has been a constant changing round.
Q197 Rosie Cooper: The public have been put at risk because you have not had enough inspectors while you were busy internally reorganising yourselves. Is that what we are saying?
Dame Jo Williams: No. It is absolutely not true to say that. We have worked entirely within the guidance we were given to make sure that we recruited people appropriately-people with the right skills to do the job.
Q198 Rosie Cooper: Would you perhaps send to the Committee a chart of how many vacancies in inspection you have had, for example, say, since your inception-the bigger numbers? I am not talking about a clerical thing, but somebody who is going to make a difference to your process. If you had a problem with this, did you disclose it when you were giving evidence at Mid Staffordshire, for example?
Amanda Sherlock: Yes, we did.
Q199 Rosie Cooper: With the Chair’s permission, I would like to look at some of your indicators about the effectiveness of the model you work on to get your proper risk analysis-sorry, that was the phrase you used before. I am talking about Quality and Risk Profiles. It does not rely on sophisticated number crunching, but rather the quality of the numbers in the first place-in other words, the information you get. As a former chair of a hospital, I am concerned. I know there are 250 different bits to it-and I will come to other bits of this in a second-but, for example, you rely on PEAT scores quite a lot, yet they are tickbox by the hospital themselves. How can that be okay?
Dame Jo Williams: The work that has been developed in relation to the NHS and Quality and Risk Profiles has been developed over a number of years. We are now in a much stronger position with analysing that information, but it is supplemented by the information we receive relating to people’s experiences. You will know that that is a rich source of information.
Q200 Rosie Cooper: PEAT scores left Stafford with 20 out of 25 for privacy and dignity and the NHS Litigation Authority gave Stafford 9 out of 10 for governance. I am hardly enthused and reassured by all that.
Dame Jo Williams: Of course, we have learnt a great deal from what happened at Mid Staffordshire. I will ask Amanda to come in in a moment, but we are absolutely clear that it is very important for us to share information, work with commissioners and work alongside Monitor-and also a range of other organisations, including, as I say, NHS Choices and patients’ groups-to ensure there is a proper flow of information.
Q201 Rosie Cooper: Surely the very people you are trying to reach are the very people who will not fill in those forms-the elderly, the confused. For example, my father would never fill in one of those. He would think somebody was going to pick on him. He wouldn’t tell you the truth about what was happening to his care. Those are the very people who, by virtue of their illness, age, infirmity or whatever, would feel vulnerable. They would not be the people who would sit and fill up those forms. If you do not have the ability to reach down and get those numbers in, you cannot rely on the numbers that you tell us you are relying on.
Amanda Sherlock: The Quality and Risk Profiles are an excellent repository for data and information, enabling people who are very skilled in analytics to identify the probability of risk in a service. That is heavily supplemented by an inspector using their professional judgment.
Q202 Rosie Cooper: Shall I read you the Mid Staffordshire numbers again?
Amanda Sherlock: The Quality and Risk Profile is a tool to support inspectors in making a judgment. It does not in any way make a judgment about the outcomes for people using services. One of the lessons in the dignity and nutrition inspection programme has been that using tools that have been used in adult social care inspection over the years, such as the SOFI tool-Short Observational Framework for Inspection-is as powerful as any set of statistics.
Q203 Rosie Cooper: Is that one that you decided to do or the Secretary of State asked you to do?
Amanda Sherlock: We were asked to pull together a programme that would look at dignity and nutrition. The method by which we undertook that inspection programme was CQC’s design.
Q204 Rosie Cooper: When information is not available for a particular organisation-when some of these categories are missing-is it presumed to be okay or is it presumed that you will need to investigate? The evidence you gave at Mid Staffordshire would suggest that you do not investigate that very much further.
Amanda Sherlock: It is never presumed to be okay because there is a lack of information. In fact, it would be the opposite assumption, that we would need to go and check.
Q205 Rosie Cooper: I will not read you the whole paragraph: "... where the QRP contains insufficient information for a risk to be analysed for a specific outcome, CQC is nonetheless treating the institution as being compliant unless information is received- A. That’s correct. Q. -to the contrary? A. Yes."
