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MEETING:
PUBLIC BOARD MEETING
DATE:
31 July 2013
TITLE OF PAPER: Grant Thornton Review - Update
SUMMARY:
This paper provides an update on the actions that CQC has and will be taking following the
completion and publication of Grant Thornton’s Project Ambrose report into CQC’s
registration and oversight of University Hospitals of Morecambe Bay NHS Foundation
Trust. The report raised significant questions about the way CQC regulates, the way it
works with others and the culture of leadership within the organisation. This paper
provides updates on the following areas:
- Responding to observations made within Grant Thornton’s report
- Action to be taken following CQC’s appearance at the Health Select
Committee on 3 July 2013
- Potential action against former or current staff following publication of
the report
- An update on police action following publication of the Grant Thornton
report
- Details of an on-going challenge in relation to the independence of
decision making between CQC and PHSO.
RECOMMENDED ACTION:
The Board is asked to COMMENT on the action being taken following publication of the
Grant Thornton report.
Executive Decision/
Board for
information
Executive and Board
decision
Executive and Board
shared decision
Executive and Board
discussion/Board
decision
The Executive Team has
made a decision and the
Board has been informed
The Board has been
consulted in order for the
Executive Team to make
a decision
This is a shared decision
between the Executive
Team and Board
This is for when it is clear
that it is a specific Board
decision (under statutory
and legal requirements)
ie. signing off the annual
accounts
* Check box as required
LEAD DIRECTOR:
AUTHOR:
DIRECTORATE
DATE:
SUPPORTING
PAPERS:
David Behan
Alun Jones
Chief Executive’s Office
25 July 2013
Appendix 1 - Analysis of issues raised in Grant Thornton
Report
Appendix 2 – CQC response to the Health Select Committee
GOVERNANCE
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AUDIT TRAIL:
This paper is provided as an update on activities
following the publication of the Grant Thornton report.
LINK TO STRATEGIC
OBJECTIVES AND
BUSINESS PLAN
There is a clear interdependency between the report and
the implementation of CQC’s strategy, with the Grant
Thornton report offering an insight into previous
weaknesses that can and should be corrected.
In the main, any financial impact relates to the effective
implementation of CQC’s strategy, thus being dealt with
under mainstream CQC programmes of work. However,
there will be a financial impact of any future Inquiry.
Failure to act on issues raised in relation to the Grant
Thornton report will impact on CQC’s future effectiveness
the confidence which the public has in it.
CQC aims to operate in an open and transparent way.
Failure to act on the Grant Thornton report will impact on
CQC’s reputation but more importantly will be a missed
opportunity to learn from past failings and improve the
way it regulate.
There is still the possibility of legal action being taken
against CQC. The possibility of an Inquiry also raises the
question of legal costs.
No specific impact
FINANCIAL IMPACT:
RISK IMPACT:
REPUTATION IMPACT:
LEGAL IMPLICATIONS:
HEALTHWATCH IMPACT:
EQUALITY IMPACT
ASSESSMENT:
Covered under any strategy implementation workstreams
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1.
Background
1.1
On 19th June 2013 CQC published Grant Thornton’s independent report into
CQC’s registration and oversight of University Hospitals of Morecambe Bay NHS
Foundation Trust (UHMB). The report was commissioned to investigate
complaints made by a CQC Board member and Mr James Titcombe, whose son
Joshua died shortly after being born at Furness Hospital in 2008. The report raised
significant questions about the way CQC regulates, how it works with others and
the culture of leadership within the organisation.
1.2
Following publication of the report, CQC was placed under scrutiny, resulting in it
being invited to account for itself at a Health Select Committee hearing on 3 July
2013.
1.3
Independent of Grant Thornton’s review, there has been on-going wider scrutiny of
the actions of UHMB and those charged with oversight of trust. This has taken the
form of a police investigation into deaths at the trust and a decision by ministers
that there will be an independent inquiry which will sit in public.
2.
