Listening, learning, responding to concerns

Published: 29 March 2023 Page last updated: 20 September 2023

Summary of findings and improvement actions

The concerns that health and care workers and the public share with CQC about health and care services are critical to its work. It is also vital that CQC listens to its own staff.

This review seeks to explore whether there are areas of culture or process within CQC that need to be improved in relation to listening, learning, and responding to concerns. The review focused on these key areas:

The review has a set of aims, which show the intended outcomes and impact that should result from CQC's response to this report. The aims have been mapped to multiple recommendations, so are not necessarily presented in order throughout the report.

These aims are:

The public, workers of services registered with CQC, and other stakeholders trust CQC to listen to and act on their feedback and concerns in an inclusive manner.
CQC has a culture, supported by effective policies, processes and practices, to listen to, act on, or respond to concerns raised by colleagues, including advisory and complementary staff, about CQC. This means staff feel safe to speak up and that speaking up is invited, welcomed, celebrated, listened to, and responded to well.
CQC has a culture in place, supported by effective policies, processes and practices, to listen to, act on, or respond to information of concerns about care from workers of services and others. It does this in a way that is free from institutional or interpersonal discrimination.
CQC works well with partners and providers when concerns about care are raised.
CQC's culture, processes including governance, decision-making and outcomes comply with, and look to lead best practice regarding, the Equalities Act 2010, ensuring:
- there is a clear understanding of best practice, where discrimination is identified, addressed and, wherever possible, prevented using anticipatory measures
- the handling of concerns about CQC raised by colleagues, including advisory and complementary staff, are free from institutional or interpersonal discrimination
- CQC makes reasonable adjustments for CQC colleagues and CQC applicants in a timely manner and in line with best practice.
Relevant CQC colleagues feel confident, skilled, empowered and supported to handle whistleblowing and information of concerns about care.
Relevant CQC colleagues feel confident, skilled, empowered and supported to respond to concerns raised by other staff, including advisory and complementary staff, about CQC.
CQC has a culture, underpinned by best practice policy, processes and practices, where staff, including advisory and complementary staff, feel empowered to make a meaningful and timely contribution during change to support improvement and transformation. This should include ensuring there is learning from, and an adequate response to, feedback from formal consultation and informal engagement.
CQC's appointment, contracting, engagement, deployment and disengagement processes relating to advisory and complementary staff are non-discriminatory, consistent with the values of CQC and ensure employment rights are maintained.
Relevant CQC colleagues feel confident, skilled and empowered to deal with employment litigation, including working with internal and external lawyers.

Organisational findings

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.

This 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.

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.

1: Reviewing how well we listen to whistleblowing concerns

As a result of this review, we have developed aims to improve how we listen and respond to workers raising concerns, which will lead to improvements in the safety and quality of care for people using regulated services. They will also support how we evaluate the delivery of the improvements to help build confidence that they can be achieved.

Aim 3: CQC has a culture in place, supported by effective policies, processes and practices, to listen to, act on, or respond to information of concerns about care from workers of services and others. It does this in a way that is free from institutional or interpersonal discrimination.

Findings:

Our review found that:

The way 'whistleblowing' is defined (see appendix A) and understood within CQC has become overly complex and there is not a common and shared understanding across our staff. In this report we will use the term 'speaking up' to describe concerns raised by workers, with 'whistleblowing' referring to when workers have shared information that meets the definition of a 'qualified disclosure'.
Most information is currently received and handled by the National Customer Service Centre (NCSC). Our process if information is received by another route is to send to NCSC to be processed. If information is not handled in this way, there is an increased risk of poor record keeping and insufficient evidence of the action we took.
We are not collecting data about workers' protected characteristics and whether we knew the identity of the worker.
Our initial action in response to concerns raised by workers is consistently taking place within 5 days. However, we do not have performance measures in place to provide assurance that the action has mitigated any presenting risk or to consider how well concerns were handled.
Our closed cultures work programme has increased staff awareness and provided improved intelligence and tools for our staff, but this is not fully embedded in our work.
Workers often tell us when they have experienced poor treatment or victimisation in response to their attempts to speak up to their employer. We do not always ask whether the worker has raised their concerns with the provider and, if so, what their experience has been.