Can I ask you what the actual position is when you get information which is conflicting? Do you go out and inspect when you do not have either the information or the resources-the score is not good enough? Do you go and look at it? What I am trying to get to is: are you confident that you are not missing poor standards? The CQC is in a difficult position because most of the country will see you as the badge that says "This is good". Yet, so much of the time, from what I have read and can see, you have large numbers of vacancies, you are stretched and you are getting ever more jobs, and we have not even begun to look at HealthWatch, which I am terrified you are going to get as well, because you do not have the resources to deal with it. I hear that you are in discussions, but you are the mechanism by which this country is supposed to be assured that the elderly, the ill and people at risk are being looked after. I can go on.
Safeguarding is dominated by issues to do with children and older patients without capacity. I don’t know what the word is. How do you evaluate that? Who puts that together? For example, the safeguarding one for children asks if there is a visiting room for children that is nicely furnished with toys and uses the national inpatient survey of adults. The "global rating scale" focuses on endoscopy units. It is used in a number of outcomes but not the one relating to medical equipment. There are some really obvious things. I want to be sure children are safe. I believe that they should have toys to play with, but that is a lot lower down on my list for being assured about children and safeguarding than things that are here. I am worried. I am seriously worried about your capacity to deliver.
Dame Jo Williams: Can I pick up one point, if I might? The public are absolutely right to be focusing on the fact that we are the regulator for health and social care, dentists and, in the future, primary care. The centre of our work is focused on that role of protection. However, we cannot do it alone. It is dependent not only on analysis of data but information flowing into our organisation from a variety of different sources, whether it is individual experiences, families or people working in the service. It is also important that we share and gather information from other organisations that I have already mentioned this morning. It is a collective.
Our job is to ensure that if we receive information that raises questions about those 16 essential standards-whether or not there has been a breach-we investigate and find out if there has been a breach. There are judgments to be made about that every time, analysing what we have learnt and what we know already, but that is absolutely central to the work that we do. We are refocusing all our energies to make sure that we do that well and that we get people out there looking at, talking to and listening to those who receive services. One of the things I would say is that providers need to be saying to themselves, "What is happening during the early hours of the morning and 24 hours a day? What am I doing as a provider of a service to ensure that those essential standards are not being breached throughout the day?"
Q206 Rosie Cooper: I absolutely agree that the providers have that responsibility, but I want to put it to you that the great British public are looking to you to make sure they do.
Dame Jo Williams: Indeed.
Q207 Rosie Cooper: Therefore, you must be fully staffed and have the capacity to do it. Genuinely, from the things I have read out, Mid Staffordshire could pass all these tests. You are reliant on information which may or may not be there or be accurate. I hear what you are saying about improvement, but it is going to have to be a huge step change-light years’ improvement-and a much quicker reaction. When you find a breach, what do you do?
Dame Jo Williams: I will ask Amanda to answer that question, but can I also reiterate where I started, that I do think we have made those step changes in the last six months. We are not there yet-and I cannot pretend that we are-and we do need additional resources to be able-
Q208 Rosie Cooper: What have you asked the Secretary of State for?
Dame Jo Williams: We need an additional 10% because we need more inspectors; we need to be able to draw in more experts by experience to go in with us; we need more people who can go in specifically with a background; and, of course, if we have additional frontline staff, we need support systems as well.
Q209 Rosie Cooper: What does an additional 10% mean?
Dame Jo Williams: It is about £15 million.
Q210 Chair: You are saying that, without that, you cannot do your job.
Dame Jo Williams: I am not saying that. We will continue to look at ourselves and say, "What efficiencies can we make?", because we know that we can improve effectiveness and efficiency internally. What I am saying is, looking at what is happening in the sector, when things are going wrong-when there is a breach-that is resource intense. We need to follow it up, go and ask questions and ensure that progress is being made. If it is not, we need to take action.
Q211 Rosie Cooper: I would like to know the detail. When you identify a breach, what happens, please?
