CQC responds to the Health and Safety Executive’s prosecution of Basildon and Thurrock University Hospitals NHS Foundation Trust

In response to the Health and Safety Executive’s prosecution of Basildon and Thurrock University Hospitals NHS Foundation Trust, Nigel Ellis, head of national inspection at the Care Quality Commission, said:

“The death of Kyle Flack was an absolute tragedy. It is clear that Kyle did not receive care appropriate for his needs, and this should never be allowed to happen again.

“We have been looking extremely closely at the quality of care for people with learning disabilities at the trust, including visits, to gain assurance that lessons have been learned.

“This involves working closely with the HSE to rigorously review policies and procedures, and to assess whether recommendations in the Ombudsman’s national report on learning disabilities, ‘Six lives’, have been implemented. We will report our full findings in due course.

“We will take all information we hold about the trust into account to inform our decision about its registration, which begins on 1 April. We will take any action that is necessary to ensure that this trust does everything that it should.”

-ends-

Notes to editors


The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. We inspect all health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations. We also seek to protect the interests of people whose rights are restricted under the Mental Health Act. We make sure that essential common standards of quality are met everywhere care is provided, from hospitals to private care homes, and we work towards their improvement.
Registration

The Health and Social Care Act 2008 introduced a new, single registration system that applies to both health and adult social care. The new system will make sure that people can expect services to meet new essential standards of quality and safety that respect their dignity and protect their rights. The new system is focused on outcomes, rather than systems and processes, and places the views and experiences of people who use services at its centre.

From April 2010, all health and adult social care providers will be required by law to be registered with CQC and must show that they are meeting the essential standards. Registration isn’t just about initial application for registration. We will continuously monitor compliance with the essential standards as part of a new, more dynamic, responsive and robust system of regulation. We have a wide range of enforcement powers to take if services are unacceptably poor.

CQC supports ‘Dignity Action Day’

CQC is ready to take part and show its support for Dignity Action Day held on 25 February 2010.

The day, organised by the Department of Health (DH), Dignity in Care Network, encourages health and social care staff and the public alike to pledge their time to support dignity and take action in communities and work places to uphold it.

The day forms part of the Dignity Challenge that sets out a ten point plan for high quality services that respect people’s dignity and which should:

1. Have a zero-tolerance of any form of abuse
2. Support people with the same respect that you would want for yourself or a member of your family
3. Treat each person as an individual – offer a personalised service
4. Enable people to maintain maximum possible independence, choice and control
5. Listen and support people to express their needs and wants
6. Respect people’s right to privacy
7. Ensure people feel able to complain, without fear of retribution
8. Engage with family members and carers as care partners
9. Assist people to maintain confidence and positive self-esteem
10. Act to alleviate people’s loneliness and fear of isolation

Find out more about the Dignity in Care campaign (you will be redirected to the DH website)

http://www.dh.gov.uk/en/SocialCare/Socialcarereform/Dignityincare/index.htm

CQC will be promoting Dignity Action Day amongst staff and encouraging staff to sign up as Dignity Champions.

Dignity is a core issue for CQC and is at the heart of its rights-based approach to regulation. Promoting dignity is key to the CQC corporate priority of ‘Making sure that care is centred on people's needs and protects their rights’

Show your support and find out how to become a Dignity Champion (you will be redirected to the DH website)

http://www.dhcarenetworks.org.uk/dignityincare/BecomingADignityChampion/

CQC's review of health care in care homes

Our review of health care in care homes has now commenced. This review will look at whether adults of all ages living in care homes have:

* choice and control over their health care;
* equal access to NHS services;
* good quality health care provided by the care home when needed.

In the next weeks we will ask Primary Care Trusts and councils to provide some information. We will use this information to assess risks in our review of health care for people living in care homes. We will then visit a number of PCTs, Councils and care homes to assess the quality of health care for people living in care homes.

* Find out more about our Review of health care in care homes:

http://www.cqc.org.uk/aboutcqc/whatwedo/improvinghealthandsocialcare/specialreviewsandstudies/reviewofhealthcareforpeopleincarehomes2009/10.cfm

Special reviews programme

This review is part of our Special reviews programme. Our special reviews and studies take an in-depth look at particular aspects of care and people’s experiences of using care. The results of all 6 special reviews being undertaken during 2010 will help us to monitor whether care providers comply with our new registration requirements.

* Find out more about our Special reviews programme

Consultation on our assessments of quality:

http://www.cqc.org.uk/aboutcqc/whatwedo/improvinghealthandsocialcare/specialreviewsandstudies.cfm

We would welcome your views on our future programme of assessments, including special reviews.

* Find out how to take part in our consultation:

http://www.cqc.org.uk/getinvolved/consultations/assessmentsofquality.cfm

Contact us

If you have any queries about the special reviews programme please contact us:

* Email: reviews.studies@cqc.org.uk,
* Telephone: 03000 616161

CQC pledges to listen to public about quality of care at Tameside Hospital NHS Foundation Trust

The Care Quality Commission, the quality regulator for health and adult social care, Monitor, the regulator of foundation trusts, and NHS North West, the strategic health authority, will take a number of measures to place increased scrutiny on Tameside Hospital NHS Foundation Trust. To read how each organisation will carry out their work, use the links below to read their statements.

The Care Quality Commission will look closely at patient care as part of the registration process.
Read CQC's statement: http://cqc.org.uk/newsandevents/newsstories.cfm?FaArea1=customwidgets.content_view_1&cit_id=35905

Monitor and Tameside Hospital NHS Foundation Trust have jointly commissioned an independent review of governance at the trust.
Read Monitor's statement: www.monitor-nhsft.gov.uk

NHS North West will be carrying out a review of commissioning arrangements via the primary care trust.
Read NHS North West's statement:http://www.northwest.nhs.uk/media/news.aspx?storyID=3445




CQC, Monitor and NHS North West to increase scrutiny on trust

The Care Quality Commission (CQC) today (Friday) pledged to listen carefully to the views of patients as it looks into the quality of care at Tameside Hospital NHS Foundation Trust.
The independent regulator is currently considering the trust’s application to register, as part of the new regulation system to be introduced from April 1.

Under the new system, all NHS trusts must register with CQC and demonstrate that they meet essential standards set by the government. Trusts will have a legal obligation to meet standards and CQC has new enforcement powers to take action where trusts are not complying.
CQC said that it was very aware of public concern about standards at Tameside General Hospital and of the need to provide an independent assessment. It plans to provide this assessment as part of the registration process, with work comprising the following elements:

CQC will scrutinise the trust’s registration application against the information it holds including from previous inspections, mortality rates and surveys of patients and staff. CQC has requested additional evidence from the trust in areas where it is seeking greater reassurance
Meetings with Tameside Hospital Action Group and the Local Involvement Network (LINk)
Written evidence from the council’s overview and scrutiny committee
Possible spot-checks on clinical areas, where there is evidence of concern

CQC’s work is part of a number of measures agreed with Monitor, the regulator of foundation trusts, and NHS North West, the strategic health authority, to place increased scrutiny on the trust. Monitor and Tameside Hospitals NHS Foundation Trust have jointly commissioned an independent review of governance at the trust, while NHS North West will review local commissioning arrangements.
Sue McMillan, CQC’s regional director for the North West region, said: “We are very aware of public concern around the quality of care at this trust and we will listen closely to what patients are saying. We want to know whether there are issues that we are not picking up through other sources. Patients are often the first to know of problems and it is absolutely crucial that we listen with great care to what they say.

“We have been monitoring the trust’s performance closely and have highlighted where improvements were necessary. We inspected the trust in December and required the trust to take action to improve its systems to prevent and control infections. The trust responded swiftly to address our concerns.

“We have also been monitoring mortality rates and have been in close discussions with the trust around its plans to reduce these rates.

“However, we are increasingly aware of the public concern and we want to ensure we take full account of this as we consider the trust’s application to register.

“This will be a fair and open process and we will report fully on any concerns, as well as any positive outcomes we identify. We will work effectively with the trust, Monitor and NHS North West, making sure we all play our part in ensuring that patients receive safe, quality care.”
CQC said registering trusts was the first step in the new system. If there is evidence of a significant breach of the standards, CQC could impose a conditional licence, requiring improvements within a specified deadline.

Once trusts are registered, CQC will continuously monitor performance by conducting inspections, analysing data and talking to patients and other NHS bodies.

Where it finds trusts are not meeting standards, it has tough new enforcement powers to drive improvements, such as issuing a warning notice, fines, prosecution, restrictions to services or in extreme cases closure.