We recommend that CQC should:

Promote a common understanding of definitions of workers speaking up and when this means they are 'whistleblowing' through a revised policy, updated systems, and associated training and guidance.
Gather equality demographics on workers speaking up and where possible on anonymous reporting to identify themes and trends; then take action to address them to improve how we support and protect workers.
Measure both the timeliness of how workers' concerns are responded to, and whether the action has mitigated the presenting risk; and implement an effective quality assurance governance system.
Develop systems so staff have contextual information and information from our closed cultures dashboard available in one place when they are handling information of concern.
Capture information and flag cases where workers have said they experienced victimisation. This should be made visible for inspectors to inform regulatory decision-making including follow up on inspection.

Aim 1: The public, workers of services registered with CQC, and other stakeholders trust CQC to listen to and act on their feedback and concerns in an inclusive manner.

Our review found that:

Our reporting of whistleblowing concerns, which is a requirement of our role as a prescribed body, has been limited, which means workers who speak up in services and the public have not had enough information about how we have been handling concerns raised with us by workers.
We do not gather information to understand enough about the barriers workers experience in raising concerns with us, or their confidence in us to respond well to their concerns.
Only a small number of workers who raised concerns with us made a complaint about CQC's response. The outcome of most complaints found that CQC acted appropriately. A common theme was a difference in understanding between the worker and CQC about how concerns should be handled, and that we have not contacted them to let them know what was happening with the information they had shared.
CQC staff reported that information reported anonymously often contained limited detail. This makes it more difficult to follow up those concerns effectively.

We recommend that CQC should:

Publish a standalone Annual Prescribed Persons Report from 2023/24 to clarify and raise confidence in CQC's response to whistleblowers and all workers who speak up to us.
Develop a system to gain feedback from workers when they have contacted us to raise concerns with an initial focus on recognising and overcoming the barriers experienced by ethnic minority workers.
Commission research and engage with external organisations with expertise in speaking up to understand workers' confidence in CQC to handle their concerns. Specific attention should be given to workers from ethnic minority groups; other marginalised groups; and the role held by the worker within the service. This must lead to action to address the findings.
Commission research to explore the implications of an increased level of workers speaking up from deprived areas.
Review guidance on our website, and web forms for workers speaking up to ensure they clearly communicate how CQC will handle and act on their information, including for anonymous reporting.

Aim 6: Relevant CQC colleagues feel confident, skilled and empowered to handle whistleblowing and information of concerns about care.

Our review found:

An unacceptable level of variation in our practice and some concerns had been handled poorly.
Evidence of positive intention from CQC staff, and examples of good practice.
Staff did not always feel they were able to act on the concerns raised by workers in the way they wanted to. For example, not carrying out an inspection in response to a concern because this was not in line with organisational priorities at the time; or because there are capacity issues in an area where there are higher risks.

We recommend that CQC should:

Revise guidance and training for staff to provide clear principles of how to:
- handle concerns raised by workers
- keep in touch effectively with those speaking up
- define what good practice looks like
- raise awareness of the issues faced by the ethnic minority workforce and other marginalised groups and understand why and how we need to modify our approaches.
Ensure high-risk cases are regularly discussed and recorded during inspectors' supervision with their manager through to closure.
Review available staff resources to make sure these are sufficient to enable both effective monitoring of services and responsive on-site inspections when there are early indications of deterioration in quality or of the emergence of a closed culture (shared recommendation with section 5).

Aim 4: CQC works well with partners and providers when concerns about care are raised.

Our review found that:

Effective partnership working with local authorities is important when responding to workers' concerns. We found we were not consistently following the progress of safeguarding investigations.

We recommend that CQC should:

Routinely follow up referrals proceeding to a safeguarding investigation, and the outcomes of any investigation undertaken.