Amanda Sherlock: In very broad terms, if a breach is identified of the essential standards whilst we are on an inspection, that evidence would be brought back, it would be discussed with a clinical expert if it was in an NHS organisation-additional expertise if we wanted to triangulate and ensure that the evidence of the breach was going to stand up to tribunal or stand up, potentially, to prosecution-and we would then make a decision as to the impact on quality and safety against the essential standards. We would then map that against our available enforcement tariff and determine what action was going to be appropriate, if indeed it was going to be escalated into enforcement action. It might be a warning notice; it might be that we would trigger a fuller investigation, if there was evidence of serious or systemic failings that were whole organisational, rather than specific to one of the essential standards; or it could potentially be that we would go down the criminal route and move to prosecution or a fixedpenalty notice. However, in a constrained financial environment, placing a fine on a provider is not usually the best way to lever essential standards compliance.
Q212 Rosie Cooper: How would the public know?
Amanda Sherlock: We would publish. Once we are-and this is a difficulty with regulations-through the appeals period we would publish that information and activity.
Q213 Rosie Cooper: Is your website up to date? It was dreadfully not up to date last year?
Amanda Sherlock: It is being updated next Tuesday. What we have introduced, where we have any concerns, is that it says "under investigation" on our website or "under review".
Q214 Rosie Cooper: Your website is still not up to date.
Amanda Sherlock: It will say where we are undertaking any inspection review activity. The website will say that we are undertaking that investigation.
Q215 Andrew George: Coming back to the risk-based method that you very much depend upon, I assume, even if your budget were quadrupled, that you would never have enough inspectors to drop the riskbased system you primarily depend upon to keep an overview of what is going on around the country. Is that a reasonable comment?
Dame Jo Williams: It is, indeed.
Q216 Andrew George: In that regard also, you depend very much upon whistleblowers, whether they be the patients, their family or staff in the system. Are you reasonably confident that your doors are sufficiently open to that happening, that the message is out there, that people are beating a path to your door and that you are comfortable people are aware of your existence in that respect?
Dame Jo Williams: I have indicated we are seeing a rise in the number of people who are working in an organisation and are concerned. We are probably also getting about 150 calls a week from members of the public expressing their concerns. In fact, that is rather a small number. Our ambition is that people would not only want to contact our central number but that our inspectors on the ground are visible, people know who they are and can make contact with them if they have concerns.
Q217 Andrew George: Through the riskbased assessment-through the QRPs as well-you are monitoring the outputs, as it were, what care is provided. However, within the 250 indicators, presumably a large number of those indicators are an assessment of the inputs. Are you assessing staffing ratios? Taking nursing care homes or even those which involve learning disability, do you have a notional view of what an appropriate staffing level would be?
Dame Jo Williams: I would ask Amanda to pick up that particular point, but the regulations themselves are focused on outcomes for people rather than the inputs, as you describe. One example that springs to mind where we did focus absolutely on the staffing level was in relation to Milton Keynes Hospital maternity services. We felt that, in order to be able to say the service was safe, they needed onetoone services for women, midwife to mother. In a sense, we stepped outside our parameters, if you like, in doing that, but we believed that, in order to offer a safe service, it was appropriate for us at that time to comment on that and to demand that that happened in order for the service to continue. What I am saying is that if we discovered there was a breach of regulations that related to the number of staff on duty, the ability to give people a good quality experience, then we would be saying to those providers, "We think you need to look at your staffing levels." Staffing levels, use of agency staff and turnover of staff are often very good indicators of a culture that is not focused on the people they are serving.
Q218 Andrew George: They are part of your QRP.
Dame Jo Williams: I am not sure that they are part of our QRP.
Amanda Sherlock: For the NHS we would have that information available.
Q219 Andrew George: You would have it for the NHS but not in the private sector.
Amanda Sherlock: No.