Ms McMillan said: “Our primary aim is to work with trusts, patients and other groups to make services better. But if it is necessary to use our powers to enforce standards, we won’t hesitate to do so.”

See here for the release: http://www.cqc.org.uk/newsandevents/newsstories.cfm?FaArea1=customwidgets.content_view_1&cit_id=35905

CQC reaction to the Audit Commission's report, Under Pressure

18 February 2010

CQC reaction to the Audit Commission's report, Under Pressure - Tackling the financial challenge for councils of an ageing population.

Dame Jo Williams, CQC's chair, said: "We all know that the context is changing. Trends such as increasing demand and rising expectations will be exacerbated by pressure on finances. That means we cannot go on as we are. To cope, we need some radical changes in the way that we organise and deliver services.

"This means shifting the culture away from a one-size-fits-all approach to care that puts the needs of individuals and carers at the centre of everything. A key part of this will involve helping people maintain their independence and health."

Read the Audit Commission's report:

http://www.audit-commission.gov.uk/SiteCollectionDocuments/Downloads/20100218-underpressure-nationalstudy.pdf

AN INTERVIEW WITH JO WILLIAMS, BOARD MEMBER AND INTERIM CHAIR OF THE CARE QUALITY COMMISSION

What attracted you to working with CQC?

I applied to become a commissioner with CQC about 18 months ago because I thought I had the relevant experience.

Most of my working life – over 30 years - has been in social services. I’d worked as a director of social services for 10 years and from there I was fortunate to move into the voluntary sector and work at Mencap. I’d really enjoyed being a director but when I got to Mencap my husband said it was like I’d died and gone to heaven because I was so enormously happy there. But aside from recognising these two different work locations and the experience I had, one of the things that made a big impact on me at Mencap was the time we worked with a group of families. Each of these families had lost someone in pretty dreadful circumstances when they were in NHS care.

After two years of working with these families we published a report called Death by indifference, in which we said the NHS had failed the six people who had died for a whole variety of reasons, not least because, in many circumstances, the people working in the health services were not seeing these people as individuals; they were seeing them as someone with a learning disability and because of that, were not really exploring their health and wellbeing.

The Health Service responded very positively to our report, established an inquiry and recommendations were made by Sir Jonathan Michael. I think it’s true to say people really did want to bring about change. So a passion has been with me all my life to try and improve health and wellbeing for everybody. I’ve been lucky with my life, and I’ve wanted through my social work and social service time to give people opportunities for a better quality of life. And the health service dimension – although I did work in a hospital at one point - really came to life with my work at Mencap.

Having been here as Interim Chair for just over a month and half, I’m enjoying meeting people and learning from everyone about what’s going on; people have been so warm and welcoming and extremely supportive. There are many challenges ahead for CQC this year.

Can you tell us about your immediate priorities as Interim Chair?

I think it’s really important for us over the coming months to make sure the processes we have to set up for registering the health service, social care and independent healthcare run smoothly. We also need to recognise that we have approached this appropriately and that if we have to follow up with actions, we do that in a way that is constructive and actually brings about improvement.

Getting that right is very important. Also, I think because we know that public sector finances are under great scrutiny, we need to demonstrate that first of all we’re looking to ourselves that we’re fit for purpose and we have to demonstrate we add value. Building our reputation in the short term, being clear about how we add value and if we can reduce burdens on people as a regulator is really important.

So, at the end of the day I think for me once we have our new powers and registration is up and running I think we should be very clear that helping those who are not making the grade to improve is a real priority and explaining to the public how we’re making a difference.

Do you have a work philosophy? What drives you?

These are hard questions for anyone to answer. I think the thing that has always driven me is the strong sense of wanting fairness in this world and a strong sense of social justice. Increasingly, really caring about people’s human rights - equality is part of that - and celebrating people’s differences, those are the things that really matter to me.

I’m at the time of life where I look back and think I’ve been so fortunate and now I’m at the point where I’ve got some energy, I’ve got some time, what can I put back that might be useful? I can’t imagine just being at home. When I stopped working as a director of Social Services I thought I would move into a different mode and do all sorts of things. So when I was appointed director of Mencap I asked if I could take a long break and they agreed to six months. But four months later I remember making marmalade and my husband said to me “You just have to go back to work!” It was so not me.I think that sums it up really, an active life and I’m nosey, I’m very curious about people and what makes them tick.

What values do you want to embed into the organisation?

I think it’s important we are absolutely clear about embracing diversity and equality, both internally as well as in the way we embrace our role. I think we should be known for integrity and high quality performance. And I think it’s so important that we are always able to substantiate what we say; people should exercise their judgement but they should do it in a very open transparent way that is subject to scrutiny.
So I think the values are about openness and transparency and as I say, integrity every time. It’s not a value really – but doing what we say we’re going to do is so important. 'Put up and shut up' people say, but I think if you commit then you should see it through.

Finally, how do you relax? What’s a typical Sunday morning like in your house?

We have a bit of a routine really. We’re usually up for a run and then it’s either breakfast at home or in a café, with lots of hot coffee and the Sunday papers. I’ve got a Blackberry now I’ve come to CQC and I’m trying not to look at it on a Sunday morning, I do try not to keep clicking onto it all the time but it’s very seductive.

But probably other than that and at some point during the day just getting my head around what’s coming up the next week, mostly, once the papers are read, it’s family time. We’ve just had a great adventure, we went to India at the end of October and took part in what’s called the ‘Himalayan 100-Mile Stage Race’ which is one hundred miles in five days and it was fabulous. People from all over the world take part. We walked up hills and were able to run downhill and on the flat – the views were amazing.

Transcription of The State of Health Care and Adult Social Care in England event

Wednesday, February .
Care Quality Commission

The State of Health Care and Adult Social Care in England. (. pm)


JOHN: Good afternoon, ladies and gentlemen. Good afternoon. Welcome to you all, whether you are from the east end or the West End. Welcome, if any of you, like me, have had a walk this morning down from Westminster tube station, welcome to ice station. Talk about the X Factor, it's Wind Chill Factor this one today. Just to tell you at lunch there will be some St Bernards brought in. That's what I call quality care. I'm delighted to be here today because, obviously, I'm quite used to speaking into a microphone but I'm not used to seeing the people I'm speaking to. So this is what real people look like?

NEW SPEAKER: No

JOHN: Oh really? I wouldn't know. I spend my life in the bowels of Broadcasting House, not an image to hold on to, but it's nice that I've come along today and thank you very much for inviting me. You are going to hear the word, I am sure, today, union used very much, so I think we should think of this really as an state of the union address. It's a sort of stock taking session, where we are with the CQC, and obviously this is the first time the independent regulator has looked across the whole spectrum, and they are most anxious, and so am I, that this is your forum. We want your comments and questions so don't be shy. I've talked to a few of you this morning and I don't think shyness is going to be a barrier. So don't be shy, do pitch in, but also, with great respect, we'd like to get through a lot of viewpoints so don't hog the microphone. That's my job. Just in case you are wondering why this quite unparalleled view -- I've never been here before and this is the best view I've seen. The blinds have come down not because we are going for illegal gambling or having a lock in, it's so you can see the presentation more clearly. With that in mind, let me introduce our first speaker, Dame Jo Williams, of course, who is acting chair of the CQC.


