What CQC inspections tell us about hospitals

In October 2015 we published our latest annual report ‘The State of Health Care and Adult Social Care’ which set out our findings on the performance of the services we regulate.

Despite the very real challenges facing acute hospitals and the complexities of how they deliver services, we have seen how outstanding innovation is improving patient care. We have been pleased to give outstanding ratings to two trusts: Salford Royal NHS Foundation Trust and Frimley Park NHS Foundation Trust. However, we uncovered some very poor care and as a result recommended that a number of NHS trusts be placed into special measures in 2014/15 to ensure they improve.

Our robust inspection model is allowing us to build up the strongest ever picture of the quality of services in acute settings. Last year we reported that there was too much variation in the standards of care between trusts. This year, our further inspections have confirmed this. The overall ratings in the sector show a lower proportion of good and outstanding ratings, compared with primary medical services and adult social care. However, the combined ratings at trust level mask the substantial variation among individual hospitals, and similarly for the variation of individual core services within a single hospital.

In each acute hospital inspection we look at eight of these core services (where they are provided) and combine them to give each separate hospital a rating. The hospital ratings are in turn collated to give an overall trust rating. A trust can therefore include many services that are good (or outstanding) but overall be rated, for example, requires improvement because there are enough services with lower ratings to affect the overall rating.

We find significant variation within trusts – for example, we may find good children’s services in trusts that are otherwise rated inadequate. Because of this variation in the quality of care across their services, many trusts do not achieve an overall rating of good or outstanding.

Nationally, critical care offers the highest quality (68% were good or outstanding), while the strongest need for improvement is in medical care (34% were rated good or outstanding). Urgent and emergency care has the joint highest proportion of outstanding ratings (4%) but also the second highest proportion of inadequate ratings (9%).  We have found that the quality of medical care and surgery are the strongest indicator of the quality of the hospital overall, with these services most closely aligned to the hospital rating. For surgery, one unit was rated as outstanding, 43 good, 50 required improvement, and six were rated as inadequate.

Where trusts are rated outstanding, the recurring factor is a culture of openness built around embedded values along with strong leadership and teamwork at all levels of the organisation and engagement with staff in identifying and implementing improvements. Whereas in trusts that are rated inadequate we have consistently seen failures to carry out basic safety checks and effectively learn from errors. Low staffing numbers and poor skill mix, which affect the trust’s ability to deliver safe care and a culture where frontline staff are unable or unwilling to raise concerns about patient care. In contrast to outstanding trusts, we see day-to-day crisis management rather than long-term planning and poor leadership and teamwork.

• To ensure we learn from our findings, and that we are providing the best care we possibly can we have a number of challenges for the hospital sector:
• Move your focus from developing individual, short-term quality initiatives to creating the right culture in which staff are able work with autonomy and confidence.
• Adopt strong values and embed them into your decision making processes. Focus on creating a culture of openness where staff feel empowered to raise issues and make suggestions for improvement, knowing they will be valued.
• Patients must be able to complain with the confidence that they will be listened to, and you should actively reassure patients that raising a complaint will not negatively impact on the standard of care they receive. Ÿ
• Use the findings from your staff surveys to improve morale and encourage continuous two-way communication.

We’ve radically changed the way we regulate over the last three years – these changes are driving improvement in the quality and safety of care, highlighting good and outstanding care and protecting people from poor care.

Now we need to further develop our approach, adapting to changes in the way health and care services will be provided in the future, while improving our efficiency and effectiveness. To do this we are holding a consultation into our strategy, which is open until 14 March. CQC will formally respond to the feedback provided when it publishes its strategy in May this year. You can find more information about the consultation by reading Shaping the future which can be found here.

Professor Sir Mike Richards became Chief Inspector of Hospitals in July 2013.