Q220 Andrew George: May I put this to you, and I will take a moment to say it, if you are saying you are stepping outside what you would normally do. Having shadowed nurses in the NHS context, but also talking to nurses and care workers in the private sector, one of the themes which clearly crops up time and time again is this sense that the staff ratio is very much on the edge of what is actually, frankly, viable to run an adequate service. That seems to be across the board, even among the best providers. They are teetering on the edge of viability. I say to the staff, "Do you complete an incident form? Do you comment on this or report it back?" On every occasion the answer is no, they do not, because, if they did, it would affect their future career prospects. They would be asked the question by senior management, "If you can’t manage, why is it that all the others on the shift can?", and so on. You have a culture in which staff are under pressure not to complain about the fact that the staffing ratios are on the edge of what is safe for patient care. Therefore, I put it to you that this is surely an input that you should be looking at as an indicator of services which are on the edge of being, if you like, compliant with the kind of quality that I believe we all want to see. Is that not a fair point?
Dame Jo Williams: It is a fair point and I think Amanda said that in the NHS we have that. Reflecting on your comments, this is a critical area. We are currently undertaking a very intensive review of a hospital-and we will be pursuing another hospital probably tomorrow. Quite clearly, in that piece of work, we are looking very much at the whole service, and the way in which they deploy their workforce and the turnover of the workforce would be very important indicators.
Q221 Andrew George: In some sectors, of course, there are professional guidelines as to what the staffing levels should be, and maternity is certainly one of them, but not all sectors have them as you know. If you are not monitoring that, my concern is there may well be a pattern emerging, both within the acute sector but also in, say, nursing care, and indeed residential care, where staffing levels are not adequate. That is possibly a point which not only needs to be taken up with the individual providers but also fed back to the Department so that it can inform policy, or possibly to the clinical colleges so that they can advise the services themselves as to what the appropriate staffing levels should be. Is that not a fair point?
Dame Jo Williams: It is a very fair point. As part of our review or inspection of a service, we would be looking at the extent to which individuals had a care plan and were central to what was happening in that organisation. Quite clearly, that will reflect on the investment in the workforce. I don’t know whether there is anything you wish to add, Amanda.
Amanda Sherlock: In adult social care, at transition to the new registration and framework, we were very mindful of the shortage of registered managers. One of the key indicators of good quality social care is the competence, the capability and availability of good registered managers. Therefore, we took a policy position of placing conditions on the registration of those adult social care providers where there had been a history of a lack of a registered manager and where there were no credible plans in place that the provider could demonstrate to recruit good, highquality registered managers. Whilst we have nothing in our regulatory framework that allows us to set any minimum staffing levels or staffing ratios, we do link it back to outcomes for service users where we can. That is then, where possible, triangulated back to our regulatory framework to enforce.
Q222 Andrew George: It is all very well having a view from a managerial perspective but, given that you have indicated today that your QRP indicators do not take account of stafftopatient ratios across sectors-I quite appreciate that, on the one hand, we are talking about active cruelty and neglect, but as far as the pressures in services across the board are concerned-do you not agree that it would be perhaps time for the CQC to include in its indicators, dependent upon the nature of the service being provided, some kind of indicator as to the staffing level you believe should be in place in order for that service to be a safe service?
Dame Jo Williams: It is true to say that if we thought individuals were at risk we would most certainly be saying there was a need for additional staffing, not only at managerial level, but actually on the ground. Our assessment will be very much based on the impact on those individuals, which gives us some degree of flexibility. However, there is no doubt that, if we felt there was a shortfall and people were being put at risk, we would ask that organisation to improve their staffing.
Q223 Andrew George: I will take as an example helping older patients with dementia and disability to bed at the end of the day. I have complaints from constituents saying that often they are taken to bed too early-3 or 4 o’clock in the afternoon. Of course, the reason for this is because of the staffing levels and that each one takes half an hour for the care worker to get them to bed. If you work it out, given the number of patients which they need to take to bed, they need to start at 3.30 in the afternoon. Thus, you have this absurdity of a care system which is inevitably going to provide poor quality care because the staffing levels simply do not ensure that the patients have an adequate, if you like, time of day to spend out in their property or in the garden.
