CQC’s suspension of announced inspections could deliver a welcome ‘maturity leap’ in quality regulation but trusts need to ensure their safety culture is strong and robust, says Cassandra Cameron
As the latest NHS performance figures bear out this winter’s exceptional service pressures, the Care Quality Commission unexpectedly decided last week to temporarily suspend routine quality inspections during January, potentially February as well.
NHS Providers and many others welcomed this as sensible recognition that on site regulatory activity will add unhelpful pressure on already overwhelmed, exhausted staff.
The regulator stressed that risk based monitoring will continue, unannounced visits to higher risk services will be maintained, and action will be taken if needed to protect patients. Some, however, fear that the CQC has relinquished its responsibility to assure minimum standards of patient safety.
There are now significant year round challenges to timely care and others have had to bear the regulator’s scrutiny; safety is admittedly the CQC’s biggest concern, so stepping back now seems unfair and risky.
This view implies two assumptions that are open to question: that the CQC makes care safer by watching over people’s shoulders, and that NHS safety culture isn’t up to the task.
Feedback from providers to NHS Providers’ annual regulation survey shows that preparing for a CQC inspection often helps to focus collective efforts on quality improvement. Trusts invest significant time, resources and effort to perform as well as possible under the CQC’s lens. To that end, patients visiting trusts with postponed inspections are being treated by staff who are well prepared and ready for the test.
What the CQC’s decision acknowledges though, is that on site inspection is unavoidably burdensome. Large inspection teams (usually including health and social care staff drawn from their own duties of providing direct care) absorb significant time, generating numerous ad hoc requests for data and evidence of compliance.
More problematic is the implication that NHS care is only as safe as the CQC says it is. This drives a compliance mindset whereby people’s intrinsic desire to do their best is undermined by a pervasive lack of trust
This activity causes significant anxiety and pressure when it absorbs attention from front line care, often demoralising staff in the process. Such resource impacts mean that it’s unlikely that on site inspection could directly improve the current situation.
More problematic is the implication that NHS care is only as safe as the CQC says it is. This perspective drives a compliance mindset whereby people’s intrinsic desire to do their best is undermined by a pervasive lack of trust.
Reliance on inspections for safety can also drive unhelpful and misleading focus on individual actions, reinforcing the “blame and shame” approach if things go wrong.
At this time, when it’s near impossible to find spare beds on wards or social care placements for discharging patients back into the community, worryingly some staff fear they could personally bear the legal consequences of patient harm that may result from delays to accessing care. We know though, that delays are complex problems that require a whole system response to fix.
What matters most for protecting patients under times of intense pressure is a provider’s safety culture: the organisation wide commitment to safety, based on shared understanding and evidence that everyone is upholding safety focused behaviours and processes and support others to do the same.
Safety culture cannot be “regulated in”; ownership lies with the provider board, to lead and reinforce this as the highest priority across the organisation in support of the frontline.
Safety can be strongly enhanced by building a closer connection between senior leaders and frontline staff, empowering staff, and involving patients in decisions
While building a safety culture takes sustained effort, the improvement journeys of numerous trusts show that safety can be strongly enhanced by building a closer connection between senior leaders and frontline staff, empowering staff, and involving patients in decisions about their care. Strong safety culture practices are those which are also most visible, informative and reassuring to patients and their families.
All providers – not just those given a temporary reprieve from the CQC – can enhance their safety cultures during this testing time by bolstering efforts in three key areas:
- Highly visible senior management and leadership, which is critical to morale and ensuring staff feel supported: Accessible leaders show openness to information about risk, can respond more swiftly when a problem arises, provide direct feedback for staff on actions taken to improve safety, listen and empower staff to resolve concerns including with patients and families, and signal that wellbeing of staff matters too.
- Encouraging vigilance, information sharing, collaboration, teamwork and clear communication on safety performance: This includes practices such as regular safety huddles and generating more insightful and timely data analysis. It also means ensuring that patients know what is happening, participate appropriately in decision making, and know what they need to do (and with whom) when they move on to another part of their care pathway.
- Nurturing staff resilience by saying thanks, celebrating good outcomes, being kind when colleagues show signs of fatigue, creating moments and a space for time out, and encouraging self care: Being flexible, trusting staff to prioritise the welfare of patients, asking what they need and responding accordingly can ameliorate burnout and reinforce the positive feedback loop between gratitude and compassion in care.
Taking a ‘maturity leap’
The NHS is at a watershed moment, but it offers significant learning opportunities too. The CQC’s decision, a temporary response notwithstanding, offers a chance for a “maturity leap” in how the NHS regulatory system functions.
Evolving from compliance focused inspections to continuous monitoring and horizon scanning, sparing use of unannounced investigations, joining the dots on a complex landscape of local operational activity in health and social care and shining light on what works well are the most effective ways for regulation to support front line safety and continuous quality improvement.
Incessant reassurance seeking through ad hoc meetings and bespoke data requests remains the most persistent burden of the current regulatory environment
Incessant reassurance seeking through ad hoc meetings and bespoke data requests remains the most persistent burden of the current regulatory environment. If the CQC can show restraint during this winter period and provider’s safety performance remains intact, then we have a real chance to use this period to improve the overall regulatory approach.
This maturity leap, however, ultimately relies on trusts demonstrating through visible leadership, effective communication, proactive information sharing and practical support for staff that even under the most intense pressures, their safety culture holds the highest priority.