JO: Thank you, John, and good morning to everyone. I'm really delighted that you have all been able to get along. Thank you for coming this morning. So, as John says, this is our first report, here it is, the first report that we've published that looks across the social care and the health system, and I'm just going to say just a few introductory remarks before handing over to Cynthia. What I want to say at the beginning is really to acknowledge the really hard work of thousands and thousands of people who work in both social care and in the health sector, and alongside them those carers and families who, together, make sure that our health and social care system works for millions of people. One of the things that we want to do as the Care Quality Commission is make sure that the voices of people who experience care services and their carers drive forwards what we do and help service drive up quality. So what is wonderful about the report is you will see people telling their stories, and I'm delighted that some of the people that have told their stories, or have stories to tell, are here with us this morning, so you are especially welcome. Thank you very much for making what, for some, has been a considerable journey. So, what can I say to you about the headlines? What does it tell us in this report? Well, the first thing to say is that there's some good news. Overall there's been real improvement in all parts of the social care and health system, and you will see the detail of that, Cynthia will say something about it. We've also seen some things really change that mean a great deal to people, things like the waiting times at A and E, opportunities to get treatment more quickly, and, importantly, a huge drop in terms of health care infections. So these are really, really important. But, of course, what we're noticing is that whilst there is this improvement, there are some organisations that are lagging behind. We talk about lagging behind the pack, and it's crucial, absolutely crucial, if the whole system is going to improve that those that are there really, really do put in sustained improvement and programmes that will bring that about. We've identified some common things that right across the system we should be concerned about, and I'll just mention safeguarding and training. Training particularly, I think, as we head into some difficult times, we are probably in them already, but even more difficult times, training often is seen as one of the first things that goes when the financial pressure is on, and we would urge you to look at what the implications of that are. I'm sure you are doing already. In terms of the agenda for choice, developing people's opportunities to really be in control and to maintain their independence, there's some very good stories there, but there's huge, huge variation. So Cynthia will talk through the detail. I just want to close by just really focusing on two or three leadership challenges, and the first thing that strikes me is that fundamental to delivering the safe, quality care that everyone wants, is really challenging everyone in the system to think about how they put the individual right at the centre of the programme of care that they are delivering, or commissioning. That's a huge challenge, but it's about making those cultural changes, cultural shifts right across the whole system, and I know that that's a leader ship challenge, it's a challenge to everybody in the system that they are aware of, but we urge you to keep on moving in that direction, towards that very focused, think about the individual, their pathway through the system, how we can make it really work for them at every point. Secondly, one of the things that we're saying in our report is that there are some examples whereby by coming together, the system coming together, health and social care, there are really good examples where people are helped to stay in their community rather than going into hospital, and at the other end, if they've had a hospital experience, getting them back home quickly. This is what people want, it actually leads to better care, but the business case is there too. We believe had there's potentially, possibly up to billion pounds in terms of the hospital bill if we are able to help people in the community. So my challenge, really, and I know this is very much at the heart of what commissioners are looking at, but it's for commissioners in health and social care to really think strategically about what more they can do to make that a reality for everyone right across the piece. I suppose my final point that I want to make is that we know the financial pressures are going to really exercise everyone even more than they are doing already, and one of the, I think things that we know, is when we're under pressure as individuals, as organisations, we kind of put the ring around ourselves, we close down. Well, my challenge is to be counter substitutive, to make sure that you actually more and more join up, make the connections, make the linkages, really think about how through thinking strategically, working together, maybe pooling resources, that join up can make that difference when we know times are going to be tough. I won't say anymore, thank you for listening to me. I'm going to hand over to Cynthia, I need to personally apologise to you, I'm leaving at .. It's been a prearranged meeting that I couldn't change predated to me moving into this role, but I'm really appreciative of you being here and thank you very much for your support this morning. (Applause).

CYNTHIA: Oh, too many microphones at the same time and probably my loud voice as well doesn't help. The price we pay for the view, or not the view as it is at the moment, is this rather odd shaped room, for which we apologise, so I'll try and make sure when I speak I need to keep turning in all sorts of different directions and not just addressing this rather splendid table here. Basically what I'm going to do is put some flesh on the bones of what Jo's already talked about, and largely that's going to talk about three things, really, patterns in quality and trends in performance, something about joined up care between health and social care, and something about personal care. So, as Jo said in her opening remarks, we absolutely need to recognise and celebrate the achievements that there have been in both the health and social care sector in improvements in the care that people are receiving, and not to do that, as Jo has already alluded to, is to deny the fantastic work that people are out there in the sector working day in and day out, and the people who support them in their work, the carers, are doing to ensure a better quality of care. So we recognise and applaud those achievements, but we recognise there is a number of NHS providers and councils who are underperforming, so there are people who buck that trend of general improvement. Again the improvements Jo has already alluded to. We picked out a number of things in the report, but centrally access in terms of NHS waiting times. There has been a dramatic drop, and I think it bears a moment's reflection to think about -- people used to wait , , years for care, now there's a week maximum referral to treatment time, which has involved looking at things like diagnostics pathways for people in a completely different way, so this is not just about the system speeding up, this is about the whole care pathway being rethought by people for the NHS. per cent of hospital trusts achieve the week time target in terms of referral to treatment. As Jo has already alluded to, rates of health care associated infection have come down dramatically and if you walk into any NHS hospital now you see a completely different culture in terms of cleanliness and hygiene than you would have done a few years ago. In social care, more people are being supported to live independently at home, and of course, although the percentage change is quite marginal when you look at it, nevertheless that means because there are a large number of people being supported, that is s of thousands of people. So these are just headlines to take a moment before we do anything else to recognise some real achievements and improvements across the health and social care sector. Nevertheless, there are come concerns across both sectors, including building a safety culture, protecting people from harm, safeguarding, and in workforce training. I'm going to say a little bit more about each of those things. One of the things that we point to in the report is in the health service the number of incidents reported to the national patients safety agency, and that's always a difficult thing when you say there's more critical incidents being reported to the patients safety agency, that might sound like it's a bad thing. Of course, the health select committee drew attention to this last year in their report. What it underlines is the requirement to develop a safety culture within NHS organisations, if incidents aren't properly reported there is no culture within organisations, within the wider NHS where lessons can be learned, problems identified, things can be moved on from. So the fact that reporting is going up is seen to be a good thing and something that is about promoting a safety culture in the NHS. Nevertheless, there's a big variation between hospitals and there's a variation between parts of the NHS, so one of the points that we make is there's very low reporting in primary care. per cent of NHS contacts take place in primary care and yet there were just over ,, I think, reported incidents from primary care, which is a very, very low number in comparison to the NHS, where the number is something like , incidents. So there's a different rate of reporting and something that we need to tackle more vigorously in primary care. Now, in terms of safeguarding, we did a particular piece of work this year around safeguarding NHS hospitals, we discovered that per cent of NHS organisations didn't comply with the minimum standards on child safeguarding, and that included training for staff, having proper reporting procedures through A and E so staff knew how to deal with incidents when they arose. So obviously the vast majority of NHS organisations complied with it, but a significant minority didn't. Again, although the majority of social care providers fully met standards relating to safeguarding procedures, per cent, organisations, because the sector is so large, failed to meet minimum standards on safeguarding. In terms of training, of course, you know, we draw attention to the fact that good services require excellent training for staff. per cent of trusts didn't meet the core standards on mandatory training for staff, and that was the lowest compliance of any of the standards. What we find in the NHS when we looked at the core standards was the biggest reason why organisations failed to meet any particular standard was about being able to demonstrate that staff had been trained in order that they understood how to meet it. So that remains a big issue in the NHS. Now, per cent of adult social care services met the minimum standards on training, that's a improvement and that needs to be recognised, but these, after all, are minimum standards on training. So that means that per cent of organisations didn't meet those basic standards on training, and in councils, when we looked at the performance assessment of councils, training and qualifications were seen as a strength in only per cent of councils. So what we're seeing is across the board in health and social care, the issue of training remains a big one to crack. Now, of course there's a debate going on about this very publicly at the moment, but by the government expects . million more adults needing care and support, and, of course, this in an era in which there's going to be much greater pressure on public finances and, rightly, people are expecting and have been told to expect much greater choice and control in terms of the care that they are receiving. So, again, as Jo has already alluded to, services absolutely have to accelerate their efforts both to work better to join up services across NHS and health and social care. In some ways we make no apologies for keeping talking about this. I know it is something we talk about endlessly across health and social care. From a personal point of view I left social care in to work in the NHS, I was recruited to work on joining up between health and social care, which we were confident we were going to crack any day now. That was years ago, so it is something that we talk about a lot, but it's something that the system has failed to crack in a comprehensive way. Showing that people have clear information and understand their options and support people in maintaining their independence. Now, moving on to joining up health and social care, well, again, I mean I think it's really important at the start to acknowledge the major steps forward that have been made across the system. More people are being supported to live independently at home than ever before. In five years, the number of people with access to council funded services to help them avoid emergency admissions has gone up significantly, and again, equally the number of people getting support to early discharge from hospital has gone up. So there is a acknowledgment across the testimony system that more people are getting support to access social funded care in a more appropriate way. Nevertheless, there is massive variation across the country. There is a three fold variation in the extent to which the council place older people in residential care, a four-fold increase in the ... day rate with repeated emergency admissions for older people in hospital, and over a fold variation in the proportion of people who have delayed discharges from hospital, so some parts of the country we see have really grasped this issue of delayed discharges, but some parts of the country are really struggling to get to grips with the basis of delayed discharge from hospital, which is a huge both financial but, more particular, emotional and personal cost to people who remain in hospital for too long. So our estimate suggests that if all areas of the country performed at the level of the best in terms of avoiding emergency admission of older people and cutting length of stay, it would result in million fewer days in hospital and billion pounds saved from hospital budgets. Again, that's a big ask, it's asking the entire system to perform at the level of the best, but this is a time when we all have to think radically about how to relieve pressure on budgets, and not just that, to ensure that people get better care. You should only be in hospital when you need to be there. If there are other alternatives available you should have access to them, wherever you live. I can't believe I'm saying this, this is another thing we thought we'd cracked years ago, but only -- when we started to go primary based -- when you said to GPs what's the thing you want to crack, and they would say discharge letters from hospitals. And you would think what a boring thing to ask for. Just more than half of GPs are saying they don't get appropriate discharge information from hospitals in time for it to be useful to them in terms of managing a pattern of care. That seems to me to be day , hour of any discussion that you might have about joining up care between, in this instance, primary and secondary care, but crucially, of course, how we support people more broadly in the community, and, again, pointing back to a review that we did about Peter Connelly, Baby P, as he was known, it was clear that one of the issues that led to the appalling standards of care that this child received was communication between organisations was really poor. So, again, we're making a point that's been made many times before but we're still not getting that bit right. In terms of our final thing, which is about giving people more choice and control. Again, you know, we start by celebrating access to NHS services. At the same time we have to acknowledge that access to health care is still a very mixed picture, so although access to secondary care has improved dramatically, people are getting shorter and shorter waiting times into hospital, nevertheless the percentage of people who say they can get hours access to their GP, so an appointment with their GP within two days, still varies very widely across the country, with per cent in some local authorities, per cent in others. In some parts of the country, London being a classic example, that access figure hasn't been cracked, although I know the opening of new polyclinics will have an impact. Access issues around primary care impact on other parts of the health and social care system without a shadow of a doubt. Another one that goes back many years, again, if you talk to people who use mental health services, a big issue for certainly as many years as I've worked across the health and social care sector, which is many, many years, is about access to out of hours support, and again only half of trusts provided adequate out of hours support to people with mental health problems. So people's sense of good access to NHS is not waiting time for acute care, it's also about primary care, and people with mental health problems being able to get immediate access to support out of hours is a major, major issue for the sector. Not all people receive useful information about their care. per cent of people are discharged from hospital saying they were given insufficient information about their condition or treatment. Certainly I can remember myself doing some work with parents with children with asthma, and having been admitted to hospital with an acute episode they were discharged with know better understanding than at the start of the process. So people need to feel more comfortable, especially as their GPs are not getting information either, more comfortable about how they are being treated and how they are going to manage it. per cent of people with disabilities using social care services said they didn't get communication in order to understand the information they were getting correctly and the options that were available to them. Again, half the people, now, who are being offered care in hospital can recall being given a choice, after all there's been choice in hospital appointments -- I forget how long it is now, looking at Anne -- four years, is it?