Dame Jo Williams: I absolutely agree with you, and I will ask Amanda to comment. It seems to me that they are not delivering appropriate care to those people they are looking after.
Q224 Andrew George: The staffing levels will not allow it, though.
Dame Jo Williams: We would be talking to that organisation about breach of compliance, because they certainly won’t be enabling people to have choice and a quality of life that we would regard as appropriate in terms of quality of care.
Q225 Rosie Cooper: How would you know?
Chair: That is exactly the question I wanted to ask. You said that you don’t have a status for looking at staffing ratios, and yet you would express a view if you felt the staffing ratios were inadequate. It cannot, surely, be right that you have no status in looking at staffing ratios.
Andrew George: You are looking at outputs not inputs.
Amanda Sherlock: You would find that out through whistleblowing, through inspections, when you would look at staffing ratios and when you would speak to staff and to residents to get their experiences of care. Then you would go back and track that with the provider and say, "This is what I am being told. Can you demonstrate evidence that this is not true?" and take that approach. However, we are not in every location 24 hours a day. We are very much dependent on that information being fed through to us.
Q226 Rosie Cooper: When this is televised, you will find so many families throughout the length and breadth of the United Kingdom screaming at the TV that they know their elderly relatives are being put to bed in the afternoon or very early evening. This is going on. It is almost standard practice. Everybody can give you a tale of it. You are saying here it is unacceptable, but how is it going on if it is unacceptable? Is it Mid Staffordshire on a smaller scale? This doesn’t make sense.
Amanda Sherlock: The public have to tell us.
Q227 Dr Wollaston: How can they make the judgment? It is easy for you to make a statement about safe staffing levels for different types of residential care.
Dame Jo Williams: I take the point.
Q228 Chris Skidmore: You are not communicating effectively enough to the public the message of saying what is acceptable and what is not acceptable. You do not have the public guidelines in place. You do not have a consistency of approach. One inspection can turn up one thing and another a different thing. Where is the consistency in quality? That is probably what we are trying to get at here.
Dame Jo Williams: We clearly need to take this away. We need to explore and challenge the evidence that you have put forward that this is happening right across the country, but-
Q229 Rosie Cooper: I am sure newspaper readers and TV viewers will inundate you now. Everybody who deals with elderly people knows this is going on. I have had a number of relatives in the last six months who have either been in nursing homes or been very ill and have since died. I have had conversations with your regional directors and the truth is everybody does know it is going on. Perhaps you are the only people who do not get that this is going on in as big a way as it is out there, but it is.
Dame Jo Williams: That is a good challenge. That is a challenge we have to take away.
Q230 David Tredinnick: What is being asked for is a clear standard-
Dame Jo Williams: I take the point.
David Tredinnick: -something that you aspire to, and perhaps this has been helpful.
Dame Jo Williams: We need to take that away.
Q231 Chair: You have undertaken to take it away. We would be interested to hear how you respond when you have had a chance to look at it. If I may claim the Chair’s prerogative of the last word, as to the proposition from Amanda Sherlock that "the public must tell us," the public would say that is what they pay inspectors for. Of course, the CQC should respond to public information but, in the first instance, the responsibility surely rests with the CQC.
Dame Jo Williams: Chair, I take that point, but, as we have explored already, it is very important that people tell us. We have a core of information, but we need additional information in order for us to see, further, what is happening.
Chair: May I bring in Yvonne, who has been very quiet? This is information to the public, I think-information the other way round.
Q232 Yvonne Fovargue: It is. Obviously there is a lot of concern after Winterbourne View about the social care system, and yet there will be people who need to use that system and need to go into it all the time. The star system has finished and there is not another system in place at the moment. How are the public to judge even the most basic quality of a home at the moment? The excellence is not coming in. I have more questions on that.
Dame Jo Williams: Did you say "the excellence"?
Q233 Yvonne Fovargue: The excellence award is not coming in. At the moment, how are the public supposed to judge the quality of a home, even on the most basic information?
