Listening, learning, responding to concerns

In this section there are organisation-wide findings and findings that cut across the workstreams. These findings came to light during the design and early stages of this review or became evident from the work of the workstream areas and the review's strategic oversight.

What we found

Understanding race

There was clear evidence, during the scoping, design phase and throughout the review, of a widespread lack of competence and confidence within CQC in understanding, identifying and writing about race and racism.

Within the limitations of this review both in time and scope, neither direct nor indirect race discrimination was able to be identified in phase 1 or phase 2 of the review as described in the Equality Act. There was however evidence identified that could correlate to systemic patterns affecting ethnic minority people, which does need further examination to be addressed. There is also a linked lack of understanding about the requirements placed on CQC under the public sector equality duty, and a need to have a wider understanding of the Equality Act 2010 and its requirements. These are issues that, from recent public events, appear to be prevalent across the public sector and health and care.

It is important because CQC, as the health and care regulator, has a regulatory Memorandum of Understanding (MoU) with the Equality and Human Rights Commission (EHRC) which, at the start of the review, was not widely understood across CQC including at senior levels. Neither was it addressed or governed appropriately and, with the lack of competence and confidence observed, urgent consideration needs to be made with regard to how the MOU delivery is assured. It is recognised that, as a result of the review, work with the EHRC has already started to address some of the shortfalls in process.

Policy, processes and practice

Within its limitations and focus, it became evident during the early stages of the review across the 5 workstreams that CQC's policies, process and practices have evolved and been added to over time in a somewhat transactional nature.

This has caused quality problems and, at times, undermines the purpose of the policy or process. A number of the processes identified didn't have robust governance or oversight, with some having no clear ownership. These issues are often found in organisations that have gone through a number of transactional iterations in policy and practice.

Confidence in taking action

During the research for this review, a number of staff highlighted that previous reviews had been undertaken, yet they were not clear what had changed as a result. Examples started from a 2013 report into Bullying and harassment in CQC through to more recent examples, such as a 2019 report by Roger Kline into Inequality in recruitment outcomes and the CQC Board Effectiveness Report 2021.

This review found that recommendations from these reports did inform a range of appropriate actions, such as Kline's report significantly informing the Equality and Diversity strategy and actions within the Workforce Race Equality Standard plan. However, staff expressed that they wanted more transparency about who is doing what and by when in response to these reviews and reports; also, to see that there are some active measures to confirm that the desired outcomes have been delivered successfully.

As well as giving confidence to staff, ongoing evaluation of this Listening, learning, responding to concerns review will be critical to ensure desired outcomes are achieved. For instance, themes on 'inclusive culture' and 'empowerment' from both 2013 and 2018 reports were still found to be evident from this review, such as:

• a fear of repercussions (Bullying and harassment, p.9; Kline, p.40)
• latent potential of staff being untapped, and opportunity missed in motivating and enthusing people working towards common objectives (Bullying and harassment, p.20-21; Kline, p.45)
• not only relying on compliance with processes and policies to encourage and embed inclusive behaviours (Bullying and harassment, p.31; Kline, p.6)
• considerations for when reorganisations take place, including opportunities needed for staff to 'grieve' for the old organisation, and ensuring sufficient attention is given to whether outcomes might disproportionately impact on certain groups of staff (Bullying and harassment, p.19; Kline, p.23)
• an opportunity to shift from formal command and control structures toward one that builds connections and motivates teams through a shared common purpose (Bullying and harassment, p.32)
• a need to set 'targets that are ambitious yet realistic' and where progress is monitored 'every six months, with detailed analytics' (Kline, p.34)
• for cultural change to be achieved, there needing to be 'multiple strategies at organisational, workplace, interpersonal, and intrapersonal levels used simultaneously over a long period' (Kline, p.8).

Similarly, discussions with CQC senior staff suggested the following matters raised within the Board Effectiveness Report 2021 were at least relevant to their experiences of Executive Team Design Authority (ETDA) meetings in relation to the transformation programme where there is cross-over of membership:

• "There is scope to focus the Board a little more actively on its role in risk management." (CQC Board Effectiveness Report 2021, p.8)
• "The majority of the Board's time and focus was directed at receiving information… there was a proportionately low volume of Board contribution during the meeting." (CQC Board Effectiveness Report 2021, p.10)
• "It is important for the Board to have a clear view about what kind of metrics and KPIs offer assurance around CQC's people and culture, particularly against the background of big organisational changes." (CQC Board Effectiveness Report 2021, p.15)
• There was a tendency for the Board to "focus on process rather than outcomes. The Board should determine a set of clear and meaningful KPIs (focused around budget, timescales, benefits and risks) to be used as a basis for Board reporting in future." (CQC Board Effectiveness Report 2021, p.23)

CQC's evaluation approach within this particular review gives some confidence that there will be more robust governance around monitoring recommendations. However, the implementation of this, and how this is then communicated to staff, will be critical to win back some of their confidence.

Recommendations for action

• CQC should review and improve the provision, delivery and governance of the public sector equality duty in its strategic and operational activities.
• CQC should look to commission an external specialist to guide and oversee a development programme to ensure that across operations, inspection report writing gateways and governance of the supporting processes there is a programme of enhanced training, skills and knowledge in issues of race, racism and wider protected characteristic discrimination as described within the Equality Act 2010. This should be delivered to the Board and the senior leadership team as priority.
• CQC should examine evidence based and academically sound anti-racism training for all its staff (in addition to the specific training above) involving the staff Race Equality Network.
• The MoU with the Equality and Human Rights Commission should have an executive sponsor, and reporting of issues should feature at Board at a frequency deemed necessary by the outcomes of inspections and assessments.
• A programme of 'lean' methodology should be used to map all processes, policies and practice that fell within the remit of this review. This should look to reduce the steps, therefore reducing the opportunities for error in delivery, while improving and clarifying the governance.
• CQC should ensure that clear evaluation criteria are drawn up against each Listening, learning, responding to concerns review recommendation. These should be reviewed and tracked at pre-agreed intervals, which should then be shared with staff.

Evaluation

These organisational recommendations will be evaluated to identify and understand the outcomes and impact of CQC's response to this report – see the section on Evaluation.