CYNTHIA: Well, the numbers are going up and it's still less than half of people who recall being offered a choice of hospital. One in four people who use acute mental health services say they are not involved in their care the way we wanted to be, and, again, the issue of direct payments, which is a very straightforward measure of people being given very direct control of the care they receive, still we see councils struggling to offer that to as many people as possible. So in summary, I'm sorry I have not managed to look round, I'm too busy looking at the slides, we'll look round when we answer questions. Going back to what Jo was saying at the outset, steady improvement across the whole of the sector as well, and we should never forget that when thinking about the issues and problems, and we've genuinely seen improvements in things that really matter to people. Nevertheless we still have organisations that lag behind the pack in terms of the quality care that they are providing, and there are common issues when we look at why organisations are failing to provide the right quality and care, the same issues come up again: Issues around safety, issues around safeguarding, issues around training for staff. Some people are clearly very well supported to have choice and opportunities and, indeed, to experience a level of independence, but the variation is still extraordinarily high between different parts of the country. As Jo said at the beginning, the real issue remains the same for both the health and social care sector, which is how are we going to generate a sector, or an experience for people where choice, control, information, proper support to independence is an universal experience for people so that the system works as if that were the end, the right, true end of the system was to give people that level of choice and control in terms of the care that they receive, because actually what you see is you see great care and you see great initiatives, and even in areas that are seen to be poorly performing and I've been going out visiting a number of councils where there have been issues in their ratings over the years and yet you see great examples where they have got to grips with issues like supporting people in the community, but that's still not in the bones of the system where people can assume that that's automatically going to be there for them. How can we ensure that the joining up of health and social care really does happen, because this is not just about an ideology or something that we think is a good idea: This is at the heart of people experiencing good care and also at the heart of tackling sustainability issues that we know are facing the health and social care sector. Against this background of financial pressures, how can we ensure that we don't retreat into our bunkers and saving our own -- ensuring the pressure is relieved on our own budget rather than working across the system. The thing we like to talk about most is the new registration system, so just in a few weeks' time now, there will be the start of a new regulatory system which will work across both health and social care, and we are drawing on the experience of the predecessor organisations, we are doing our absolute utmost to make sure that people that use services and their carers are the absolute focus of the information that we do, our drive to see improvement in the system, and our understanding of what represents a high quality experience. Now, there's a clear understanding of what those standards should be set through legislation. We absolutely have a new set of enforcement powers, particularly for the NHS, who have not really experienced anything like this in the past, opportunities, then, to tackle poor performance, to tackle poor care very quickly and to focus in on those areas where we know care for people is not good enough. Equally beyond our work with registered organisations, organisations that provide care, are the assessment of commissioning, working with local authorities, working with Primary Care Trusts to look at where commissioning can better drive through the sorts of changes we need to see. You can find out more by wandering around today and by looking at our state of social care report. We have a really good accessibility part of our website, so as part of promoting the state of care report, the website, there's an accessible version on our website, so we hope that you will have a look at that. There's lots of videos of people telling their stories about care, we have our own video box here so we hope you go into that and take the opportunity to talk to us directly about our experiences, and I think it's time for questions. (Applause). JOHN: Thank you very much indeed Cynthia. As I say, I want to hear from as many people as possible today. That is the whole point of the exercise. But, first of all, I'd like to hear from some representative organisations. Their response to this and if I may I will start with Tom Wright who is chief executive of Age UK.


TOM: Thank you very much. Can you hear me? Is that working now?

NEW SPEAKER: No.

JOHN: That ones dead. Maybe we could bring another one over.

TOM: Right, I think it's working now. First of all, can we welcome this excellent and important report. I think it's vital to allow the issues and concerns to be raised and for councils and trusts to improve on the back of it, so first of all to welcome this excellent report. I just want to touch on three things that we particularly welcomed from it, three points of progress and perhaps three areas that we have more concern on. I think fundamentally the recognition of a cultural shift to enable people to better shape their own care is a fundamental issue going forward, and we very much welcome that focus. I think expansion of local services to prevent unnecessary hospital admissions is progress as well, although we need to be conscious for the over emergency readmissions continue to rise, so a word of caution on that particular point. Thirdly, we all recognise how important workforce training is, and particularly better training relating to older people's care is an area that we would highlight. Perhaps three areas of concern for us, one is equality targets, we're only seeing per cent of councils monitoring those equality targets and we know for many older people there is continuing discrimination of provision of health and social care services, so I think there is a challenge going forward. This point about proper information, and the fact that nearly per cent of health care trusts say they meet minimum standards doesn't equate to the per cent of patients who say they don't. So clearly the numbers aren't right or we are not getting that provision correct. Lastly we welcome the fall in those delayed hospital discharges, but the stagging variations are quite significant, and we hope the worst performing trusts should be looking to organisations for support in improving their patients' experiences. Perhaps I may leave you with one thought. If there are . million more adults needing health and social care in , the provision of services is a real challenge. per cent of councils now limit services to people with substantial or critical needs, and I think we all need to be conscious of the funding challenges that that extra care is going to require, just when eligibility and support across councils is declining. Thank you.

JOHN: Thank you very much, indeed, Tom. Jo, do you want to respond? I know your time is limited. We will discuss those points in more detail. Let me bring in now Jo weber from NHS confederation and see what Jo has made of the presentation today.

NEW SPEAKER: Yes? Okay. Can I say that we also welcomed this report, particularly because increasingly a lot of the issues that face social care face health as well, particularly as financial constraints start to hit across the system. If we don't learn how to work together in an integrated way, we are not going to deliver particularly for people with long term conditions, and particularly given the demographic pressures that we're under. So some sort of report that goes across health and social care and looks at the whole of the impact of the system on patient care and how patients are treated I think is something that we really welcome, and we hope that this develops further over time. I think a couple of issues for us would be around ensuring that if we are going to work in this way, we increasingly try to align the way in which services report in terms of their regulation, so what we're not doing is increasing the burden of bureaucracy on organisations, which need to be leaner, fitter and definitely with the resources very much more towards the frontline. Secondly, I think we still have work to do on the evidence base of what works and some of the studies that the CQC are going to do I think would be helpful to see where there are examples of good practice, and thirdly, I think we do have to pick up very clearly the variation issues and really go into the detail of where that variation is something that relates to differences in local need and where there are variations that need to be picked up by local NHS organisations working through their strategic partnerships with their local councils.


