Some critical, urgent learning from recent CQC reports

Posted on 17/06/2019 by Ed Hammond.

The Counties and Unitaries Scrutiny Network at its meeting earlier this month (June 2019) took information from the Care Quality Commission (CQC) on some of the key issues arising from recent inspection reports (largely published between March and May 2019). I thought that there would be wider interest in these reports – they speak to critical issues (and concerns) around health and care services across the country. Some of the issues raised in these reports are extremely worrying, relating as they do to “life and limb” services.

It’s for local areas to consider how they respond to these issues – as national studies, councils will have to consider how they satisfy themselves that concerns are being dealt with area by area. But there is no question that scrutiny should be asking questions to satisfy themselves on these points, even if matters do not get escalated to committee for formal consideration. Of course, if scrutiny does ask questions (of CCGs, other care providers and indeed the council) relating to these subjects and the answers it receives seem unsatisfactory or beg further questions, it may well be appropriate to escalate matters to committee.

CQC is completely overhauling its enforcement and inspection activity at the moment to focus on those services and organisations of most need – but even so, there seems to us to be a pressing need to consider scrutiny’s role in bolstering inspection and improvement for care at a local level.

We recognise the resource constraints under which scrutiny operates; we are conscious whenever we write anything suggesting that scrutiny in councils do or look at policy issue “x” or “y” that this could be seen as presenting an additional burden – and, worse, an expectation that scrutiny has the resource to effectively oversee a policy and delivery area as complex as that relating to care. All we would say is that, if you’re a scrutiny practitioner, you should throw these issues into the mix when it comes to work programming – even if you don’t end up carrying out formal work on the issues below, maintaining a watching brief is vital and necessary – we talk about how you can do this in a resource-light way in our “Good scrutiny guide”, published imminently – the new statutory guidance also engages with this issue. At the end of this post we make some suggestions on “next steps for scrutineers”.

Certainly, in doing the above, we’d strongly recommend signing up to CQC’s regular monthly information bulletin if you haven’t already done so.

With these caveats out of the way, here’s a quick summary of some of those recent reports and a sense of what they mean for scrutiny.

Interim report: review of restraint, prolonged seclusion and segregation for people with a mental health problem, a learning disability and/or autism

Instigated by Secretary of State for Health and Social Care Matt Hancock in 2018, this report presents interim findings from a review of the cases of 39 children and young people cared for either in segregated units or on a mental health ward.

Preliminary findings:

  • Many of the 39 had been communicating their distress and needs in a way that people may find challenging since childhood, and services were unable to meet their needs;
  • A high proportion of people in segregation had autism;
  • Some of the wards did not have a built environment that was suitable for people with autism;
  • Many staff lacked the necessary training and skills;
  • Several people that we have visited were not receiving high quality care and treatment;
  • In the case of 26 of the 39, staff had stopped attempting to reintegrate the, back onto the main ward – usually because of concerns about violence and aggression;
  • Some were experiencing delayed discharge from hospital (and therefore being kept in segregation) as there was not a suitable package of care available in a non-hospital setting.

The next part of the review is looking at restrictive practices in a wider group of settings – further recommendations will be made in March 2020.

The state of care in independent doctor and clinic services providing primary medical care

This report looks at a sample of reports from the CQC’s comprehensive inspection programme of independent doctor and clinic services (ie services not provided by NHS providers).

CQC had a range of concerns – some of which relate to basic issues around patient safety and safeguarding. CQC reports that enforcement action has been undertaken, but scrutineers will want to satisfy themselves of the local situation where independent practitioners form a part of the primary care landscape.

Particular concerns included:

  • Safe and effective prescribing of medicines;
  • Awareness of safeguarding needs – particularly for children and their parents/guardians;
  • Arrangements for clinical oversight and good governance;
  • Managing patients’ care records;
  • Securing and recording patient consent;
  • Sharing information with other medical professionals.

The state of care in independent ambulance services

Independent ambulances services mainly provide non-emergency and specialist services to the NHS, but an increasing number also provide 999 services for the health service, either routinely or at peak times. Again, for scrutineers, there will be a need to understand their local exposure to these issues and associated risks – particularly bearing in mind that many of the shortcomings identified are,, again, extremely basic and do raise significant concerns.

Particular issues include:

  • In general, the high variability in the quality of these services;
  • Poor governance and recruitment processes;
  • A lack of basic checks for employment references, DBS checks, and even that drivers were entitled to drive ambulances;
  • Many providers provided little to no training – even for the transport of patients under emergency response (placing both patients and other road users under significant risk). Other basic training deficiencies included a lack of awareness of safeguarding needs or the needs of those with mental health problems;
  • Some providers had a lack of understanding about the management of drugs; some lacked a Home Office licence for the handling and storage of controlled drugs.

Even in basic issues around fleet management, CQC found some inadequacies. This was not a concern shared by all independent ambulance services, but they found:

  • Vehicles not being regularly serviced (and vehicles not having MOTs);
  • Missing or faulty equipment, and/or equipment not being regularly checked.

In some respects, independent ambulance services are exempt from CQC oversight. This includes in respect of medical cover at large events. This is clearly a matter of local authority event managers, and licensing services, to pick up. CQC has raised concerns over this shortcoming in its power to DH.

Monitoring the Mental Health Act

CQC carries out an annual report on the use of the Mental Health Act. Findings included:

  • General improvements;
  • Continued concerns about quality and safety of care in mental health wards;
  • Despite high quality of care planning overall, a concern that a substantial proportion of care plans of detained patients are of poor quality.

Next steps for scrutineers

For scrutineers, a possible approach would be:

  • Research into the extent to which your council is exposed to some of the issues highlighted in this report (through a closer reading of the reports and the inspections to which they relate at a local level);
  • Conversations with colleagues in children’s services and adult social care to identify whether concerns or risks have been identified, and where remediation and improvement plans are in place;
  • If necessary (ie if members are not satisfied by these plans, or where the nature of the risk appears unclear) escalation for more formal consideration either by way of a committee discussion or even the establishment of a task and finish group.

Naturally while care matters primarily affect county and unitary authorities, there may also be an interface with services provided by shire district councils.

About the Author: Ed Hammond

Ed leads CfGS's work on devolution, transformation and on support to councils and other public bodies on governance and accountability.