2: Reviewing our Freedom to Speak Up policy

Our review found that:

The CQC Freedom to Speak Up Policy had not been updated to reflect the new national policy and guidance published by NHS England in 2022.
A revised policy prepared in 2022 and rejected by the Board in 2022 did not reflect the national guidance in significant ways.
There had been a lack of proactive support for the CQC Guardian, for example 2 of the 3 Guardians left and were not replaced and administrative support had been withdrawn. The remaining Guardian has continued to support people within the limitations of the available resource.
The non-executive lead for Freedom to Speak Up at CQC left the organisation in December and has not been replaced. We are currently exploring options to cover this role.
Our latest CQC staff survey, and feedback received from the engagement carried out for workstream 4 of this review (see section 4) show a lack of confidence in speaking up. The positive responses to the statement "I think it is safe to challenge the way things are done here" fell from 49% overall in 2021 to 29% overall in 2022.
There is therefore work to be done to ensure that everyone working at CQC, including specialist professional advisors, experts by experience, contractors and people seconded into CQC are aware of the arrangements and the support available.
While the national policy position deliberately uses the term 'speaking up' as opposed to 'whistleblowing', it is important that training and support is provided to ensure that a protected disclosure is recognised when it is made.
A new policy will be an important first step and further work will be needed to build a vibrant speak up culture. This should be seen as part of the wider work on culture at CQC.

Aim 2: CQC has a culture, supported by effective policies, processes and practices, to listen to, act on, or respond to concerns raised by colleagues, including advisory and complementary staff, about CQC. This means staff feel safe to speak up and that speaking up is invited, welcomed, celebrated, inclusively listened to, and responded to well.

We recommend that CQC should:

Adopt the proposed new Freedom to Speak Up policy (being presented separately).
Take immediate steps to implement the new policy, including:
- the appointment of an executive lead for Freedom to Speak Up
- the recruitment of additional guardians
- the allocation of additional resources, including ring-fenced time and administrative support.
Use the Freedom to Speak Up 'reflection and planning tool' to inform a further programme of development and improvement, reviewing our position against all 8 principles.
Explore and align the above development work with the wider work on culture.
Ensure that barriers to speaking up, including ethnicity and disability, are considered and addressed, taking account of relevant guidance, including the National Guardian Office publication, Inclusive Freedom to Speak Up.
Ensure a summary of the actions identified from the above exercise is captured and reported back to Board jointly by the executive lead and lead guardian.
Ensure effective standard operating procedures to support the policy are devised and implemented.
Implement a programme of regular review of the effectiveness of Speak Up arrangements using the Freedom to Speak Up Quality Statement and the joint National Guardian and NHS improvement tool.

3: Learning from the tribunal case

The independent review commissioned by us to examine specifically the handling of the Mr Kumar case found that:

There is the potential for multiple investigations in a whistleblowing scenario because other bodies have review/regulation functions, in addition to us. For example, in Mr Kumar's case there was a separate review by the Royal College of Surgeons into surgeries and clinical decisions where Mr Kumar raised concerns. This can lead to inconsistent conclusions.
There wasn't a clear management structure for the flexible workforce, nor was there a clear process for determining the allegations against Mr Kumar. The letter of disengagement sent to Mr Kumar did not detail the behaviour in question and was used by the Tribunal as a fact from which they could infer that the protected disclosures had a material influence on the detrimental treatment of Mr Kumar. The Tribunal did not make any finding of any behaviour of concern on the part of Mr Kumar.
Mr Kumar assisted with inspections within the region of his employer NHS trust but he did not inspect any hospital that he worked in, or was part of the trust that employed him, nor one which was in the same clinical pathway. It is foreseeable allegations and counter-allegations may be made where individuals are part of inspections in the local area in which they work.
It was not clear who in CQC was in charge of the early conciliation process, nor where the instructions to the Government Legal Department came from. The CQC response to Mr Kumar's employment claim at the outset appeared to be led by CQC's witness in the case but although witnesses will potentially be the point of contact for the facts of the case they should not be the point of contact for instructions on litigation strategy.
Opportunities were missed to assess the case merits at an early stage and there was a limited interpretation of Mr Kumar's pleaded case. There was a heavy reliance on the Government Legal Department.
CQC's focus appears to have been on the financial side of the settlement but Mr Kumar was clear he was seeking recognition by CQC of their actions and where they had fallen short of expected standards.