JOHN: Thank you very much indeed, Jo, and, finally in this section, Richard Jones from ADASS. NEW SPEAKER: Thank you very much. Again, a welcome for a report that talks of improvements, but I think from a ADASS perspective, no resting on our laurels, and certainly that is a improvement across councils, where per cent of councils are working at good or excellent rate at a adequate rating, but most importantly in terms of our provider partners and the work that has seen improvements there, but we have further work to go. The things I pick up would be about citizens. We're on a journey from moving from talking about people and working with people as clients, which comes from a word which means to recline, so we're working with people and pulling them up. So it is a working gift to people as customers, which can leave you with all sorts of experiences to people as citizens. So choice and control changes fundamentally the way we have to do our business. We are on that journey and it is a journey about helping people live the lives they want to leave, and one of the challenges I throw back to the commission, and it's a challenge for all of us, is that in order to continue on that agenda we have to provide a regulatory framework that actually measures what matters, because if we get some of our performance indicate caters wrong, we'll hit targets but get performance wrong. So that's a theme we have a lot to learn about in terms of the public sector and ADASS. Secondly integration. We've all been around this many, many times and you can go back to the s and s, so yes, it's a no brainer, but why haven't we got there? I would suggest, again, in terms of a challenge to all of us, but also to the commission, is that what we know with words is when at a local level people get a focus on citizens, there's almost a moral imperative in a partnership that we're going to do something about this and organisations get aligned to deliver. That's fine but if we're going to scale that up to the challenges we're now going to face, we do need a system that regulates, performance manages and sets outcomes which citizens recognise and cut across the whole system. So you are going to have to help us in this journey. The third thing I would just raise is the issue of resources: Sure, there are efficiencies to be made across the system. Over the last ten years we have powered, in a sense, money into both public sector and health, productivity has gone down year on year and there has to be a better way to manage our resources. That has to be for me and to ADASS a universal offer to all citizens, wherever they live, in terms of support, advice, wherever they live, and a system which flexes around them and their needs. Finally, it is not for you to make comment about at this stage, but given the financial pressures and the demographics we need an sustainable solution to the system. When the politics have died down, perhaps through some of your studies you are going to help us understand how a sustainable settlement will support carers better to do the jobs they are doing and to provide us with a workforce that is valid and remunerated for the work they are involved in. We are clearly on a journey and CQC looks forward to working with you on some of those challenges. (Applause).

JOHN: Thank you Richard. You have cued up nicely, since we are talking about carers, we'll have a couple of contributions now from service users. I'll come to Janice in a moment, but may I introduce Sandra, who is a service user and a representative from LINk?

SANDRA: My name is Sandra Boyle, I am a service user and I think that the regulatory role of the CQC is absolutely vital to those of us who are dependent upon others for personal care, which is why I volunteered to become an expert by experience for CQC. As chair of the Harrow gate district branch of the north Yorkshire LINk, I think despite the good work carried out by the CQC, there is some room for improvement. I also believe that a close working relationship between CQC and LINks would help to bring the general public's views and concerns into the vital work of CQC. It's important that people who use services and their carers are involved with shaping and improving outcomes in health and social care, as this directly affects us. This valuable interaction needs to happen through collaborative working, and I welcome continued opportunity to work with CQC and other statutory bodies to help drive improvements and make changes happen.

JOHN: Thank you very much. (Applause). And Janice, Janice Clark.

JANICE: Hello, I'm Janice Clark and I'm a carer. I'm heartened by much of what I have heard and read today, particularly that the report has involved real people in its preparation, and from that we can look forward to inspections based on people's real life experiences of joined up care. But as a carer I've got worries. The report itself is very light on carers. There's nothing much in there about our current situation or about our futures which, you know, we've heard about the financial situation, the demographic changes, and so, therefore, our circumstances must really, really be focused on. The rights of carers have been hard fought for for over years and they still haven't been properly implemented. The introduction of personalisation offers a vision of freedom and equality. When my time comes I want to continue to do the things that I and my family enjoy for as long as possible. Not wither away, warehoused in a day centre or worse. As an older person I can see the benefits of health care and support, but I expect you all to recognise that carers are involved and included in the process, or our rights will be eroded even further. As a carer I'm bitterly disappointed that the work of the Care Quality Commission has been severely undermined by the omission of carers from the legislation for the regulations that carers must comply with. This will make it harder for CQC to enforce carers' rights if we remain unmentioned. I look forward to hearing what you have to say about those issues for carers. (Applause).

JOHN: Well, Jo, would you like to address that last point first, really? Carers have always been the Cinderellas of the service and is enough being done to turn that around.

JO: I just want to say that I actually, yesterday, just spent a few minutes at our meeting with carers and the point were well made. We clearly do have to go away and look at what the issues are and how we address them appropriately. I think in my opening remarks I acknowledged the huge contribution that carers make and I think everyone in this room understands that and knows it, so we really need to think through what the issues are and make sure that those rights are not overlooked and there is due attention paid to them, so I absolutely take on board the comments that have been made this morning. If while I'm on my feet I could just say a couple of things. People's responses have been most helpful and I hope we will get more questions, but I just did want to make the point that we will only be effective if we truly do work in partnership with many of the organisations here today. We need to properly share information, we need to hear about those real experiences, and we will do everything we can to develop that network so that we are responsive as the regulator and learning from other people's experiences, but, importantly, using information and sharing information, because, you know, everywhere I go people say to me, quite rightly, what is the added value you are bringing, you know, we're kind of scrutinised, we have requests for information coming out of our ears, we can't bear it if you just add to that burden. So one of the challenges to ourselves is to think about how we are adding value, what we can do to reduce that burden and how we make sure we work in partnership with you all to make sure we do our job well. Quality in health services, we are all Guardians of it in one way or another, and when we share that information we will have a better system coming through, so some good challenges to take away. The test will be in a few years how we are delivering on those challenges posed, so thank you.

JOHN: I think it makes sense for me to stand here, then I can see you all, and this forest of hands that I'm sure is now about to shoot up. Who would like to kick us off. We have the microphones, now we have put pence in the slot they are working. Would you like to tell us your name and who you represent.

NEW SPEAKER: John Burton from the social of care managers. The launch of the state of care is a symbolic occasion, and it's symbolic that this launch takes place from such a lofty and luxurious place. We are more concerned about what's happening on the ground. Yesterday I attended the A G M of a very small charity that runs care homes and they've had to close one of their care homes that's been running for years, serving one of the London Boroughs, and move residents out of that home. They've lost their home. They've had an unjustifiably low rating by CQC and the local authority won't place people there any longer, and every day I hear from care home managers who have to wrestle with the paperwork from CQC, including the absurd so-called A Q U A reports, which is where managers of homes are meant to tell CQC just how well they are doing, or they're meant to tell CQC how badly they are doing, and this means that CQC doesn't just have to inspect the home apparently. If it is a two or three star home it won't be inspected for two or three years. We want a regulator that's actually going to look at really what happens on the ground, visit homes regularly and frequently, and be accessible to the residents and the relatives.

JOHN: And is that going to happen?

CYNTHIA: I will pick that up. Well, the great thing about the system at the moment is we do have an opportunity, because we're implementing a different piece of legislation, the health and social care act is allowing us to look again at how we register homes, both the standards that the homes have to comply with in changing, so they are more focused on what outcomes people are achieving for people who lives in those settings or receive care at home, and so, you know, if homes are achieving good outcomes for people who live in them, or care providers or hospitals achieving good no doubt comes for users, that's the thing we're focused on and the thing we're going to address very directly. We are looking again at things like the surveys, so the A Q U A thing you describe, we're looking at and the whole pan apply of services, we're looking at, so we're completely relooking at the survey methodology we use to understand what's going on and we're also looking at how we conduct inspections because, again, we have an opportunity to rethink the excellent work that the previous commissions did. So all of that we're relooking at. We've got -- we're engaged -- Linda Hutchinson who is overseeing the project is here and I am sure she would be happy to discuss that with you, but one of the things we're doing through the process of looking at that is seeing how frequently we want homes to be inspected and what the nature of that inspection is. So your remarks are absolutely timely, but at the same time we will go on talking to local authorities about what sort of providers they do commission care with to make sure they are only commissioning care with providers who meet the highest standards, otherwise we are all criticised for apparently going on tall rated care that doesn't meet standards.

JOHN: Over at the east end.