Dame Jo Williams: Our 16 essential standards mean that, on organisational activity, if there is compliance then the essential standards are being met. As Amanda has said, if we are following up an investigation because there has been a breach, it is very important that that information is available. In terms of decisions relating to people’s future care, it does seem to me that looking at information from ourselves is one part of the picture. It is very important that-these are critical decisions to people’s lives-people talk to others in their community and look, themselves, at what is available. They know the individual that they are concerned for, so there will be something about making sure there is the right service for that particular person.
Q234 Yvonne Fovargue: You have already said it is difficult for the inspectors to go in and look at this. It is even more difficult for a lay person, particularly when it is for their own. There was the star system, at least. I don’t just want compliance for my 83 yearold old mum. I want a standard of excellence. I am a bit concerned about the excellence award because it is a voluntary system that not everyone is going to go into. How is the public going to recognise the excellence standard? There might be another home that has not agreed to go into that but is just as good.
Dame Jo Williams: If that scheme comes in, it will be in the public domain. I want to go back to your initial reflection that the public don’t know how to find out what is going on. From the people that I talk to, it is the way in which they are greeted when they visit a home, the way in which they look around and see what is going on, whether there are activities and how are people spoken to. People can make a judgment about cleanliness and the way in which food is presented. There is a great deal that people can do by looking and seeing for themselves. Our work is to ensure that those essential standards are met and that that information is in the public domain. Over and above that, as I say, there is a lot about making a personal judgment yourself by looking and asking questions.
Q235 Yvonne Fovargue: What information will appear on the provider profiles? You have already said that for social care you do not look at issues like staffing levels. What information is going to be there? Will it be enough?
Dame Jo Williams: That is a very good challenge. What we will be saying to the public is: these are the essential standards. If there has been a breach and we are following up, that will be available to the public too. As to the question you raise about the excellence scheme, it is still out for consultation. I am not convinced yet that we have identified how it would work well and how it would address the question that you raise in terms of making sure a particular additional kind of service someone is looking for is available.
Q236 Yvonne Fovargue: What is happening in the meantime? Are the provider profiles up yet? When will they be going up?
Dame Jo Williams: They will be going up in the autumn, but there is already information on the website about individual establishments.
Q237 Yvonne Fovargue: Why is there delay?
Dame Jo Williams: It is partly to do with the volume of activity that we have had to undertake to make sure that the data is accurate-the numbers are very significant. Also, we have to make sure we are not misleading the public in any way in the information that we put out.
Q238 Yvonne Fovargue: It has slipped again now, hasn’t it? It was going to be January, then the summer and now it is autumn.
Dame Jo Williams: Next week our website will put up the information, but we will go further than that in the autumn to enable people to find out even more information. That is what I am saying.
Q239 Chair: Dame Jo, before bringing in Rosie on HealthWatch, can you not understand that people might think this is a more urgent priority than the processing of the registration of dentists and that there is a problem here about priorities within the CQC?
Dame Jo Williams: I understand what you are saying, Chair, but we will be at the point next week of making sure that that information is up to date and available to the public. Of course, it is really important that it is accurate. That has been our driving force in making sure that, before we put it out, it is accurate, and we are continuing to work very hard to make sure that, by the autumn, we have something that doesn’t mislead, is easy to access and is understandable by members of the public.
Q240 Rosie Cooper: I must admit it sounds like a bureaucratic nightmare, to which we are about to add HealthWatch. Can you tell me how you see HealthWatch operating under your auspices? Will that, too, become a bureaucratic nightmare? Forgive me for putting words in your mouth, but you are going to have to react so much more quickly. Your website was out of date seven or eight months ago. It was really out of date. You weren’t putting inspections up on there. If you are telling me that it is only going to be okay next week, I really am worried. How do you see HealthWatch operating under your auspices? How are you not going to let it just become part of this bureaucratic nightmare? What do you see it achieving? Should it be under your auspices or would it be better off somewhere else?
