Agenda Item: 4
Paper No: CM/06/13/03
MEETING:
PUBLIC BOARD MEETING
DATE:
31 JULY 2013
TITLE OF PAPER: UPDATE ON MID STAFFORDSHIRE INQUIRY
RECOMMENDATIONS
SUMMARY:
The Mid Staffordshire Inquiry report by Robert Francis QC was published on 6 th February
2013. The recommendations significantly informed CQC’s Strategy 2013-16 and our
Business Plan for 2013-14, published on 18 April 2013. This paper describes how we are
embedding the recommendations into our work and how we will monitor and report on
progress with implementing the changes, as well as giving a brief update on the
recommendations we are leading on, and some of the key ones we are working with
others on.
RECOMMENDED ACTION:
The Board is asked to ENDORSE the work underway to implement recommendations of
the Inquiry and to monitor and report on delivery, and to NOTE progress to date in
implementing key recommendations for CQC.
Executive Decision/
Board for
information
Executive and Board
decision
Executive and Board
shared decision
Executive and Board
discussion/Board
decision
The Executive Team has
made a decision and the
Board has been informed
The Board has been
consulted in order for the
Executive Team to make
a decision
This is a shared decision
between the Executive
Team and Board
This is for when it is clear
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* Check box as required
LEAD DIRECTOR:
AUTHOR:
DIRECTORATE
DATE:
SUPPORTING
PAPERS:
Paul Bate, Director of Strategy and Intelligence
Robin Wilson, Senior Planning and Performance Manager
Strategy and Intelligence
31 July 2013
Annex A – Mid Staffordshire Inquiry recommendations – CQC
update July 2013
Page 1 of 5
Agenda Item: 4
Paper No: CM/06/13/03
GOVERNANCE
AUDIT TRAIL:
The Executive Team discussed and agreed this paper on
24 July 2013
LINK TO STRATEGIC
OBJECTIVES AND
BUSINESS PLAN
CQC’s Strategy and Business plan both significantly
reflect the Inquiry recommendations.
IMPLICATIONS FOR NCSC
None
FINANCIAL IMPACT:
Changes are part of a costed budget of baseline and
transformation activities, which have been agreed with
DH
RISK IMPACT:
The key risks to delivery of our business plan are
captured as part of the Strategic risk register, with
mitigations monitored at ET and Programme level, and
reported to the Board through regular performance and
risk reports.
REPUTATION IMPACT:
As recorded in the Strategic Risk register.
LEGAL IMPLICATIONS:
A number of legal implications lie within the
recommendations, including the proposed criminal law
sanctions, which CQC will pursue with legal advice, and
in conjunction with DH.
HEALTHWATCH IMPACT:
Recommendations about further user involvement in
CQC activities (eg: 58) will be the subject of further
discussion with HWE.
EQUALITY IMPACT
ASSESSMENT:
Activities to implement the recommendations are part of
our Strategy and Business Plan, and an EIA for both
these documents was completed and published in April
2013.
Page 2 of 5
Agenda Item: 4
Paper No: CM/06/13/03
1.
Background
1.1 The Mid Staffordshire NHS Foundation Trust Public Inquiry was announced on 9
June 2010, following a Statement to the House of Commons by the Secretary of
State for Health (Andrew Lansley MP). The Inquiry, governed by the Inquiries Act
2005, examined the commissioning, supervisory and regulatory organisations in
relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between
January 2005 and March 2009. It considered why the serious problems at the Trust
were not identified and acted on sooner, as well as the lessons to be learnt for the
future of patient care. The Inquiry hearings began on 8th November 2010 and ran for
thirty-seven weeks, concluding on 1st December 2011
1.2 Robert Francis QC published his report on 6 February 2013, which included 290
recommendations. The report’s overarching conclusion is that “a fundamental change
is needed” to put patients first. The recommendations, as set out in Robert Francis’
press statement at the time, were that the system needed:
-
-
A structure of clearly understood fundamental standards and measures of
compliance, accepted and embraced by the public and healthcare
professionals, with rigorous and clear means of enforcement
Openness, transparency and candour throughout the system
Improved support for compassionate caring and committed nursing
Strong and patient centred healthcare leadership
Accurate, useful and relevant information.
1.3 CQC has taken into account the report’s recommendations, as well as initiatives
announced by the Prime Minister, including the creation of a Chief Inspector of
Hospitals role.
1.4 CQC published its Strategy ‘Raising standards, putting people first – Our Strategy for
2013 to 2016’, and our Business Plan 2013/14 on 18 April 2013. Both the Strategy
and Business plan were shaped following extensive consultation and were
significantly informed by the Inquiry recommendations. In our business plan we set
out 8 key objectives in 2013-14:
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Improve assessment and judgement of all the services we regulate by
appointing Chief Inspectors
Improve the safety and quality of care in NHS acute hospitals and mental
health trusts by changing the way we inspect them
Identify, predict and respond more quickly to services that are failing or are
likely to fail by using data, intelligence and evidence in a more sophisticated
and transparent way
Improve our understanding of how well different care services work together by
introducing specific reviews
Work better with other regulators and partners to improve the quality and
safety of care
Publish better information for the public - including organisation ratings
Introduce a more rigorous test for organisations applying to provide care
services
Build a high-performing organisation that is well run, has an open culture that
supports and enables its staff
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Agenda Item: 4
Paper No: CM/06/13/03
2
Executive Summary
The rest of this paper sets out:



Progress we have made in taking forward the recommendations we lead
How we are embedding the recommendations; tracking and reporting progress
How we are working with the DH and other bodies
Progress we have made in taking forward the recommendations
Since April we have:

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Appointed the Chief Inspector of Hospitals, Professor Mike Richards, who started
on 16 July
Appointed the Chief Inspector of Adult Social Care, Andrea Sutcliffe
Launched, on 17 June, the first of several planned consultations on changes we are
making – the first one covers:
o Future regulatory model
o Fundamental standards and an outline of how these might be built on by
higher ‘expected standards’
o Chief Inspectors’ and specialist team roles
o New inspection regime - NHS and independent acute sector (intensive
inspections and use of specialist experts and clinicians)
o Better information for the public
o Ratings – outline proposals
o New registration process, including duty of candour
o Intelligence led monitoring of information and evidence to identify poor care
and reduce risk to service users
o Set out intentions to enforce more rigorously
Made significant progress in preparing to carry out new in depth inspections of NHS
acute hospitals starting from October 2013 including work to establish the teams of
inspectors; the approach to selecting those NHS Acute Trusts to be inspected first,
and determining how we will evaluate the inspections.
Undertaken work with other Monitor, NHS TDA and NHS England on common
frameworks, and with professional bodies and service users on developing
standards, guidance, and assessment frameworks
Built up significant capacity and skills to deliver the programme of change to CQC
The report at Annex A gives a progress report on the CQC lead recommendations, key
recommendations we are working on with others, and other actions announced by the PM
and the Government, arranged by relevant themes in our Transformation programme.
We give a due date and a status indicator for each. One recommendation is shown as ‘At
risk’ – 16 - because the discussions with the DH around enabling prosecution to take place
without a Warning Notice are still ongoing.
For the purposes of brevity, we have summarised the recommendations themselves. The
numbering is as used in Robert Francis’ report.
How we are embedding the recommendations; tracking and reporting progress
There are 36 recommendations that we are leading, and there are a further 73 where we
are contributing.
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Paper No: CM/06/13/03
Our Strategy and business plan are being delivered through a transformation programme
to develop our regulatory model with key themes which include:

Developing our regulatory model:
o Fundamental Standards
o Registration
o Inspection and assessment
o Ratings and publication
o Single failure regime
o Mental health
o Surveillance
o Collaboration and Intelligence sharing
We have mapped the recommendations into these themes and lead managers for each of
the relevant projects are reflecting key recommendations in the plans of their projects, and
reporting on progress through regular programme status reporting. This will feed into the
quarterly performance and risk reports to the Board and DH Accountability meetings.
In addition a special report to the Board in November will give a further progress update by
recommendation. This report will be repeated at 6 monthly intervals.
Working with the DH and other bodies
CQC is a member, together with other key ALBs, of an Assurance Board set up by the DH
to ensure collective agreement on the Autumn Patients first and foremost response to
Robert Francis’s report and to support policy development on the response. The group is
proving a useful forum and has for instance been holding productive discussions on the
operation of a single set of quality indicators across the entire NHS system. The autumn
consultation response will include both a narrative and a bringing together of actions on
each of the 290 recommendations, and CQC will contribute to these as appropriate.
4 Conclusion
The Board is asked to NOTE progress on key recommendations CQC is leading and
ENDORSE the approach to embedding, tracking and reporting on the Mid Staffordshire
Inquiry recommendations.
Name:
Title:
Date
Paul Bate
Director of Strategy and Intelligence
31 July 2013
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