NEW SPEAKER: Hello? It's dead. I'm Richard west, I'm a carer with learning disabilities with CQC, et cetera. One thing I would like to say is that the Easy Read book is very, very good, and we want to make sure that there's more accessible information across everywhere, it is very important when writing information that information can be made very clear and simple to use. The other question is, I don't want to get at councils, but it's still very poor services in some councils when looking at carers with learning disabilities. So the question is, someone said about the councils improving, well, it affects the other way round, less improving, and we want to make sure that standards are fair for us. So when it comes to the green paper by the government it means that we don't get service or we don't get nothing at all. That's the reality of it. How are you going to make sure that there are -- we're going to have good services, but the cuts are coming on the way, how can you make sure you deliver that.

JOHN: I would have thought -- thank you Richard -- proper information is something relatively easily addressed. You could get somebody to take a look at how informative and explanatory the information is, but getting a level playing field, that's going to be one of the big challenges, isn't it? Let's take some more questions. The lady here in the middle.

NEW SPEAKER: Pandora from Westminster LINk. Social care and medical care should join up together to form a safety net, and that reminds me of a conversation between St Peter, the patron saint of doctors and St Luke, the patron saint of fishermen. St Peter said: How do you define a safety net? One that's in good repair with no holes and small enough to make sure that the fish don't escape. St Luke said: That's right. Don't let any of the fish get away. What are you doing to make sure that doesn't happen?

JOHN: Okay, we'll pick that up in a moment. Shall we go over to this side, just to be democratic?

NEW SPEAKER: David, I'm chair of skills for care and skills for care and development. I welcome the report, I hope constructive discussions to make if I may. One is about the quality of Care Commission, which I think affects outcomes considerably, the second thing is I know we all try to identify not only good practice, on occasions best practice, one of the things that prevents good practice becoming acceptable right across the country is the question of scalability, and it's something that I think you can assist us with at CQC. My final point is that although we're seeing very considerable moves in terms of the health service with community and primary care interventions taking the place of previously acute admissions, we haven't yet unwound social care into that, and I think there are some very big gains for the nation to be made. So those are three points and you may wish to comment on them. Thank you.

JOHN: Okay, Dame Jo has to slip away. You know how it is, these tables at the Ivy, you have to book them months in advance and when your time comes, you have to prioritise. Thank you Dame Jo. I'll be along later for the brandies. Around about .. She'll still be there. Thank you very much indeed. I'll get back to you in a moment. Sir here at the front.

NEW SPEAKER: Maurice Hoffman, I'm a member of Brent LINk. Now, I and colleagues have been to a number of meetings -- JOHN: I am afraid we might have to use the other microphone. Sorry about that. NEW SPEAKER: Maurice Hoffman, I'm a member of Brent LINk, which is in Wembley. Myself and my colleagues have been to a number of meetings about Joint Commissioning across north west London. There's PCTs, five or six general hospitals, there is an organisation, west London alliance, which consists of six councils for social care. Now, when we have presentations made about moving care from -- health care from acute down to local areas, it sounds like a lovely book you get in a travel agents, everything is made wonderful and lovely. Now, it's going to be very complex to move these services, which are intertwined in London, certainly, so my question to CQC is are you going to come in afterwards and see what happens and congratulate or criticise, or are you going to be proactive to make certain that these massive changes across London and maybe elsewhere, CQC will be involved to make sure that we get the quality of service all the time.

JOHN: Thank you. A very good point. We will summarise all those in a moment. I did promise this young lady here that she would be next. Thank you. NEW

SPEAKER: Hello? JOHN: They are blipping a little bit, aren't they? We should have brought along a megaphone, I think. I think we ...

NEW SPEAKER: My name is Dot Gibson, I'm the General Secretary of the National Pensioners Convention. Just as a brief statement, we're having loads and loads and loads of people phoning in to our offices about the problems that they face, which are many and varied and very worrying, but, you know, there isn't time to report on that.

JOHN: No. Do you think what you have heard today is going to help that situation?

NEW SPEAKER: The CQC is coming to the pensioners Parliament as they came last year so we know that we will have the opportunity. I just want to say this: Adult social services, a lot of the money going into the councils is not now ring fenced, so the politicians on the council are deciding where they are going to spend that and it often takes money away from adult social services. One of the things that has happened is the diminution of the work of wardens, which is causing more stress to older people and therefore needing more care, but, already, medium and low care is often not provided by local authorities and, therefore, people are falling through the net, as our friend over there said. The continuation from the Commission for social care inspection, I wonder whether -- the longest report that that commission made which this commission replaced was, in fact, very, very worrying and I'm not sure how the continuity of the two commissions took place. For instance, the criteria for the points system, for the services, I'm not -- you know, I'm completely unclear as to how that works. That leads me on to registration and the statement that there are clear expectations. Has there been a consultation about this registration? Who was involved in that consultation? Can we know what the criteria is that these organisations must fulfill in order to get that registration? I also wonder, and this is my last point, I'm sorry -- I also wonder, and I can't remember what the hell it means, what is the relationship between the CQC and the POPS arrangement. Somebody around here will know what it means. That is now being rolled out across the country, and it came up at the UK advisory forum, which is a new body which the government has set up, and I think we need to know, at least, those of us who are active with pensioner organisations, where that fits in to all of this, because we seem to go to all these various bodies and we're never quite clear where they fit together.

JOHN: We probably haven't got time to go in detail into that, but this isn't the first question about registration and how it will work, or about the question of finance. Because, as you have said yourself in your presentation this morning, or Jo did, there will be a lot more people in the system, . million, I think you said, and obviously money is not going to go up, so how are you going to square that circle.

CYNTHIA: Okay, absolutely no idea what -- I've got two microphones on, neither of which seem to be working, but I would soldier on. Yours isn't working, is it?

JOHN: It will be.

CYNTHIA: I know, shall I stand there? I've left behind my crib notes so I shall ad lib. If I can pick up first of all the issue of registration, because I think that related to the point of that reference over there as well, so the registration, the high level quality standards and safety standards that now all of adult health and social care, including the independent health care sector will have to abide by were established by our friends not a few yards away, it looks like, in Parliament. So they were established by Parliament and they are intended to be enduring standards of quality and safety that anybody would wish to see in the system. So they are not meant to be driven by what the government of the day is particularly interested in. They have things like running safe services, safeguarding vulnerable people, cleanliness and hygiene, having proper complaint procedures, having the right quality of staff, so they are high level standards. They were consulted on -- there was a consultation exercise that took place a number of years ago and then Parliament voted on, so they are the government's own standards and they are now enshrined in the health and social care act , and it then became the job of the Care Quality Commission to publish something we call the compliance -- thank you Richard for your kind words about the Easy Read version, we have produced an easy read version about whether organisations have met those standards, and those standards do relate to joining up care, so your challenge about how do we know whether care is joined up. There are a whole range of ways in which we as an organisation will need to look at that, but one is through the registration process which asks that organisations are properly talking to their partners in delivering care, that's a legal requirement now enshrined in the act. Another way of doing it is through looking at particular studies, so, for example, just going back -- the challenge of carers, and I absolutely take your point about the fact that the legislation doesn't mention carers does limit our legal powers for carers, so one of the special studies we are doing is looking at first contact that people have with councils about accessing care and part of that will be about looking at how carers are treated, so the special studies that we do will address concerns around joining up and pick up issues that are not covered by the legislation in other ways. Two other points, if I may, firstly about the issue of commissioning, which was raised by David, and, by implication, by other people. Clearly, and this relates to things like (inaudible) older people, in our judgments about how councils and Primary Care Trusts are commissioning services, one of the things we look at is what the current government initiatives are and what targets they are expecting the Commissioners to meet and say: Are they meeting them, can we see that progress towards budgets, things that the government are demanding health and social care provide, or targets they achieve, reductions in ill health, longer life spans, better access to particular sorts of services. These are all things that we will look at as part of our commissioning judgment. So as well as registering providers, we are required by legislation to look at how commissioners are doing and whether or not they are achieving things that the government want them to achieve and that will include, increasingly, looking across health and social care, because, you know, we are uniquely placed to do that in the system and say: Is the system working together to achieve the things it needs to be achieving, and I take all the challenges that people like Richard Jones level at us to make sure we are focusing on the things that are important, and seeing ourselves, and I absolutely believe this completely, that we see ourselves as part of contributing to what good care should look like. Again, the challenge from the gentleman over here. Yes, there is always the regulator comes in and gives us a score out of ... understanding what good practice looks like and ensuring that's promoted around the system and there are many other organisations, ADASS is one of them, the local government association who I know are represented here today, the NHS confederation, lots of organisations absolutely see that promotion of good practice as being central to what they do. The final comment I want to make in relation to this interesting range of points made is about the money. Again, I would go back to picking up a inference in what Richard was saying. We absolutely know that there will continue to be pressure on council and public finances generally, you would have to be very naive not to have worked that out, and we do make the point in the report that per cent of councils are now focusing their funded care on those with the highest needs in their communities, but, nevertheless, we do see excellence in the practice of councils who are, nevertheless, focusing on funding those with the highest needs because they are great at providing advocacy, advice, support, information, they signpost people well, so people feel supported as they are accessing services and understanding what their options are. Obviously, it would be fantastic if more people could get the financial support that they need, but excellence isn't just about who gets funded. Excellence is about the local authority, and, indeed, the PCT working with them, supporting people to understand the choices and options that are available to them. Some of that, the costs associated with that are not significant.