Dame Jo Williams: I want to challenge you about the bureaucratic nightmare, but I will leave that on one side. HealthWatch is an opportunity for us to have a very effective way to gather further information from the public. That relies on the development of local HealthWatch organisations, which will, I hope, be able to hold organisations to account, be gathering information and listening to people in their communities. I would not want it to be exclusive. We get a lot of information from other organisations in communities and so we do not want that to stop. It will enable us, we believe, to do our job even better.
Q241 Rosie Cooper: I hope that is true, but, let me tell you, hope is not a strategy. You need to find a mechanism to make sure those things really do happen. Frankly, for me, Health and Wellbeing Boards, which all of this will play into, will become talking shops. What we need to know is that somebody is listening. To go back to Chris’ point about whistleblowing, it is not just about HealthWatch, local HealthWatch, it is about how individuals make their way through your system. I can’t go away from, "I do believe it is overly bureaucratic." Your chief executive talked about being reactive. I don’t think there is anything wrong with being reactive as long as you react quickly enough. Sadly, I do not think, so far, perhaps you have been. It comes to the priorities bit, which is where I started out.
Dame Jo Williams: Yes, quite.
Rosie Cooper: How much time do you spend on registration? People are depending on you.
Dame Jo Williams: Indeed.
Q242 Rosie Cooper: You cannot fail, and you have.
Dame Jo Williams: I absolutely agree with what you are saying about people depending on us. It has not been an easy journey to get to where we are, but where I started was to say that we have made significant progress. We are in a much stronger position than we were at the beginning of the year. We are getting people out, visiting, seeing services, making judgments on a regular basis now and putting that information into the public domain. We are developing different methods of operating, pulling in people who we are calling "experts by experience." We need, if we are able, to demonstrate that we are and give the evidence for additional resources. I would like to see us recruiting people who would work over weekends-to some extent we are doing that now-and specifically recruiting people who would work different hours, doing the early hours of the morning. We need to have a roundtheclock workforce. Our inspections do happen outside office hours, but not enough.
Q243 Rosie Cooper: As chair of a hospital, I wasn’t paid to go and visit the wards at 3 am, but I did.
Dame Jo Williams: Exactly my point.
Q244 Rosie Cooper: This is the final one from me and then I will stop. You mentioned before that you wanted another £15 million. Did that include the money for HealthWatch or is that excluding HealthWatch?
Dame Jo Williams: No, it does not include HealthWatch.
Q245 Rosie Cooper: How much do you think you ought to get upfront now-on the record, if you can? How much do you think it would take to make HealthWatch work properly?
Dame Jo Williams: The figure we have been talking to the Department of Health about is in the region of £3 million.
Q246 Chris Skidmore: I have a quick question about complaints data. You mentioned you are receiving 150 calls a week currently as a result of Winterbourne View and Southern Cross. Is that not the tip of the iceberg in that what you have is a codependency on local authorities as safeguarders? Certainly my own experience is that people will often go to the local authority first to complain. Are you receiving data from local authorities about the number of complaints they are receiving?
Dame Jo Williams: No, we are not.
Q247 Chris Skidmore: Do you not think you should?
Dame Jo Williams: Indeed. As I said earlier, we are working with 16 local authorities, looking at the flow of information between the two organisations. Quite clearly, understanding where there are areas of concern and complaint is crucial information.
Q248 Chris Skidmore: You will find you will get the 150 calls but, nationally, what local authorities are receiving and whether they are effectively following them up is tipofthe-iceberg stuff.
Dame Jo Williams: It is also fair to say that if a local authority now is concerned in any way about provision, the relationships are such that they would contact us. I am clear about that.
Q249 Rosie Cooper: What about if it is a local authority’s provision of domiciliary care-care in the home? How does that relationship work? They are not going to tell you about when they are going wrong. Lancashire County Council, I am sure, wouldn’t be telling you, in my patch. I tell you.
Dame Jo Williams: Yes. We rely on other people too, absolutely, but the point-
Q250 Rosie Cooper: Let us drill down there. That is really important. How do you deal with local authorities who, for example, would be the paymasters in local HealthWatch? How do you deal with making sure that you inspect them with rigour as well?
