Published: 24 January 2023
Purpose of the review
The Care Quality Commission's (CQC's) Listening, learning, responding to concerns review is an independent review to identify improvements to how we learn from, respond to, and act on concerns. During autumn 2022, CQC witnessed a number of challenges that raised material concerns in these areas. It was critical that this review and its governance had a high level of independence and credibility to support confidence in its process and outcomes and critically the evaluation that will need to follow the publication of the review and delivery of the associated recommendations.
The review will look to discover the root causes or drivers for challenges and within the limitations of the review look to qualify and quantify findings, that will enable appropriate and impactful recommendations to be developed. Each recommendation will have thorough consideration on how they are best evaluated in providing assurance to the public and the CQC board on the delivery of the recommendations.
This review takes place in two phases. Zoё Leventhal KC of Matrix Chambers will lead the first phase – an independent review into our handling of protected disclosures shared by Mr Shyam Kumar, including whether ethnicity played any part in the management of those disclosures. There are five workstreams of phase 2 of the review which will:
- review how well we listen to whistleblowing concerns. This will include conversations with people who have whistleblown to us to understand their experience.
- further to the above workstream, we want to understand the perceptions of raising concerns with us among health and care staff and registered providers, as well as the expectations and experiences of people who use services and their representative groups when they raise concerns about care with us. This includes the timeliness and quality of our responses. We will explore how well our approach works to hearing concerns raised by people who use services. We will identify where we need to make improvements. We will review our current and proposed Freedom to Speak Up policy to ensure it is fit for purpose, reflects national guidance and aligns with best-in-class policies in the NHS.
- review and learn from the Mr Kumar's Tribunal case. This will include a case review to help identify improvements in our decision making, escalation processes, and how we work with others.
- look to understand how we engage with and listen to our colleagues through transformation and organisational design. We will look at our policies and procedures relating to secondments and our flexible workforce, and how we can be a leader in reasonable adjustments.
Running through the review will be a focus on inclusivity. This includes understanding whether race or any other protected characteristic has had any impact on how we treat information of concern.
We have set up a governance panel which is comprised of 50% independent members to oversee this work and help to ensure the independence and credibility of the review.
The expected outputs will include a root cause analysis of the issues, with a clear roadmap of suggested improvement and evaluation criteria.
Confidentiality
All documents and information created, obtained, discussed, reviewed or used by the Review Board should be considered as confidential and must not be shared or disclosed onwards without the permission of the Chair of the Review Board (see below).
This duty of confidentiality extends to the final report (prior to its publication by CQC) and to draft reports.
This duty does not apply to the extent that it would prevent any member of the Review Board from raising concerns in accordance with CQC's Freedom to Speak Up process or otherwise from making a protected disclosure under the Public Interest Disclosure Act 1998.
Purpose of the CQC Listening, learning, responding to concerns review board
The purpose of the CQC Listening, learning, responding to concerns review board (the Review Board) is to oversee and review the delivery of phase 1 of the review into the protected disclosures made to the CQC by Mr Kumar and the associated phase 2 workstreams, as well as making recommendations for phase 2. On completion of the review the Review Board will also provide the CQC Board with its recommendations on both the findings, recommendations and the evaluation criteria.
Governance
- The Review Board has been established to provide independent governance prior to CQC Board scrutiny, therefore will receive the phase 1 review ahead of the CQC Board. This Review Board will provide the CQC Board with reports on progress.
- CQC Associate Non-Executive Director Dr Ali Hasan will chair the Review Board and provide a direct connection to and oversight from the CQC Board.
- The review lead, Scott Durairaj, Director of Integrated Care, Inequalities and Improvement is responsible for the programme steering group and delivery of all workstreams to time and budget.
- Kate Terroni, Director of Adult Social Care, Integrated Care and Interim Chief Operating Officer is the executive lead and retains ultimate accountability for the successful delivery of the review.
- There will be three independent members covering human resources and organisational development, legal, and a specialist for race and human rights. These members have been recruited to provide expert input to the review on specialist and cross-cutting issues.
Membership and frequency
The Review Board will meet monthly until the publication of the review at the CQC public Board. The membership of the Review Board is as follows:
Chair
- Dr Ali Hasan, CQC, Associate Non-Executive Director
Programme support officer
- Jade Wright
Members
- Kate Terroni, Chief Inspector Adult Social Care, Integrated Care and Interim Chief Operating Officer
- Scott Durairaj, Director of Integrated Care, Inequalities and Improvement
- Professor Joy Warmington, Racism Specialist
- Arpita Dutt, Independent Legal Representative
- Anne Robson, Independent HR Representative
Support arrangements
Secretariat support is provided by the programme support officer. Papers will be provided to Board members in enough time for members to be able to read/digest prior to the meeting. Late papers will only be deferred to the next available meeting with express permission from the Chair.
Roles and responsibilities
- Oversee and provide assurance against phase 2 workstream plans:
- Whistleblowing
- Freedom to Speak Up
- Legal Case Handling Review
- Management of Change, Data and Insight and Learning
- Raising concerns about care with CQC
- Ensure that key input and decision making is provided to maintain public confidence and credibility and to report progress, concerns or risks to the CQC Board to ensure it is informed of delivery against plan
- Agree and source necessary resource to ensure successful delivery
- Agree any internal or external engagement and/or communications relating to the final report
- Agree draft report of findings by end of February 2023
- Ensure the CQC Board receives the final report, implement and track progress as the review moves to recommendation delivery
- Agree final report and proposed implementation by 31 March 2023.
In attendance
- Meetings will be chaired by Dr Ali Hasan, Associate Non-Executive Director. Kate Terroni will act as Chair of the Review Board in the absence of Dr Hasan.
- Other officers may be invited to attend for discussion of items relevant to their responsibilities.
Virtual sign off
- Recognising both the pace and priority of the review decisions will be able to be signed off via correspondence if enough detail is provided in a paper. If a member feels it would be better to discuss at the Review Board before signing off, then the paper will need to go to the next meeting
- Virtual endorsement via correspondence will be done in the Teams channel usually within five working days (recognising the meetings are monthly) on occasions where sign off is required before the next Review Board.
Evaluation
The review's objectives will be measured and evaluated drawing on evidence from the following:
- People Staff Survey Results
- Annual Provider Survey
- Staff Equality Networks
- Public Awareness Survey
- Freedom to speak up analysis
- Trade Union engagement.