JOHN: Let's move on to some more points.

NEW SPEAKER: My name is Roseanne. I use the service. I had a review done a couple of weeks ago and I was told that my review, because of my conditions, had deteriorated, so my -- I needed more care, more support. I was told: Yes, you are getting -- you have qualified for more money. Then when it comes round to it all going to the I -- wherever it goes, I get told: I'm sorry, there's not enough money in the fund. You can't have it. So where am I going to get that extra support for my care?

JOHN: Okay, thank you very much indeed. I have been remiss and not introduced the fourth member of our quarter at the time, or our trio now, Maggie, who is head of review of studies at CQC? Maggie, a lot of issues that have been raised, not least had a variation in the provision of services, discrimination, which still, sadly, goes on. As I say, variation issues, all those sorts of things. Is there any point you would like to address from what you have heard from the audience here today.


NEW SPEAKER: That's a very important question. My microphone is working, at least. I think the variation in performance is -- we've seen in all of the themes that we've looked at. We've seen it in safety, performance of individual services, we've seen it in the extent to which services are joined up to meet individual needs, and that's the challenge, really, for us as a regulator and a challenge for the system: How can organisations learn from the best?

JOHN: You see, I would have thought that that's one of the most challenging things. Fixing physical things is one thing but changing cultures is very challenging, isn't it, and there has to be a will there, not least on the part of managers. Do you think that will is there, because if it isn't, it's not going to work?

NEW SPEAKER: I can't speak for all the managers in all the services that are out there, I think that's the challenge, it's such a complex system, so many services involved in providing services for people. I think everybody that works in the health and social care system wants to provide the best they can for people, that's why they work in the system, but cultural change is hard. It involves people at the frontline, people at the top of organisations, but everyone is there wanting to do the best for people.

JOHN: I have to ask you, Cynthia, do you believe, truly believe, that joining up all these services is the right way forward, or is it more that it's the only way forward, given the sort of financial constraints that we have and will have?

CYNTHIA: Well, in answer to that question I'm going to try and address the point that you made as well, your question to us, because I think at the heart of all of this, actually I'm not sure that joining up, if you were to say to me: What's the single thing that's most important in all of this, I would say the single thing that is most important is getting to an understanding of what people who are using services actually want. The person who is using services, what do they want of that system, because joining up is a by product of that. Most people who we talk to about receiving services, or when you are receiving services yourself, you are not sitting there thinking: Gosh, I wish it was more joined up. You are thinking: I want the system to work for me, I want proper opportunities to challenge the system, proper choices in the system. And actually joining up between health and social care, or between community based services and hospital based services are absolutely at the heart of a response to that, because most people -- given that most people who are in receipt of care actually need primary and secondary care to work together, they need social care and the NHS to work together, it's a by product of really focusing the system on the people who are using it and understanding what they need the system to deliver for them. Going back to your point, your challenge to us, I mean the reality is I can't tell you why your local authority -- I assume that was a local authority -- would say on the one hand: Yes, you need more money, but on the other hand would say: No, we can't afford to fund it. That might be a legitimate thing -- I'm sure it is a legitimate question that the council faces. The problem with it in some ways is how that's explained to you, what people explain to you some of the options might be, whether you have any appeal around that. So that's the bit that needs rethinking. David Nicholson, the chief executive of the NHS, he is constantly talking about care wrapped around the patients, that's one of his favourite expression,s, and he's absolutely right, the real challenge is are we absolutely focusing on the needs of people who use services and their carers and how we can get the services to deliver for them.

JOHN: And also a point, too, about information. This lady, please, in the centre. Can you tell us who you are and who you represent?

NEW SPEAKER: Hi, Stef Dennis, I work for Age Concern and Help the Aged. Following on from what Cynthia has been saying about putting the individual at the centre of care and having talked about the challenges of the future and working in partnerships in organisations that are represented here today, the CQC has already been running a very innovative project, experts by experience, which has been mentioned this morning, whereby service users and company inspectors on a small percentage of regulatory inspections and given that it includes experts by experience as a manifesto, I wondered if now is a good time to ask how CQC propose to continue keeping service users and carers at the very heart of the inspection process, because this must surely be seen as one very effective and real life way of putting people at the centre of their care and understanding what a true centred personal approach is.

JOHN: I'll get back to that in a moment. Let's take a couple more.

NEW SPEAKER: Kim Newton from Gateshead LINk. What I'd like to say is just to emphasise the importance of partnership working with LINks, the local involvement networks. As an example of good practice, Gateshead LINk identified a lead from the CQC in our area and we compared the CQC standards on local authority care and the local authority did the comparison, and we looked together at improving services for local people, and that's the key, and we're hoping to continue the work with CQC and I would encourage other local involvement networks to try and establish a lead with the CQC and continue the work with people. JOHN: Keep up the good work and keep up the good questions.

NEW SPEAKER: Marie McWilliams from the older people's advocacy alliance. I'd like to thank Cynthia for mentioning the word advocacy, because in a lot of cases that's all it gets, just a mention and it's non-existent. I think we need to remember as the number of older people are growing, they need the opportunity to be heard, and many older people feel they are not being listened to and in many cases they are not being given the opportunity to be listened to. This week we have heard from two of our member organisations who have been providing advocacy to people independently in the local area for between and years and suddenly the Commissioning authority, generally the local authority, have pulled back from that funding because times are hard. It's getting worse, and whilst the message from central government coming out is that advocacy is important, there needs to be a reminder to local government that that is the case. Thanks.

JOHN: Yes, a good point. I'll take a little batch of these.

NEW SPEAKER: Hello, Emma Dickson from the King's Fund. Obviously we welcome this first report from the Care Quality Commission. Obviously we've talked quite a lot about money today, but one thing that hasn't been mentioned which will happen between now and the next report of the Care Quality Commission will be a general election, and I think we must just reflect briefly on the implications of what the different political parties are saying both around funding, which has been mentioned today, but also directly about regulators. Obviously I think everybody agrees that whoever is in power after the next election that spending is going to be heavily constrained, and obviously it is reassuring that we're going into that with most organisations providing safe care. But obviously there is a really important role for the regulator in ensuring that standards continue to be met during the funding downturns. One of the biggest fears that's been voiced is that organisations will slash and burn and make poor decisions that will have an impact on the quality of care. I want to ensure how the regulator is going to be sensitive and pick that up as it is happening in real time and feel confidence that the regulator will have both the intelligence to pick that up and the powers to act. We've also heard optimism about where savings can be made, and other people have mentioned the fact about a move to community care, better integration and things that we've wanted for a long time, and the challenge has been to make that happen. So it is important that regulation and registration don't inhibit this shift in care that we know is needed away from acute hospitals and residential care from community to people's homes and I think already Care Quality Commission have done a great deal to demonstrate that but I think it will be very important to make sure that happens. Just in terms of politics, obviously lots has been said about the unjoined up issues between social care and health care in terms of funding and we at the King's Fund have been working for a long time with other organisations to try and get a settlement for the future funding of health and social care and I think that's going to help with the users' experience of care if, indeed, there is more generous funding an a longer term settlement around social care funding. I think the politics of this, hopefully, won't mean that we have a further change in regulators, obviously the Care Quality Commission only just getting yourselves in gear, but obviously there is a fear that a lot of people are talking about the bonfire of the quangos, and so I suppose it's just a note of reality that we are in an election year and sort of what that means for the regulator.

JOHN: Yes, as we've touched on before, far from money being tight and budgets won't go up, they're going to come down. Both parties are committed to that. How do we carry on in this sector when we hear that funding for advocacy will go down.

CYNTHIA: Thank you Anna for ensuring that we end on a low point! I think we decided to have a splendid room for our state of care report so that if we only ever produced one you would all remember it. Well, we can't remember what they said, but the view was fantastic! JOHN: I'm wondering why Jo left, do you think she knows something we don't?