Aim 10: Relevant CQC colleagues feel confident, skilled and empowered to deal with employment litigation, including working with internal and external lawyers.

The independent review commissioned by us recommended that CQC:

Considers whether we need to enter into Memorandums of Understanding with other bodies that have review or regulation functions (for example, Royal Colleges) to ensure they are notified of any parallel investigations being undertaken by us.
Clearly identifies who in CQC has responsibility for managing our flexible workforce and ensure they understand our legal duties (with training provided), including the need for a fair process for managing allegations, the need to give clear and detailed reasons for decisions and the need to be clear and transparent when we have not acted as we should. Provide specialised training to our HR team on whistleblowing legislation.
Does not use specialist professional advisors in inspections within the local area where they work in their substantive post.
Clearly identifies who in CQC has responsibility for providing instructions to the Government Legal Department in employment litigation, including early conciliation – this should be someone sufficiently senior with the necessary skills and knowledge. It should not be a witness, nor should it be the HR professional who supported the matter before litigation.
Undertakes a full assessment of the pleaded case straightaway and take legal advice on the merits at an early stage in order to build a litigation strategy. Discovery of documents should take place as soon as a claim is made and factual evidence assessed accordingly. The case timeline should factor in time to obtain Treasury approval for any settlement and consideration should be given to the possibility of making admissions where appropriate.
Puts in place a programmed dialogue with the Government Legal Department to deepen its understanding of us and our priorities. When workplace disputes arise, recognise when mistakes have been made and take steps to rectify them as soon as possible.

We have looked at these internal review findings and recommendations and, in order to take them forward, we also recommend that we:

Widen CQC's 'conflicts policy' for specialist professional advisors so that it covers all services within their own integrated care system or in relation to clinical pathways which might cross multiple integrated care systems including their own.
Where an employment tribunal claim is lodged against CQC, set up a team in CQC to respond to the claim, including case preparation, litigation strategy and instructing external employment solicitors and counsel, as appropriate. The team should not include CQC witnesses. The Director of Governance and Legal Services and the Director of People should have oversight of the team and ultimate responsibility for CQC's handling of the claim.
Ensure that CQC's Executive Team is notified of any high-profile or complex employment tribunal claim that has been lodged against CQC.
Ensure that employment tribunal claims lodged against CQC are represented in CQC's Risk Register.

4: Reviewing how we listen to our staff

Managing organisational change

This review found that:

Overall, CQC did not follow its own best practice policies in respect of Management of Change (MOC) and the Trade Union Recognition and Facilities Agreement which could have prevented the breakdown in trust, confidence and communication which followed. This led to the collective grievance and a letter to the Secretary of State, with stories in the Health Service Journal.
MOC had most recently been reviewed in May 2021 just prior to this reorganisation process, so it was current. Failing to follow MOC resulted in failing to apply CQC values which are set out clearly at the beginning of the MOC.
It is important to recognise that there is a significant cultural understanding needed as to why these policies are important and ought not to be disregarded.
- clause 1.1 of the MOC policy states, "It is important that our approach to managing organisational change is consistent with our core values. The relevance of those values to managing organisational change is demonstrated in the following ways…Excellence, Integrity, Caring and Teamwork…"
- the policy also incorporates flexibility. Clause 3.2 of MOC states, "Structural change and staffing reorganisation exercises that might potentially involve redundancies and/or have a significant impact on employees (regardless of numbers) must be conducted in accordance with this procedure and the principles that underpin it. However, the procedure does allow for the necessary flexibility and management discretion to accommodate particular circumstances, including, but not limited to, localised and small-scale organisational change."
- MOC procedure fulfils best practice and legal requirements
The review has highlighted a need for CQC's Senior Leadership Team (SLT) and Executive Team (ET) to read the policies and understand why they exist. They aim to maintain strong relationships, they enshrine CQC's values, they build trust and better communication with the workforce and by using them they address legal requirements, thereby safeguarding CQC.
CQC had a good intention around not following the MOC Procedure, believing following it would increase staff anxiety by unnecessarily putting staff at risk of redundancy.
As of 31 January 2023 ongoing concerns from staff on the lack of detail and how proposed changes will be put into practise will be addressed by the new roles of 'Deputy Directors of Transition'.
Only 9% of staff surveyed in the September 2022 Pulse Survey believed CQC effectively implemented change; key concerns included a lack of staff involvement, not listening when concerns were raised, and changes being rushed through which was felt to be against CQC's values.
Some equality impact assessments (EIAs) were undertaken at key stages, but they did not consistently inform decision making. Some equality impacts also appeared to have not been adequately assessed or mitigated.
There is evidence that public sector equality duties were not fully understood by all critical parties involved in EIAs.
In the Grade B reorganisation, some staff felt compelled to state a preference for a role they may not have wanted due to a lack of information; however, over 95% of workers did get the preference they requested.

