Emerging findings from radical new approach to hospital inspection – compassionate care is alive and well in the NHS

6 March 2014

The Care Quality Commission (CQC) has published findings from its 18 pilot hospital inspections completed last year, the first step in a radical change to its approach.

The chief inspector of hospitals, Professor Sir Mike Richards, led teams of specialist inspectors and members of the public representing patients, to complete this work between July and December last year.

The report concludes that compassionate care is alive and well in the NHS. Inspectors found care and compassion among frontline staff in every hospital visited, as well as a strong commitment to the NHS.

We observed a lot of good practice. Inspectors found that critical care services were delivering high quality, compassionate care and were able to demonstrate how they monitored quality.

Maternity services were also generally providing good quality care, and were good at monitoring their effectiveness. Almost all units were using a performance dashboard that helped them understand their performance.

Many of the trusts were found to be making a determined effort to improve care for people with dementia, for example by creating dedicated wards.

However, inspectors found significant variations in quality between trusts and even between services within trusts.

Accident and Emergency Departments (A&E) were found to be under greater strain than other hospital services. Some haven’t adapted to increased volumes of patients, which is leading to overcrowding, long waiting times and staff shortages at times.

Outpatient services were poor – they were not responding well to patient needs across most of the hospitals inspected, with patients waiting unacceptably long times to be seen and some clinics being overcrowded as a result.

The report also found that apart from critical care and maternity, most services cannot demonstrate whether they are delivering effective care or not.

This inspection programme builds on elements of the review of trusts with high mortality ratios led by Professor Sir Bruce Keogh. The key new component of the process is the introduction of a ratings system, as trialled here with three trusts, which aims to help patients understand the quality of care as well as being a driver for improvement. 

In all inspections, inspectors asked if services were safe, effective, caring, responsive to people’s needs and well-led and CQC is consequently now finding out more about hospital quality than ever before, according to Sir Mike.

‘This review shows that inspections with larger, more expert teams work.  Our experience so far shows we are moving in the right direction and we have had positive feedback from the hospitals and others.

‘However, we will not rest on our laurels and are continuously improving our approach. We are indebted to the hospitals that bravely volunteered for a trial rating. Ratings will be very helpful for patients, allowing them easy access to information about quality and allowing excellent hospitals to trumpet their own achievements.

‘Where we find excellent patient care, we will make sure this is highlighted and reflected in the trust’s rating.’

The new approach to inspection will see trusts receiving an official rating of outstanding, good, requires improvement or inadequate. Three of the 18 trusts inspected in the pilot programme agreed in advance to receive a trial rating.

The Royal Surrey County Hospital NHS Foundation Trust has a ‘good’ rating.  The Heart of England NHS Foundation Trust has a ‘requires improvement’ rating*; since rating the hospital we have carried out another unannounced inspection and seen improvements made by the trust. Our report of this inspection will be published soon. The Dartford and Gravesham NHS Trust also has a ‘requires improvement’ rating, and we will be carrying out an unannounced inspection in the near future to review improvements.

Other findings in the report include:

•  ‘Critical Care’ performed the best out of the eight core services, with ‘Outpatients’ the least-well performing. This was unacceptably poor.
• Patients were not always moving through hospitals as they should have been, with delays from A&E to Acute Medical Units and then onwards to wards (this is referred to as ‘patient flow’). We also found delays moving patients from critical care to surgical and medical wards and hospitals also had problems moving patients from wards back into the community.
• There was a link between staff engagement and better patient outcomes.
• A “them and us” culture between clinicians and managers was often in evidence within trusts that performed poorly.
• Trusts have made progress in moving towards the delivery of seven-day-a-week services but this varied across trusts and needs to improve.

CQC recommends hospitals, commissioners and other national bodies such as the Trust Development Authority, Monitor and the Department of Health, act on these findings to make sure patients receive the services they deserve.

CQC has separately commissioned an independent review of its pilot programme by Professor Kieran Walshe to help it build on the learning already identified and this will be published later this month.

Sir Mike added “We still have a lot to learn, but we have already begun to make some improvements to the inspection process. We want to make sure all our inspections are consistent in their approach and credible in their findings, that way they will be meaningful to the public and help drive improvement in hospitals”

We will be asking the public, patients and people working throughout the hospital sector for their views on how we should further improve our approach to inspection in a consultation starting in April.

Notes to editors:

CQC’s learning from the pilots

Our new approach to hospital inspection is a radical change, and we have learned a great deal from this first pilot wave.  We have already made a number of changes to our Wave 2 pilot inspections, for example

• We will in future collect more information especially from national clinical audits to enhance our assessments of effectiveness.
• We are now routinely asking for more specific information from trusts in advance of the site visits, so that we can incorporate this into the key lines of enquiry.
• We’ve reduced the number of information requests we make to trusts during the site visit, and targeted our requests more effectively at what we need.
• We are now piloting an in depth assessment of complaints during the pre-inspection phase
• We have also started work to look similarly at a sample of recent patients with comorbidities or complex needs (case tracking), review a sample of safety incidents, review board minutes.

Three particular areas we have identified for development are:

• Consistency: It is important that we have a consistent approach in both how we assess services and how we make judgements about quality. This includes selecting and training the right inspection staff and clinical experts, defining key lines of enquiry, and being clear ‘what good looks like’.
• Credibility: Senior expert representation on the inspection teams is vital. We were pleased to recruit and involve a large number of specialists and experts from the acute sector during Wave 1, and they brought a significant amount of credibility to the inspection teams. We recognise that we need to recruit more senior managers with ‘trust-wide’ roles (such as chief operating officers) and to access the right level of expertise in some specific areas, for example A&E. We also know we need to do more high quality training for teams.
• Improving our processes: We know that we have to improve the processes that we were testing in Wave 1. We need to do more to prepare for the main inspection – some areas of assessment are difficult to do in the short space of time available on site, for example looking at complaints handling, looking at clinical information flows, and assessing leadership. There are also issues about the logistics of organising the inspection and making the process sustainable for everyone involved.

Background to the inspections

• CQC selected 18 trusts for this programme using its Intelligent Monitoring system. They appeared to represent a range of risk. The system was created as part of CQC’s new approach to inspection (Link here).
• All trusts had an unannounced visit within one to two weeks of the initial inspection.
• Ratings will be determined for all eight core services at every trust. Each service will also be given a rating on each of the five questions, each hospital will receive an overall rating and each trust will receive an overall rating.
• The five questions that underpin CQC’s methodology are about whether services are safe, effective, caring, responsive and well-led.

* CQC has issued a Warning Notice to the Heart of England NHS Foundation Trust’s Good Hope Hospital, in relation to its A&E services. An unannounced follow-up inspection took place on 26 February and these findings will be published shortly. 

Ends

For media enquiries, call the CQC press office on 020 7448 9401 during office hours or out of hours on 07917 232 143.

For general enquiries, call 03000 61 61 61.