CYNTHIA: She's off to apply for a job. If I can address some of those points, staff with Stef Dennis' points. There are so many people from the old CSCI here, it would be dreadful of me, I would say it if you were not' here boys in the corner, but it would be remiss of me if I didn't acknowledge that the experts by experience programme was one that we inherited from the CSCI, and indeed, from MHAC who has their own programme of engagement of people who use services acting together, so we inherited from the outgoing commissions some really innovative ways of engaging people who use services, and, absolutely, it's our commitment to both continue that and develop this. As we move into a new era we're thinking about how we can use web based technologies to support people, we have a number of groups who engage with service providers and we're hoping to extend those. So I think we have a fantastic tradition to build on and it's our determination that we will go on doing that. Certainly, again, just going back to the regulatory inspection work that we will do, obviously at the heart of that not only are we concerned to involve people who use services as co-experts with us, but also to ensure that when we do go out and look at services, as people have already challenged us this morning, that we're focusing on the experiences of people who use those services and trying our best to judge services through their eyes rather than through the eyes of someone with a particular professional agenda, if you like, coming at it from a different perspective. So that is absolutely the challenge to us to maintain that. Again, the person from LINk, thank you again for the compliment. Again, I think that's something we inherited from the health Care Commission, working hard to engage with LINks. One of the things we are doing now is as we continue to develop our risk judgment, our understanding of how organisations are perfecting, NHS organisations particularly here, once the new system comes into play, that LINks will have automatic opportunities to feed into that, so the LINks will be at the heart of understanding that and supporting us in making sure how well services are doing. Thank you for that, it's something that we want to go on to support. Marie's support about the advocacy work with older people. I absolutely support what you say. One of the comments we make in the body of the report, which I'm sure you haven't had a chance to get yet, it's page , we make the point that we identify I think it's per cent of councils needing to improve their availability of advocacy services for older people. I absolutely support you, and I think it's something that the NHS will need to learn from the social care sector, that an advocacy system is absolutely at the heart of choice for people, and that even people who are well accustomed to making choices in their normal working lives or whatever, when faced with making a fundamental choice about a NHS service or a social care service will feel very disempowered by the system and to have people expert in supporting people through that decision making process is going to be absolutely crucial, and I think it's an area where social care have made much more progress than health care have, and there is something to be learned from that. To turn finally to Anna's point, in terms of are we going to start picking up the quality of care through the financial squeezes that we are in. One of the things we say about the registration system is that we're intending for it to be as fleet of foot as possible. Obviously the social care system was accustomed it a real time assessment of providers because it was a licensing system, but we're bringing that into the NHS, we're determined to bring that ongoing understanding of compliance against core standards into our judgments around the NHS and therefore that should give us an ability to move faster and, of course, we have much stronger enforcement powers when we start to see things going wrong. Also, other people have made reference today to special studies, the reviews that we do, and we're doing one of those, looking at the impact of the financial downturn on the sector, so we're trying to be alive to that as an issue. Obviously, clearly we rise above party and politics here in quango land, but I have to say I know nothing -- I think the idea of having a quality regulator for health and social care is well embedded in the system, and whilst this is our first report and we're still very new as a regulator, I absolutely am convinced and satisfied that quality regulation is here to stay across the board. JOHN: Okay, anybody want to make -- yes, two or three sort of final points to ponder, because lunchtime is upon us.

NEW SPEAKER: Pete, chief executive, royal college of nursing, like everyone else I applaud this report and I think it is helpful. Two points, one was on the issue that a gentleman about minutes raised about self reporting and self assessment. Realistically that has to be the way forward, because the infrastructure that would have to be set up by the CQC couldn't be justified so that every residential home, care home, clinic was expected, as I say, could not be justified. The key, though, is that the self declaration and self assessments must be publicised widely and carers, users of the service should be au fait with what people are declaring and they should be signed off by someone very senior in the organisation, NHS trust executives, owners of the homes. Then what should happen is they should step up the random inspections, but across the piece, not just the places declaring problems. The second thing is this: Over the year I have seen huge distraction from the tablet to create good regulatory systems by the constant reorganisation. In the NHS we had CHI reports, star assessments, reporting and so on and so forth. I personally believe the CQC has made a good start, despite the criticism it has had, and I would hope that who ever wins the next general election allows it to continue so that we have a system of regulation and inspection that we all feel confident in.

JOHN: Thank you very much.

NEW SPEAKER: Hi, I'm from contact a family, we support families with disabled children. A fear and then I'll end on a solution if that helps. The fear is in your presentation, Cynthia, you mentioned that per cent were not meeting minimum standards on training. Contact a family research has shown that one of the biggest barriers to family in receiving the quality of care that they want is actually the attitudes of the professionals they deal with on a frontline basis with the pressures on budget, so I wanted to express that fear about making sure that frontline professionals are adequately skilled not just in clinical issues, but actually in attitudinal stuff. The solution, you mentioned in your presentation a few times the tension between developing people focused services and reductions in funding. I actually would like to suggest that that isn't a tension. Contact a family has been leading work on disabled children to get parents involved in strategic level decision making about how services are planned and commissioned, and although that work is in its infancy, there are clear examples of involving parents at that very strategic level not only are we getting services which parents and families want to use, which are achieving positive outcomes. In some instances they are actually cheaper. I would suggest that that tension might be more perceived than real.

JOHN: Okay. I think that's it, that's a positive note to end up. Did you want to wrap things up, Cynthia?

CYNTHIA: I do. If I may, the comments in contact a family were appropriate and spot on. There are aspects of engagement of people that cost virtually nothing for organisations yet transform people's experience of what care is like. Also I'm very interested to hear what you are saying about more economic or efficient solutions that families can come up with. It doesn't surprise me at all, again, good practice the rest of the system needs to learn from. If I can just comment on Peter's remarks. Peter, you have clearly been reading our publicity, because everything that we have said -- so you get the prize, first in the queue for lunch or whatever it is. We absolutely support, of course self assessment is going to be critical to what we do but so is judgment about risk. One of the things that we are absolutely committed to doing is putting both the self assessments, the judgments that the organisations are making and our -- the judgments, sorry, that CQC are making and our understanding of risk in that organisation absolutely out there to the public. So, in the fullness of time, starting later on this year with the NHS, every single organisation that we regulate will have a risk profile, a quality and risk profile that talks about the key areas of quality for providers and it will be published, our view of how the organisation is going will be published and no doubt all the data behind that that allows us to make those judgments can be available if you wish to see it, but the headlines are there, any concerns we have will be addressed as soon as we start to take action or investigate further any concerns we have with that organisation. So we absolutely acknowledge in doing that that we're moving into a completely different era about what the public except to see from quality of services and that things might not be as good as we thought. Can I say one final thing. It would be absolutely remiss of me if I weren't to finish today -- first of all, thanking everybody that comes, but from CQC's point of view to mention Maggie who is here and also (inaudible) sitting by the window whose work this is. They've worked very hard to make it an interesting report and we're very grateful to them. Internally we're grateful, you know who you are. Externally we want people to know we are grateful, so thank you very much from me. (Applause).

JOHN: Thank you very much indeed. Thank you Cynthia, Maggie and Dame Jo in her absence. Now, I've presented a programme on Radio calls you and yours, and in those days, back in the , when I first started, social care was a subject we hardly touched on at all. It was something people did for themselves, they made their own arrangements, and how things have changed. It was a very invisible sector. Just as important as it is today, but largely untouched by anybody, and boy has that changed. I mean, look, only today, it's front page news in the times, there's a leader about it and pages about it. There can be no more important subject than this, and whenever we do report on this in you and yours, which is quite a lot, we have a huge post bag, or these days inbox. It touches us all, doesn't it? It's going to touch us all, and just a few years ago my mother, who was in her s, had a stroke, and health care and social care -- I always think they sound so clinical -- that she received, because this wasn't social care, it was love, support that she received, it was compassion and humanity. So it was not care, it was treatment that was life affirming, life changing, life prolonging in her case, and the quality of her care put the quality back into her life, and I remember I used to go and see her every week. She is up in Macles field, and I live here in London and they said this is terrific, fantastic, but it's different here, you wouldn't get that in stock port or wherever. That's something as a consumer I would like you to address, that everyone has that rolls railways treatment that my mum had. Thank you for coming, I hope you have found it important, I hope you have found it interesting. Anna, talking about politics, go back to your constituencies and make sure you do something, go and have lunch and there will be a video booth, as Cynthia mentioned. Lunch is served, look out for those St Bernard's. Don't fall over. Thank you very much indeed. (Applause) (. pm)