Care Quality Commission

Finsbury Tower
103-105 Bunhill Row
London
EC1Y 8TG

[email protected]
By Email

Telephone: 03000 6161612

Fax: 020 7448 9311
www.cqc.org.uk

17 September 2014
Dear Sir Robert,
Freedom to Speak Up Review Evidence from the Care Quality Commission
Thank you for the opportunity to provide evidence to this review. In particular we
welcome that Sir Robert Francis QC is leading this work, given the knowledge and
learning gained from chairing the Independent Inquiry into the care provided by the
Mid Staffordshire NHS Foundation Trust, and subsequently the Mid Staffordshire
NHS Foundation Trust Public Inquiry. We believe that this review can make an
important contribution to improving how staff who raise concerns about NHS
services are treated and that the information they provide is used more effectively
to improve the safety and quality of care that people receive and experience.
We believe the issues that need to be tackled around getting staff and people using
services to speak up about the quality of the care they experience are challenges
that are shared across the health and social care system by the different national
and local organisations that seek to improve quality of care. It is therefore not just
an issue for CQC but it is one where we believe we can make an important
contribution.
The Care Quality Commission (CQC) is the regulator of health and adult social
care in England. Also it is a Prescribed Body under PIDA, meaning that employees
of health and social care organisations can make protected disclosures to CQC
where they have concerns about their employing organisation.
Although your review focusses on the NHS, we believe strongly that these issues
need to be addressed at the same time in adult social care services. We know from
our inspections that these issues often show up frequently as important findings
when we inspect adult social care services and need to be addressed.
We thought it would be useful to set out some of the changes we are making to the
way we inspect providers of health and social care services, highlighting the
importance of people who use services and staff who work in services being able
to raise concerns about the safety and quality of care. We believe that every
complaint and concern raised by staff or people using services is an opportunity to
improve as they provide vital information to help CQC to understand the quality of
care.
Chairman: David Prior Chief Executive: David Behan CBE
Registered office: Finsbury Tower, 103-105 Bunhill Row, London EC1Y 8TG

These changes in CQCs approach build on the learning from the Francis Public
Inquiry, the Clwyd/Hart Review of Complaints, Winterbourne View, Health Select
Committee reviews and other examinations of failures in care. CQC believes that
to address these recommendations there needs to be a fundamental shift in the
way that we handle concerns, complaints and whistleblowing. We have provided
below a description of what we are doing and would be happy to provide more
details if this would be helpful to the review.
In order to develop our programme of work we have reached outside of CQC to
draw in expertise from those who have experienced the complaints system and
being a whistleblower, as well as working with external organisations with insights
into peoples experiences of care. This has included employing James Titcombe as
our National Safety Advisor to advise on the development of our new approach to
inspecting how providers handle complaints from people using services, working
with the Patients Association to learn from and build on their good practice
standards. Also we have worked with Dr Kim Holt, herself a whistleblower and
campaigner for staff rights through Patients First, in developing proposals to test
how providers manage staff concerns about safety and the quality of care. We
have been testing these proposals with groups of people who have experienced
the complaints system and whistleblowers. We have set up a whistleblower panel
to help us to develop our methodology. This panel, consisting of a group of people
who have contacted CQC to share their concerns, have met twice and the purpose
is to use their experiences to help us to develop our methods for assessing how
well provider organisations are supporting and responding to members of staff
raising concerns. We held a workshop with a group of people who have made
complaints against NHS and other services to learn from their experience.
We have a number of historic whistleblowing cases that are referred to CQC. They
usually do not present safety and quality issues that we have to immediately
address, especially if they are a number of years old. However they do present a
series of challenges for CQC. The individual may come to CQC with a hope that
we can help resolve their case or hold the provider to account for its actions in this
case. Whilst each case provides learning for us about the problems that can occur,
and how we need to design our new methods of inspection in order to detect
similar problems and take effective action, we do not have the remit to resolve the
individual case. Some of the cases are complex and there are whistleblowing and
human resource/employment issues intertwined. People can ask for anonymity but
it is difficult to investigate issues of quality and safety and preserve anonymity.
There can be a poor understanding of what protection under PIDA (the Public
Interest Disclosure Act) actually means to them and what in practice can be done
to protect individuals like them. For the individual this can leave them with the
sense that for people like them they have no one that they can turn to who will fight
their corner. For CQC and its staff it can leave us feeling relatively helpless in these
circumstances in terms of being able to protect and promote the interests of people
using services.
We believe that we are on a journey towards improvement. However, whilst we
have been making changes over the last 12 months as part of a broader work
programme across CQC, we still have much to do over the next 12 months and
beyond, and some of the work described is still work-in-progress. Some of the