It is recommended that CQC:

Updates the MOC Procedure so there is a named Executive owner to receive a 'formal dispute', such as the Chief People Officer. However, if one or more Executive Directors have already been significantly involved, the dispute should be referred to a named non-executive director, such as the 'Senior Independent Director'.
Updates the MOC procedure to consider pausing future significant organisational change activity where there is a significant impact on employees and when unions raise a formal dispute and request that the 'status quo' be applied; this should only continue once the dispute is resolved. CQC should consider engaging a senior legal officer to provide guidance to Senior leaders in the case of significant reorganisations.
Improves the grievance resolution timeline in line with ACAS guidance on grievance procedures. This states that if there are 2 or more related grievances there is some flexibility in how to run the grievance procedure.

Aim 5: CQC's culture, processes including governance, decision-making and outcomes comply with, and look to lead best practice regarding, the Equalities Act 2010.

It is recommended that CQC:

Ensures equality impact assessments (EIAs) are conducted in a timely manner, include all protected characteristics and actively inform planning and decision-making during the change process, as well as after the changes have been implemented.
Undertakes EIAs for outstanding areas specifically in relation to all the Grade A changes including voluntary and compulsory redundancy.
Considers positive action regarding the needs of the 1 disabled worker who was not given their first preference in the Grade B reorganisation. Also review workforce equalities data utilised with EIA to identify any disparity of outcome by age.

Aim 8: CQC has a culture, underpinned by best practice policy, processes and practices, where staff, including advisory and complementary staff, feel empowered to make a meaningful and timely contribution during change to support improvement and transformation. This should include ensuring there is learning from, and an adequate response to, feedback from formal consultation and informal engagement.

It is recommended that CQC:

Applies the MOC process in full in all circumstances where significant organisational change "might potentially involve redundancies or have a significant impact on employees". If there is a desire or need to deviate, this should be mutually agreed with trade unions or staff directly involved (and staff forum if appropriate).
Offers formal 'trial periods' to staff who are taking up the newly created role of Assessor, and engage in co-design arrangements to be put in place for those who do not believe this is a suitable alternative employment.
Ensures that key decision makers, such as the Executive Management Team and People Directorate, understand collective consultation and redundancy legislation requirements in detail and with proficiency.
Ensures the Board is made aware and, via Board Briefings, is encouraging a focus on strategy, oversight and assurance on people-related issues, and considers having a non-executive director or independent member on the people committee for greater assurance.
Updates existing and future transformation programme governance, management and delivery plans.
Ensures the lead for transformation engagement is a full member of relevant programme groups where proposals and decisions are being made.
When managing organisational change, ensures change management best practice is followed and embedded.
Ensures that equality networks are involved as a key stakeholder in co-creation of engagement strategies.
Carries out actions to contribute to staff feeling that 'change is effectively implemented at CQC', when managing organisational change.
Improves staff experience on feedback. Indicate the time that Grade B Inspector and Assessor roles will work at and away from their contractual base and share this with staff. CQC should then enable staff to change their preference if they decide.