2.1
2.2
2.3
2.4
3.
3.1
Executive Summary
Grant Thornton’s work and the attention directed towards wider and historic
failures at UHMB raise a number of significant issues that CQC has an opportunity
to learn from and address as it seeks to implement its strategy.
The Board is asked to note and comment on activities summarised in this report
which seek to respond to issues raised within Grant Thornton’s report. These
activities include potential action against current or former staff and follow-up
actions resulting from CQC’s appearance at the Health Select Committee.
The Board is asked to note the position with regard to police action and an inquiry
to be held in public.
Finally, the Board is asked to note the details of an on-going challenge in relation
to the independence of decision making by CQC and PHSO in relation to the
death of Joshua Titcombe.
Responding to Grant Thornton’s report
Grant Thornton’s report raises a number of significant issues about the way CQC
operates and the culture and leadership. Appendix 1 provides a full analysis of key
issues documented within the report and remedial actions that are being taken, or
could be taken. In summary form, the topic areas and actions can be summarised
as follows:
Approach to Inspection
3.2
Grant Thornton makes number of observations about the way in which CQC has
undertaken inspections in the past. They point to a lack of clinically experienced
staff, a lack of experience specific to the service being inspected, insufficient
guidance and wide ranging risks to patient care being missed.
3.3
We are currently consulting on the way we should inspect services. From August
2013 CQC aims to carry out a mixture of announced and unannounced
inspections of hospitals, with bigger inspection teams led by the Chief Inspector of
Hospitals. The teams will also include a senior NHS clinician or executive,
professional and clinical staff, Experts by Experience patients, carers and other
experts. Certain departments or wards such as accident and emergency,
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maternity and paediatrics will always be looked at during these inspections. The
Chief Inspector of Hospitals has recently announced the first wave of inspections
to be undertaken using the new approach.
Approach to risk assessment
3.4
Our strategy for 2013-2016 outlines our plans to change the way we inspect and
risk assess services, and how we will introduce ratings for trusts. As we make
these changes, we will take account of weaknesses raised in Grant Thornton’s
report, ensuring that surveillance methodologies are used to target inspections.
Further potential actions should include:
•
Limiting the use of self-assessment in any new regulatory methods
•
Use of validation where assurances are given by third parties
•
Adopting a lower threshold of suspicion
•
Reviewing how information relating to Serious Untoward Incidents (SUIs) is
used
•
Ensuring that there is a common internal view on regulatory risk at trusts (only
one list)
•
Ensuring that the right information is available at the point of regulatory
decision making
•
A robust approach to registration.
Duty of candour
3.5
The Grant Thornton report indicates a number of ‘missed opportunities’ including
the failure of the trust to provide a copy of the ‘Fielding report’ into maternity
services at UHMB. CQC does now oblige providers to disclose critical information
following registration. The government is considering legislation to enforce a duty
of candour, but regulations are not yet drafted. Further work may be required to
ensure that CQC’s requirements of providers are clear to them and that action will
be taken by CQC in instances where information is suppressed.
Failure regime
3.6
The Grant Thornton report echoes the findings of the Deloitte report from 2013,
which called for improvements in how decisions were made and documented as
well as greater clarity around how different powers are used e.g. section 48
investigations
3.7
The planned introduction of a ‘failure regime’ will offer a clearer roadmap for
escalation of concerns about a trust, including clarity on accountabilities for CQC,
Monitor and the NHS Trust Development Authority.
Governance – Corporate
3.8
The report points to a number of weaknesses in governance arrangements
leadership culture and handling of concerns raised.
3.9
Action: New Board members and Executive Directors have been appointed and
the Board, Executive and Leadership teams are leading on a number of initiatives
to develop the culture of the organisation, focusing on openness, transparency
and learning. One example is recent work to support a zero tolerance to bullying
and harassment.