broader agenda requires partnership working with other national and local
organisations (e.g. the Parliamentary and Health Service Ombudsman, the Local
Government Ombudsman, Healthwatch England, Monitor, The Trust Development
Authority), such as agreement on what good practice looks like.
As we begin to consistently hold providers to a higher standard of encouraging and
responding to concerns, complaints and whistleblowing we must hold ourselves to
the same standard. Work to improve our own processes and make listening and
responding with compassion and clarity a core competence of CQC staff is also
underway. We have recruited a customer experience expert, who has experience
in both the public and private sectors, who will be joining us in September to take
this work forward over the next year.
As we are still learning and improving, we would be keen to contribute further to
this review whenever there are opportunities and learn from the evidence it
gathers, its conclusions and recommendations.
How we are changing our inspections
We believe that the strongest lever that CQC has to improve the performance of
providers on concerns, complaints and whistleblowing is through the methods we
use to inspect providers.
Before a new style inspection takes place we gather information on concerns,
complaints and whistleblowing in the following ways:

Encouraging users and staff to contact us directly through our website

and phone line, and communicating these concerns to inspectors when
they decide where and when to inspect a service

Asking national and local partners (for example, the Parliamentary and
Health Service Ombudsman, the Local Authority and Healthwatch) to
share with us concerns, complaints and whistleblowing information they
hold

Analysing national data sources such as the NHS staff survey (e.g.
would you feel safe raising your concerns? Confident my organisation
takes action?) and the Social Care Information Centre complaints data

Analysing responses from public website such as NHS Choices and

Patient Opinion where people record their experiences of care

Requesting information about concerns, complaints and whistleblowing

from providers themselves we are currently working to include a selfassessment questionnaire for hospitals

During our new style inspections we draw on different sources of evidence to

understand how well providers encourage, listen to, respond and learn from
concerns:

We hold listening events with the public at the start of an inspection to

hear experiences of good and poor care.

We discuss with users and families throughout the inspection their

experiences of care. These discussions can often be led by Experts by
Experience on the inspection team, people who have recently had
experience of similar care in another provider.

We encourage members of staff to raise any concerns with our

inspectors. For example, on hospital inspections we hold focus groups
with junior doctors, run by a junior doctor who is on our inspection team,
to encourage them to share any concerns which we need to follow up.
Other staff forums are conducted by a peer on the inspection team and
are held with senior doctors, junior nurses and care assistants, senior
nurses and administrative staff. We offer to speak to people who have
contacted us to raise concerns directly one-to-one or at drop-in
sessions on a confidential basis. Also we provide comments cards that
people can complete and send to the inspection team providing their
views about services.

Other evidence sources may include reviewing provider complaints and

whistleblowing policies, indicators such as a complaints backlog and
reviewing case notes from investigations.

We are proposing to further strengthen these approaches over the next six months
by:

From October on large inspection teams, we will have a designated lead

for complaints and staff concerns. While staff are encouraged to raise
concerns with any member of the inspection team, having a designated
lead will help ensure that information is brought together to form an
overall view of how well-led and responsive a provider is.

From October every new style inspection of providers registered with

CQC will ask a set of questions on concerns and complaints and judge
the answers against explicit characteristics of good practice that will
consider (the questions are still being finally agreed within CQC so the
exact wording may change):
o As part of judging the responsiveness of services we will ask how
are peoples concerns and complaints listened and responded to and
used to improve care?
Do people who use the service know how to make a complaint
or raise concerns, are they encouraged to do so, and are they
confident to speak up?
How easy is the system to use? Are people treated
compassionately and given the help and support they need to
make a complaint?
Are complaints handled effectively and confidentially, with
regular updates and a formal record?
Is the outcome explained appropriately to the individual? Is
there openness, transparency about how complaints and
concerns are dealt with?