Reasonable adjustments

This review found that:

CQC's general approach to reasonable adjustments was founded on strong strategic aims, governed by policies and processes that advocated good practice, and were currently subject to quality improvement projects.

However:

these processes were not consistently applied
the overall approach was unstructured and did not always meet the needs of staff
the level of ambition to improve reasonable adjustments did not match the time and resources available.
there were a number of common criticisms from staff.

Aim 5: CQC's culture, processes including governance, decision-making and outcomes comply with, and look to lead best practice regarding, the Equalities Act 2010.

It is recommended that CQC:

Updates the Reasonable Adjustments Policy to incorporate comments from the Disability Equality Network group.
Modernises the Flexible Working, and Critical Illness Policy and Procedures to recognise reasonable adjustments and make the tone more supportive. Approve them through groups, including staff networks.
Revises the Workforce Disability Equality Standard 2022/23 action plan relating to 'reasonable adjustments'.
Improves the process for agreeing reasonable adjustment requests, looking for alternatives if the request is impractical, unaffordable, or could cause harm.
Ensures that the proposed means for tracking reasonable adjustments across CQC (as per the Workforce Disability Equality Standard Action Plan) is accessible to managers, who are enabled to access and review the adjustments for any new team members they are responsible for. The Disability Equality Network should support and inform what 'good' looks like from their perspective.
As part of the onboarding and welcome process before all new staff start, including those on flexible contracts, any specific reasonable adjustments should be discussed and agreed to be shared with the line manager. However, CQC should also allow any disability to be kept confidential. All new staff should be referred to the Reasonable Adjustments policy and tailored adjustment agreement approach during induction – both new starters and new managers, so they understand what is available to them, and what they are required to do if relevant.
Reviews and reduces the timeframe agreed, in partnership with the Disability Equality staff network, from when reasonable adjustments are requested to the supportive involvement of occupational health and the adjustments being delivered. There should be a centrally held record of all reasonable adjustments and requests to enable monitoring and tracking to deliver more rapidly, and to ensure, in organisational change, adjustments can be anticipated.
Offers support and advice from occupational health when it is not known what adjustments may be helpful, or there is a concern on practicality, affordability or if it could harm the health and safety of others. 'Interim adjustments' should be agreed while this advice is being sought on the original request.
Asks questions about a need for reasonable adjustments sensitively, understanding that it may have been difficult for the person to broach the subject. Although staff members only need to share information they are comfortable providing, they should understand CQC only needs to make a decision based on the information it is given.
Agrees and delivers a minimum standard that ensures reasonable adjustment skills, knowledge and responsibility is delivered to all those with line management responsibility.

Contracting advisory and complementary staff

This review found that:

Before September 2022, there were no comprehensive policies or processes in place governing the appointment, contracting, deployment and disengagement of advisory and complementary staff.
Since this time, a wide range of improvements have taken place, such as drafting an advisory and complementary workforce strategy and guidance, and establishing a working group to support these staff. However, there are some missing elements to the strategy and unclear governance and resources.
Outside the more recent guidance, there was concern that current approaches were not aligned with CQC values and did not appropriately safeguard employment rights.
When considering equalities workforce data for this group of staff:
- there were high rates of 'Not Declared' against all other protected characteristics, so no significant conclusions could be drawn
- the contract documentation for these staff appeared clear and in line with legal requirements, with the possible exception of annual leave entitlements.

Aim 5: CQC's culture, processes including governance, decision-making and outcomes comply with, and look to lead best practice regarding, the Equalities Act 2010.

It is recommended that CQC:

Comprehensively reviews equalities workforce data for advisory and complementary staff by:
- investigating drivers for high 'Not Declared' statuses and reducing levels of non-disclosure to below 5%
- actively monitoring equalities data to inform planning and decision making to ensure no disadvantage occurs.

Aim 7: Relevant CQC colleagues feel confident, skilled, empowered and supported to respond to concerns raised by other staff, including advisory and complementary staff, about CQC.

