The new inspection framework sets out five ‘domains’, assessing providers on whether they are: safe; effective; caring; responsive to people’s needs; and well-led.
At The King’s Fund, we have been working with the CQC to help them develop their proposals in the one area that is new for the regulator – looking at how well-led an acute trust is. As part of this, the CQC will assess trusts using five key lines of enquiry: the enacted organisational vision and strategy; the governance arrangements; the organisation’s leadership and culture; how providers engage, seek and act on feedback; and the extent to which the provider seeks to continuously learn and improve. Significantly, these five lines of enquiry cover the leadership and culture of a provider, not just their governance arrangements.
It is heartening that CQC has made understanding culture an important part of its new regulatory framework. At the Fund, we are passionate about the role that culture and leadership can play in supporting organisations to deliver high-quality compassionate care for patients. Culture – 'the way we do things around here' – highlights what a provider places value on and is a powerful influence on the behaviour of staff at all levels. Nurturing appropriate cultures means supporting an environment in which openness, candour, honesty and transparency are encouraged.
Leaders in an organisation are key determinants of how the culture within that organisation develops, and for this reason it is crucial that providers are clear about their leadership strategy. This includes making sure they know what leadership capacity and capability is needed now and in the future, and where it needs to be located in their organisation. Proactive development of a leadership strategy by boards can help nurture the kind of organisational culture that is 100 per cent focused on continuous learning and delivering high-quality compassionate care.
Part of this leadership strategy may also include developing collective leadership that supports clinical leaders and managers at all levels, and that works across services and departments to reinforce the values of the organisation. Boards will need to assure themselves that they are clear about the values that drive them and the leaders in their organisation, and that these values are shared, with a focus on quality, compassion and candour.
Although the focus on culture and leadership is very welcome, boards may find being inspected on these criteria challenging. In our work with the CQC, we have been encouraged by its new way of approaching the inspection process. The new model intends to be less about inspectors coming into an organisation solely focused on box-ticking and developing ratings and more about getting under the skin of the culture and leadership of an organisation to share key learning from the inspection with the organisation– it’s more of a peer review.
It is also encouraging that CQC’s new model of inspections proposes to learn from an ‘appreciative inquiry’ approach, which uses support and challenge to develop learning organisations, and which builds on the successes, not the negatives. Our experience highlights the importance of this type of peer review approach that supports and challenges in order to develop learning organisations. We’re currently working with providers in one region to train staff from acute trusts to form a network of peer reviewers who can use the CQC assessment framework to drive continuous improvement and quality.
As The King’s Fund has argued before, regulators cannot alone ensure quality, and can only ever be the third line of defence against poor care - the first line of defence being frontline staff, and the second being the leaders and boards of organisations.
The consultation documents published last week signal the key areas of focus for the regulators, so providers can start gearing up for inspections now – they don’t need to wait until CQC comes knocking.