3.10
An independent governance committee has also been formed to provide
assurance to the Board that CQC has an approach to decision making and
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governance that supports the promotion of a transparent, open and accessible
culture. In the light of the Grant Thornton review, and in the context of
organisational changes underway, further consideration will be given to the
effectiveness of internal governance structures.
Governance – Operational
3.11
Regulatory decision making: CQC is currently making significant changes to the
way in which it inspects and risk assesses NHS Trusts. As part of these changes,
CQC will clarify governance arrangements and guidance for staff so that there is
clarity on where and how regulatory decisions are taken and the mechanisms for
ensuring the quality of those decisions.
3.12
Systems and processes: As a result of the Grant Thornton review and the need to
improve operational systems and processes, CQC will undertake an audit of the
efficiency and effectiveness of records and documents management policy and
practice.
High performing organisation
3.13
The Grant Thornton report highlights a number of specific and detailed issues
which CQC would wish to tackle as it strives to become a high performing
organisation. Full details of these issues can be seen in Appendix 1. Of particular
note are Grant Thornton’s observations around training and guidance for
operational staff.
3.14
One of the key priorities listed in CQC’s 2013/14 business plan is to build a high
performing organisation. Amongst other initiatives, CQC is developing a training
academy, implementing programmes to ensure that leaders are equipped to lead
the workforce and improving the systems, tools and processes that enable staff to
work more effectively and efficiently.
Setting and achieving performance targets
3.15
The report demonstrates how timeliness of action can directly impact on the
effectiveness of regulation. In implementing its new strategy, CQC is considering
the impact that delayed action may have on the effectiveness of regulation and is
setting improved Key Performance Indicators.
Registration
3.16
The Grant Thornton report raises a number of issues in relation to the approach
taken to transition registration of NHS providers in 2010. Many of these issues
were specific to the period in question. Nevertheless, in line with CQC’s strategy
for 2013 to 2016, action is being taken to strength registration. Registration will be
a more rigorous test to deliver safe, effective, compassionate and high-quality
care. Registration will be legally binding and we will make sure that named
directors and managers commit to meeting the standards and are tested on their
ability to do so.
Strategic partnerships
3.17
The report suggests that relationships with some external stakeholders were
dysfunctional with, for example PHSO concerns not being logged or followed up in
a systematic way.
3.18
CQC has developed a memorandum of understanding (MoU) with the
Ombudsman which outlines the principles of how the organisations will work
together. A key principle is the need to make ‘our own independent decisions’ and
acknowledge each other’s statutory responsibilities as well as sharing information.
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3.19
4.
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CQC’s business plan for 2013/14 details its commitment to working better with
other regulators and partners to improve the quality and safety of care. This will
see the further development of Information Sharing Agreements and MoUs as well
as structured meetings with a range of partners to ensure that information is
shared between relevant organisations. A list of current information sharing
agreements and MoUs can be found in Appendix 2. Further details of on-going
partnership development work, including formal partnership arrangements with
bodies such as NHS England will be presented to the Board in a strategic partners
update paper on 31 July.
Activities following CQC’s appearance at the Health Select Committee
4.1
Following the publication of the Grant Thornton review, David Prior and David
Behan appeared at a hearing of the Health Select Committee on 3 July 2013.
CQC committed to provide a further written response to a number of questions
which required further consideration or investigation. This response has been
shared with CQC’s Board and is also attached at Appendix 2.
4.2
CQC’s response to the Health Select Committee confirms that it has committed to
write to the Secretary of State in August outlining its response to the Grant
Thornton report, including any actions it is planning to take
5.
5.1
6.
Potential action against current or former staff
Following the publication of the report, CQC has committed to review the evidence
used by Grant Thornton to produce their report, including transcripts of the
interviews, for the purpose of considering whether action should be taken against
any current or former employees. Hempsons Solicitors, who specialise in
employment law, have been instructed by CQC to assist and advise on process.
Further updates will be provided to the Board.