How are lessons learned, shared with others and is action

taken as a result of investigations when things go wrong?
o As part of assessing how well-led a service is we will ask how does
the provider engage, seek and act on feedback from people who use
the service, the public and staff?
Is the value of staff raising concerns recognised by both
leaders and staff? Is appropriate action taken as a result of
concerns raised?

We are starting to design a set of training and support for inspection

team members and other CQC staff that is likely to include issues such
as understanding the legal framework, facilitating staff forums, how to
manage sensitivities in handling concerns such as confidentiality, use of
inspection guidance and tool kits, identifying good and poor practice.

In terms of complaints handling we plan in hospitals and other care

sectors to carry out an audit of a randomly selected (by CQC) sample of
closed files to understand if these have been handled in a way that
matches the good practice we expect to see.

We are currently carrying out a quick probe on complaints, concerns and

whistleblowing across all sectors to get an idea of how well health and
adult social care providers are doing on these issues. Professor Sir Mike
Richards will be publishing a report later in the year, which will highlight
what we have found through these inspections, identifying themes
across all sectors including examples of good practices.

Inspection reports will include a sub-heading on Learning from

Complaints and Concerns. If staff raised concerns this can be mentioned
in many parts of the inspection report but specific issues about poor
response to concerns will be mentioned under the Culture subhead
within the section on Well-Led.

In terms of enforcement and bringing about improvement there is a

fundamental standard 16 that relates to complaint handling.
Fundamental standard 17 relates to good governance and includes the
requirement to seek and act on feedback from relevant persons such as
staff. Breaches of these regulations are not a prosecutable offence but
can lead to CQC taking regulatory action against a providers registration
or inspectors making recommendations for improvement.

CQC activity on staff concerns and whistleblowing

We thought it would be useful to also provide this review with information on CQCs
activities on staff concerns and whistleblowing.
During 2013/14 9,495 people contacted CQC to raise concerns about their
employers or their workplace. This year in the period between 1 April 2014 and 8
September 2014 4,114 people have contacted CQC. These contacts are logged
by a team within our National Customer Services Centre and are tracked to ensure

they are responded to by the relevant inspector in a timely manner. The table
below provides details of how they have been resolved:
Answering of enquiries by people who contacted CQC to raise concerns
about their employers or their workplace

Year

2013

2014

Brought forward planned

review

793

494

No other action taken

1,250

511

No outcome recorded

3,154

Noted for future reviews

2,557

1,231

Outcome not recorded in

reportable format

112

73

Referred to another body

789

413

Triggered a responsive
review

639

279

WB not yet complete

201

1,112

Grand Total

9,495

4,114

Note: No outcome recorded. It is likely that this occurred because the process of
recording this information in CQCs CRM information system was not a mandatory
requirement. This does not mean that the information was not acted upon
appropriately by inspectors. Changes have been made to this process and as of 14
February 2014 no whistleblowing enquiry will be able to be closed without an
outcome being recorded against it. All whistleblowing referrals are discussed
between inspectors and their line managers at regular meetings.
In term of language used, we are aware from our engagement that people do not
like the terms complaints and whistleblowing as they appear a negative way of
describing when people make the effort to provide feedback and raise concerns in
order to avoid others having to repeat their experience of poor care. This negative
tone can act as a barrier to others speaking up. Also terms such as whistleblower
and complaint can be used by different parties to mean different things adding to
confusion people feel when trying to navigate their way through the processes. We
are planning to standardise CQCs use of terms such as these through training and
guidance to inspectors over the next 12 months.

Finally, we would like to emphasise that the first responsibility for dealing with staff
concerns has to be with providers. Any proposed changes that introduced further
tiers or organisations into the system should avoid undermining the responsibility of
providers. Resolving the issues around concerns is ultimately about creating better
employee relationships and openness, building on existing good practices.
We hope this information is useful to your review and we would be keen to become
involved in other activities where we could contribute.
Yours sincerely,

David Behan
Chief Executive
Care Quality Commission