Recommendation 26

Direct action over policies

In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake in-depth investigations where these appear to be required.

In A new start – Consultation on changes to the way CQC regulates, inspects and monitors care, the Care Quality Commission consulted on new approaches to inspection which fully reflect this recommendation.  On 17 October 2013, it published the responses to the consultation in A new start: Responses to our consultation on changes to the way CQC regulates, inspects and monitors care services, which showed that there is broad agreement with the new approach.  It has appointed a Chief Inspector of Hospitals to take the new approaches forward, starting in acute hospitals, but also alongside new Chief Inspectors of General Practice and Adult Social Care, who will extend and develop the approaches for their respective sectors over time. The Deputy Chief Inspector of Mental Health will report to the Chief Inspector of Hospitals on how this applies to mental health services.

The first of new hospitals inspections have already begun, and the Care Quality Commission is reviewing its approach to carrying out investigations in light of its new inspection methodology, the single failure regime and the learning from its report of its own regulatory process at University Hospital of Morecambe Bay.

Through the use of larger inspection teams and longer inspection visits, Care Quality Commission inspections now include more observation of care and contact with patients and staff. The use of specialist inspectors means a stronger focus on practice and case note review. A key part of the new inspection is to hold ‘listening events’ prior to each inspection to inform the focus of the inspection. The overall focus on quality, rather than regulations, means far less emphasis on checking policies and procedures.

The Care Quality Commission’s large, specialist inspection teams, and their focus on the delivery and experience of services rather than only on compliance with regulations, means that the new inspections are able to include in-depth investigation of individual providers.

The Care Quality Commission also has a specific power of investigation which can cover providers, services across providers, and commissioners. The Care Quality Commission is reviewing its approach to using this power.


Under the leadership of the Chief Inspectors, the Care Quality Commission has put in place specialist inspection teams that subject providers to greater scrutiny. Inspections now routinely involve expert inspectors and people with experience of receiving care.

The Care Quality Commission inspection teams will hold a public listening event before the start of their site visit or on the evening of the first day. The Care Quality Commission may plan additional listening events depending on the size, geographical spread and demographic profile of the trust. These events are intended for members of the public, so the trust’s management and press are discouraged from attending. The listening events are promoted through appropriate public communications channels, for example, local community group newsletters and local media.

The inspection team will also interview directors of the trust and staff at all levels, at a minimum interviewing the chair, chief executive, medical director, director of nursing, chief operating officer, director of finance, non-executive director responsible for quality/safety, board director responsible for end-of-life care, service leads for the core services and the complaints lead. The inspection team will also hold focus groups and individual interviews including junior doctors, registered nurses and midwives, consultants and other medical staff, student nurses and healthcare assistants, administration and support staff and foundation trust council of governors.

The Care Quality Commission recruits, trains and supports people who use services- known as ‘Experts by Experience’- to accompany its inspection staff on inspections of health and social care services and its visits to monitor the use of the Mental Health Act.

Experts by Experience also attend listening events, consultations and staff training events and take part in activities to develop the Care Quality Commission’s strategy and processes. The Care Quality Commission currently works with around 500 Experts by Experience covering a wide variety of backgrounds.

During inspections, Experts by Experience spend time talking to people who use the service and observing the environment. They have first-hand experience of receiving care so they know which questions to ask to get as much information from the visit as possible. Their findings are used to support the inspector’s judgment on the service and can also be included in the inspection report.