Police action
6.1
Cumbria Police force is continuing to investigate the death of Joshua Titcombe
and have considered the evidence within the Grant Thornton report in relation to
this. On 18 July they confirmed that there are no on-going specific investigations
into CQC as a result of the report.
6.2
It is understood that following a referral, the Metropolitan Police may be
considering whether there is a case to answer in relation to misconduct /
misfeasance in public office. As such, a charge of this nature would be aimed at
an individual rather than an organisation and communication on this matter would
not in the first instance be directed at CQC. CQC has however written to the
Metropolitan Police and offered to assist should they wish to pursue any such
matters.
7.
Independent Inquiry
7.1
Ministers have agreed to support a transparent and independent Inquiry, which will
be held in public and which investigates the failings in maternity and neonatal
services at UHMB. Dr Bill Kirkup has agreed to Chair the Inquiry and terms of
reference are currently in the process of being discussed and drafted.
7.2
CQC understands that early draft versions of the Inquiry terms of reference
indicate a relatively narrow focus on safe provision of maternity and neonatal
services rather than regulatory decision making. Further information on the
emerging terms of reference will be shared with the Board as it becomes available
and/or any specific decisions need to be taken by the Board.
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8.
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Continuing concerns about the independence of decision making by CQC and
PHSO
8.1
Following publication of the Grant Thornton’s report on 19th June 2013, Mr James
Titcombe contacted David Behan to voice concerns about the conclusions
reached by Grant Thornton. His concerns were articulated in a number of emails,
asking the key question “Did CQC and the PHSO act independently and properly
in relation to the issues raised by Joshua's death”.
8.2
This continuing complaint will be considered by the Governance Committee on
30th July and there will be an update at the Board meeting on 31 st July.
9.
Conclusions and next steps
9.1
The Board is asked to note and comment on activities summarised in this report
which seek to respond to issues raised within Grant Thornton’s report.
9.2
The Board is asked to note the position with regard to police action and an inquiry
to be held in public.
9.3
Finally, the Board is asked to note the details of an on-going challenge in relation
to the independence of decision making by CQC and PHSO in relation to the
death of Joshua Titcombe.
Name:
Title:
Date
David Behan
Chief Executive
22 July 2013
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Appendix 1- Analysis of issues raised in Grant Thornton Report
Topic
Report
Issue articulated in Grant Thornton Report
Page
8 Lack of clinically experienced staff
Approach to inspection
Wide-ranging risks to patient care, identified in Fielding report,
135 were missed by CQC – suggesting “engagement” with the Trust
and SHA was flawed and ineffective
Inexperienced inspectors lacking maternity experience and lack
152
of confidence in own ability
HSC questions
requiring
Action to be taken
follow-up
From August 2013 CQC will carry out a mixture of
announced and unannounced inspections of hospitals. The
inspection teams will be bigger and will be led by the Chief
Inspector of Hospitals. The teams will also include a senior
Q95, Q99, Q101- NHS clinician or executive, professional and clinical staff,
Q106
Experts by Experience patients, carers and other experts.
Certain departments or wards such as accident and
emergency, maternity and paediatrics will always be
looked at during these inspections.
