1. Leadership and Regulation Paul Burdon, CQC
Informing the RPM

2. England’s population is 53m
Scope of CQC’s remit
Hospitals and clinics
245 NHS trusts
1,500 independents
Ambulances
10 NHS trusts
250 independents
Care homes and domiciliary care
12,500 providers
25,500 care homes
1.75 million people use adult social care
11 million NHS and 1.6 million independent inpatients
22 million dental patients per year (15m NHS, 7m private)
Primary medical services
9,000 providers
Primary dental care
8,000 providers
England’s population is 53m

3. Our 5 key questions

4. Well-led
By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality care, supports learning and innovation, and promotes an open and fair culture 4

5. Key Lines of Enquiry Are services well-led?
Is there the leadership capacity and capability to deliver high-quality,
sustainable care?
Is there a clear vision and credible strategy to deliver
high-quality sustainable care to people, and robust plans to deliver?
Is there a culture
of high-quality,
Are services
well-led?
Are there clear responsibilities, roles and systems of accountability to support good governance and management?
Is appropriate and accurate information being effectively processed, challenged and acted on?
Are there clear and
effective processes for managing risks, issues and performance?
Are the people who use
services, the public, staff and external partners engaged and involved to ensure high-quality sustainable services?
Are there robust systems and processes for learning, continuous improvement
and innovation?

6. Outstanding characteristics
Good and effective leadership extends beyond the manager and those values are cascaded to inspire staff
Staff training and support
Open culture – people who use services/ staff/ relatives shared views and issues
Strong links with local community
Effective oversight of staff
Staff communication

7. Inadequate characteristics
Weak leadership
A lack of vision for the organisation and clarity around individuals’ roles and responsibilities
A poor culture of safety and learning ie. lack of learning from complaints/events analysis
Lack of supervision and training opportunities
Regular management changes
Closed culture – views not listened to or acted on

8. State of Care 2015/16 - findings
Improvements in the quality of care
Good leadership is an important part of improvement
Re-inspected after being rated as
23%
improved to
Re-inspected after being rated as
53%
While this shows that regulation can support providers to offer people better care, CQC’s analysis also reveals that some services are failing to improve despite being given clear information on where improvement is needed.
47% of providers that were re-inspected following a rating of ‘requires improvement’ were not able to improve their rating. Most worryingly, in 8% of cases, the quality of care had deteriorated so much that the rating was downgraded to ‘inadequate’.
improved to
Source: CQC – State of Care 2015/16 (figure 1.15) Note: Re-inspections of all services first rated inadequate

9. Driving improvement
We spoke to leaders, staff, patients and local representative groups at 8 hospital trusts that have shown significant improvement to look at the steps that leaders had taken and the effects these actions had on staff and patients. From this work we identified a number of key leadership themes.
The NHS needs more money and part of that is going to be needed for staff pay, but despite the pay restraint that we have seen over the last few years, improvements have been seen within trusts – Mike Richards
None of the trusts mentioned capital injection as a reason for their improvement. 9

10. Reaction to initial inspection report
Trusts were able to make rapid improvements when leaders viewed our inspection report as an opportunity to drive change.
‘Initially I felt demoralised…but when you step aside and look overall, you can accept that what the report was saying was fair’ (Hospital Consultant)
We saw that trusts were able to make rapid improvements when leaders viewed our inspection report as an opportunity to drive change. Trusts that had recognised issues in their organisation were able to have open and honest conversations with staff and patients on how they could make improvements, and then take action to put these in place. Leadership teams who were in denial about problems made little or no progress in improving their organisation.
We found that when trusts went into special measures or received a rating of requires improvement, some staff were unaware of the extent of the issues. They hadn’t realised that things in the trust were not as they should be. Or, they were so focused on their own service that they could not see the bigger picture of care across the trust.
But this was not a common view. In most of the trusts we visited, staff knew things weren’t right and were taking steps to make improvements. Those driving improvement felt supported when leaders accepted the need for change. 10

11. Visible leadership
Leaders knew they had to be visible and approachable in order for staff to feel supported.
‘Calm people down, listen to them and go to see them physically – both patients and staff’ (Chief Executive)
Leaders need to lead and be seen to lead. Our improving trusts placed emphasis on the visibility of leaders: chief executives and senior staff spending time on the ‘shop floor’ meeting staff and setting up regular challenges of communication.
For example, in one trust all matrons and lead nurses work on the wards every Tuesday bridging the gap between the management and the ward staff. 11

12. Cultural change
Trusts knew that it was not enough to create an improvement plan – they had to engage and motivate their staff to help drive it and move from a culture of blame to one that celebrates success.
‘ Improvement starts and ends with staff engagement. Getting staff to understand that they had the answers and the means to improve was critical.’ (Chief Executive)
Trusts knew that it was not enough to create an improvement plan – they had to get the staff engaged and motivated to help drive it. Moving from a culture of blame to one that celebrates success is another key theme of trusts.
‘Cultural change can move really quickly, it doesn’t have to take decades’ – Mike Richards – however quick change depends on listening to staff.
Some trusts changed the leadership team to help drive improvement. For others, it was about empowering existing staff to take leading roles in effecting organisational change. Trusts that unleashed the potential of their staff now see improved patient outcomes and higher staff morale.
The study found a correlating improvement in the staff survey with 5 out of the 8 trusts reporting a 9-11 per cent improvement in the number of staff that would recommend the hospital to thir family and friends. 12

13. Vision and values
Leaders placed an emphasis on getting to know how staff felt about working at the trust and understood that staff needed to have ownership of the values if they were to be meaningful.
‘The values are the blueprint for how we want to work together, and are a massively unifying element that helps to reinforce what we are trying to achieve.’ (Head of Communications)
Leaders worked with staff to produce a set of shared values that would underpin positive cultural change. The trusts understood that staff needed to have ownership of the values if they were to be meaningful. Leeds used technology to ‘crowdsource’ staff views on how to make the trust a great place to work. 13

14. Governance
Addressing problems with governance was a priority for most of the trusts. The right connections needed to be in place from board to ward.
‘The processes and systems had been broken for some time. So the financial systems and systems for setting budgets had been broken, the governance systems for managing the board, and clinical governance…There was no consistent oversight of the organisation.’
Good governance meant looking at how the board worked and putting new systems in place throughout organisations. 14

15. Patient and public involvement
Taking the views and experiences of patients and the public into account is vital to making improvements
‘The patient council has a genuine influence on the trust. We’re not governors; we’ve got no legal powers. But we are like the trust’s conscience.’
A fundamental part of the improvement journey has been listening to staff and patients, including through listening events and the ongoing work of the Patient Council. At Wexham Park, focus groups help to address cultural sensitivities and Mid Essex emphasised that a fundamental part of its improvement journey has been listening to staff and patients. 15

16. Looking outwards
Trusts pointed to the power of being open with staff and the public
‘The temptation is to pull down the shutters, but actually the thing to do is keep up a dialogue.’ (Chief Executive)
An outward looking approach is another aspect that’s enabled improvement. We heard how trusts reached out to their communities and encouraged staff to use social media to share stories and interact with patients and the public. They also involve patients and the public in the work of the trust, shaping services and providing feedback 16