Amanda Sherlock: In exactly the same way as we do with any other sector that we regulate. The proportion of directlyprovided local authority care is now relatively small. It has been an interesting journey over the years, from when it was a much bigger proportion and registration inspection units were part of local authorities, to the setting up of an independent regulator and working through the challenges that they posed for some local authorities in bringing their directlyprovided services up to an appropriate level under the Care Standards Act-now under the Health and Social Care Act. We would not take any kind of lesser approach with our local authority or with an NHS trust than we would with an independent adult social carer or independent healthcare provider.
Q251 Rosie Cooper: I may not know what I am talking about now. Do you regulate care companies that provide care in people’s homes?
Dame Jo Williams: Yes.
Amanda Sherlock: We do.
Q252 Rosie Cooper: Those organisations are famed for-we have seen it in the press-the 15minute call where the patient or the resident gets only five minutes because five minutes is spent arriving, making the call to tell people they are there, people then get almost a choice of what they want doing and then the carer has to register the fact that they are about to leave, and they are gone. They are invariably late. Even though you have a rough idea when they are coming, they can be an hour or two either side. The elderly and those people that are sitting in their own homes are expected to take it. If they complain, it gets very, very difficult-and I know because I have had absolute experience of this-so they are not likely to complain. How would you regulate those companies providing care at home? You only have their documentation to deal with it, unless you go and visit individuals in their home. Do you do that?
Amanda Sherlock: It is a very difficult area that the chair and the board have asked us to look at.
Q253 Rosie Cooper: But that is why they are getting away with it.
Amanda Sherlock: When care is provided in an individual’s own home, that is an interesting dilemma for a regulator, to go and knock on the door and cross the threshold into someone’s own home. We have done it when we have been following up on specific complaints, but, as a matter of-
Q254 Rosie Cooper: I would very much appreciate it-and I presume the Committee would-if you perhaps wrote to us on that basis because we are now saying to the great British public, "You don’t want to be in care homes. You don’t want to be in residential accommodation. You want to be in your own home, but in your own home we can afford you less regulation because we don’t come in and see what is being provided to you or your family and we have to rely on what these companies who are making money tell us." That does not seem to be the way of the future to me.
Dame Jo Williams: Could I intervene? I endorse what you are saying about those kinds of visits in which people are being rushed and hurried. It is extraordinarily difficult. I spoke at the Directors of Social Services conference earlier this year saying to them that, as a system delivering services to people, it did not seem to me to be appropriate. That was a challenge to them. I visited an authority last week-Sunderland-where they had a total system of telecarers. There were four vans covering the city throughout 24 hours of the day. If people were in need of some service in addition to the routines that were going on, they could make contact. It was inspirational to see the way in which people were put at the centre of the service. If I might say, one of the other roles that I am fulfilling is working with Andrew Dilnot, looking at the funding and how we pay for longterm care. Undoubtedly, and we have said it publicly, there is a shortfall in the funding. One of the consequences, I think, is that those who commission services are commissioning for minutes rather than thinking around the service for the individual. It is a matter of major concern, and I agree with that.
Q255 Rosie Cooper: We need to protect the people who we are encouraging to receive services in their own home.
Dame Jo Williams: Certainly, indeed.
Rosie Cooper: From the comments made today, they do not have much protection.
Q256 Chair: Thank you very much. Could I conclude with one final question of fact? Earlier in the conversation you said that there has been a longstanding issue of unfilled vacancies in CQC and its predecessor organisations. Are those unfilled vacancies unfilled because of lack of resources or for other reasons? Is it a budget issue?
Dame Jo Williams: No, it is not a budget issue.
Q257 Chair: It is not a budget issue.
Dame Jo Williams: No.
Q258 Chair: Thank you very much. You have given us plenty of food for thought and I think you have said, once or twice in the conversation, that we have given you some food for thought as well.
Dame Jo Williams: Indeed you have.
Chair: Thank you very much.