First wave of inspections announced
Two issues to address - spotting issues and understanding
consequences of decisions. Experts will be used and they
will receive training to assist them. Also relates to
Q95, Q99, Q101thoroughness
106
Q65-72
Q85-86
Conflicting information around whether a follow-up inspection
12 is mandatory following the date of a compliance warning notice
being reached – enforcement policy insufficiently detailed
8 Over-reliance on self-assessment (registration)
Over-reliance on third party assurance e.g. SUIs had no clinical
8
commonalities (SHA)
Lack of validation of information received from the trust or
126
assurances from the SHA
126 SHA declarations accepted at face value
CQC allowed a Trust with ‘an apparently delinquent culture to
263
divert regulatory scrutiny from poor standards of care’
Failure to follow up key information that might have identified
264
risk
290 Reliance on ‘old’ data for registration and compliance decisions
Trust not highlighted on mortality outliers analysis at time of
decision not to investigate
Weaknesses in management information systems – failure to
capture within CQC all known and available information about
8
the Trust and required follow-ups resulting in downgrading of
risk
11 Sharing of SUIs with CQC – relied on SHA encouragement
Regional risk panel views not consistent with views of regional
124
director
141 Appropriate degree of professional scepticism not shown
48
Approach to risk assessment
146
Question of whether CQC should downgrade risk ratings on the
basis that a provider is carrying out its own review – e.g. Fielding
290
Septicaemia mortality alert in December 2009 apparently
ignored
New methods are being developed and guidance will be
revised
Q76-77
Q76-77
Q76-77
New approach to inspection, risk assessment and rating of
trusts will take account of these weaknesses. This will
include use of strategic partnerships to ensure that
information sharing is effective and surveillance
methodologies being used to target inspections
Key points to address:
Use of self-assessment
- Validation where assurances are given by third parties
- Adopting a lower threshold of suspicion as suggested in
Francis report
- Review of how SUIs are received interpretted and acted
on
- Ensuring there is one internal view on risk (one list)
- The right information being available at the point of
regulatory decision making (including registration)
- Robust approach to registration
Mortality alert – CQC contacted Trust in Jan 2010 to say alert was
103 being assessed. No evidence to indicate any action or follow up
taken at the time or during registration
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Report
Issue articulated in Grant Thornton Report
Page
Topic
Duty of Candour
HSC questions
requiring
Action to be taken
follow-up
7 Obligation to disclose critical information following registration Q64, Q67, Q84
7 Lack of prescribed procedures – investigations
Door closed referral to investigation - regional staff member
perplexed by investigation procedures
162 Lack of coherent plan for dealing with the trust
CQC less assertive role than perhaps would have been
183
appropriate in the circumstances (left SHA to ‘hold the ring’)
Why was an investigation launched in this case and at this time –
185 repeat of Deloitte findings – clarity around decisions made and
where
189 Investigation – what is the trigger or escalation route
Updated registration paperwork does oblige disclosure.
Regulations relating to duty of candour are not yet drafted
and further work in this area is required.
51
Failure regime
198
6
Governance - Corporate
The Deloitte report from early 2013 details a number of
weaknesses. Failure regime will offer a clearer roadmap for
escalation of concerns about a trust, including clarity on
accountabilites for CQC, Monitor and TDA
Process for developing Terms of Reference for an investigation
are unclear, including where they should be signed off
Poor Governance in relation to dealing with issues of
operational weakness (+whistleblowing)
Q12, Q95-98
13 Failure of REC to discuss UHMB and role of REC (RRC) in general
Q12
18 Dysfunctional relationship between Board and Exec
Q52
Board ineffectiveness:
222 and - Members requesting information and not receiving a response
Q12
224
- Board agendas and minutes (failure to discuss UHMB)
(includes whistleblowing)
Lack of transparency around why certain decisions were made or
7 changed – undocumented inspections and decisions not to
Q35
inspect
7
Weaknesses in governance and procedures to assure quality
accountability and proper management of CQC’s operations.
New Board members and Executive Directors have been
appointed.
An independent governance committee has been formed
to provide assurance to the Board that CQC has an approach
to decision making and governance that supports the
promotion of a transparent, open and accessible culture
Consideration to be given to internal governance and
whether RRC is fit for purpose
Current overhaul of inspection and risk assessment
approaches needs to be articulated
Need to be able to articulate how quality, governance and
risk management works within new approaches
Q31,Q74, Q116Notes to be required from meetings
119
Inspector training/professionalism
165 No record of purpose, motivation or objectives of visits to trust
An audit of records and documents management policy and
CQC decision making – original decision not to investigate –
practice has been commissioned and this will include
16
Q35, Q71-73
recorded rationale could have been clearer
consideration of:
- whether records and documents policy is in line with besy
13 Lack of clarity around why the decision to investigate was made Q35
practice and legal/professional requirements
Lack of records to show why action wasn’t taken (Follow-up after
- information held is complete, recorded, captured or
17
Q35
assurances given to PHSO)
placed into the formal records and documents system, and
No evidence of an improvement letter being issued – record
is not inappropriately deleted
9
keeping impacting on transparency
- information is accessible to those that need it and in a
Is further inspection required if SUI occurs after a warning notice
New methods are being developed and guidance will be
13
is issued?
revised
Q21-30 and 32- Policy of retention of back up tapes being reviewed and
31 Retention of historical emails older than a year
34
considered as part of audit detailed above
91 Meeting between CPHSO and CQC CEO not ‘memorialised’
Governance - Operational
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Report
Issue articulated in Grant Thornton Report
Page
Topic
250 Perception that an internal document might pose an 'FOI Risk'
HSC questions
requiring
Action to be taken
follow-up
Q37-Q39
CQC to develop as a high performing organisation, allowing
successful implementation of policies through active
engagement of all staff, communication and training,
including the development of a training academy.
Approach needs to ensure that expertise is not seen as a
proxy for thoroughness
Lack of clarity between the intentions of the policy makers and
171
the compliance team’s interpretation of the policies
High Performing
Organisation
8
Lack of clear procedures, guidelines and effective training for
CQC staff – registration
8
Continuity of oversight by the regional team in assessing risk
and compliance
Q99-116
There is a risk associated with internal change and CQC will
need to ensure that structured handovers take place during
any transition.
Business Continuity:
- Briefing of incoming Regional Director
129
- No individual in the region had continual oversight of the trusts
and its history
232 Internal review report – the alleged order to delete
Setting and achieving
performance targets
Slow publication of inspection reports not aiding transparency.
Inspection in Feb, publish in June
13 Warning notices issued slowly (6 weeks)
Lack of prescribed procedures – registration
7 and 8 Lack of resources, capacity and time to conduct pre-registration
inspections
202
8
Registration not taking into account all of the available
information both within CQC and known by other stakeholders
8
Lack of clarity over responsibilities of the regional team and
central functions regarding registration approval
Need to ensure that the FOI Act is understood by staff and
that transparency and openness are part of CQC’s culture
Q37-Q39
Q88-94
Need to consider management culture when staff raise
issues or draft reports, the contents of which may be
contested.
Clear policies are needed and CQC will improve KPIs
Action is being taken to strength registration in 2013/14.
Registration will be a more rigorous test to deliver safe,
effective, compassionate and high-quality care.
Registration will be legally binding and we will make sure
that named directors and managers commit to meeting the
standards and are tested on their ability to do so
Registration
127 Register now check later mentality
Transition registration – lack of training, resources and
130
qualifications
Mortality alert and potential compliance conditions not
132 mentioned in Assessment Record used for registration
assessment
Strategic Partnerships
Training issues documented in mid staffs evidence and
improvements have been made
Qualifications – inspection regime is changing
Resources – CQC has requested and secured further
resources as necessary
New approach to be articulated – need to demonstrate
how surveillance methodology will be used to target
inspections
CQC has developed a memorandum of understanding
(MoU) with the Ombudsman which outlines the principles
of how the organisations will work together. A key
Dysfunctional relationships with external stakeholders/partners 7
Q84
principle is the need to make ‘our own independent
including information sharing
decisions’ and acknowledge each other’s statutory
responsibilities as well as sharing information. These are
principles that CQC is also pursuing through the
development of Information Sharing Agreements, MoUs
and scheduled meetings with a range of other partners to
Q70, Q72, Q74,
ensure that information is shared between relevant
No evidence that PHSO’s concerns logged or followed up in a
69
Q75, Q79-83,
organisations.
systematic way
Q116-121
Audit of records and documents management policy and
practice has been commissioned - as outlined above
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Appendix 2 – CQC Response to the Health Select Committee
Annex provided as separate electronic file
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