Aim 9: CQC's appointment, contracting, engagement, deployment and disengagement processes relating to advisory and complementary staff (non-substantive) are non-discriminatory, consistent with the values of CQC and ensure employment rights are maintained.

It is recommended that CQC:

Updates the advisory and complementary workforce strategy.
Ensures a 'handbook' or similar suite of policies or processes are created to cover all advisory and complementary staff.
Ensures that contracts being offered to staff (including extensions) are in line with each business need. They should not be tailored to avoid milestones that accrue key employment rights.
Ensures measures are taken to recognise the skills, knowledge and organisational benefit of the advisory and complementary workforce in line with CQC's values, rather than simply a resource. This should include gathering insight into the experience of advisory and complementary staff (such as through a survey) to ensure they feel valued or to inform actions.
Reviews and audits all staff members' appropriate entitlements, including leave and contracts, to ensure they are compliant.

5: Reviewing the expectations and experiences of people who raise concerns about care with us

Expectations of people who use services and workers when they raise concerns about care with us

Our review found that:

CQC is not generally meeting the expectations of the public or people who work in care services when they raise concerns with us. We do not meet expectations in terms of the follow-up service people receive and the action taken as a result. This demonstrably affects public confidence in CQC.
CQC's role in handling concerns raised by members of the public is inherently confusing. CQC invites feedback from the public about their experiences of care, but is not able to resolve their concerns or investigate their complaints. This is because we do not have the powers to do so, except for complaints made under the Mental Health Act.
The public understands our role once it is clarified with them. However, when someone shares a concern with CQC, they can be frustrated that we can't resolve it. This can undermine their trust and motivation for sharing feedback with us. People from ethnic minority groups and disabled people, who are more likely to have a poorer experience of care and face discrimination, highlighted the impact of this frustration and undermining of trust with us.
Some people from ethnic minority groups and some disabled people who use services told us they felt they were unlikely to trust CQC with their concerns because they had no knowledge of CQC or our role. Health and care workers who had less knowledge about CQC said they were unsure about whether they could trust CQC with their concerns.

When the public and health and care workers raise concerns with CQC, they see this as a serious matter. It can also often be a last resort following a lack of response with the provider or other parts of the health and care system. They are often distressed by their experiences, and may fear reprisals by the service, such as being evicted.

Members of the public with disabilities were concerned about whether CQC would understand that people with protected characteristics are disproportionately affected by discrimination.
Health and social care workers from ethnic minority groups had low expectations of CQC responding to concerns about discrimination. Our research did not provide evidence about what drives these low expectations, including whether or not they are specific to CQC, but research in Workforce Race Equality Standards reports states that more people from Black and minority ethnic backgrounds have personally experienced discrimination compared to their White colleagues.

People's experiences of raising concerns about care with us

CQC's channels for providing feedback are easy to find and easy to use and generally meet the public's and health and care workers' expectations. Some improvements could be made for people who are fearful or traumatised, whose first language is not English, who face communication barriers due to disability or sensory impairment, who have low literacy skills or who are digitally excluded.
Most people who contacted us by phone had a positive experience of the way the call was handled. They felt listened to, with only a small number not feeling heard. People generally described our call handlers as 'sympathetic' and 'concerned' about their experiences, especially since they were often distressed or angry. Overall satisfaction with the service provided by telephone is 4.6 out of 5 (from a total of 19,954 responses).
However, overall people who took part in our research generally did not have a good experience of raising concerns about care with us. This was driven by people expecting that CQC would investigate and resolve their concern and that CQC would provide clear and frequent communication once people had raised their concern.
While anyone raising a concern receives a generic response from CQC, further follow-up is at the discretion of the inspector and is therefore inconsistent. People who do have their concerns followed-up and are contacted have a better experience.
The lack of follow-up provided to people who raise a concern with CQC means that they could not necessarily know whether or not they had been discriminated against. A small number of the public who had raised a concern with CQC felt the lack of follow-up from CQC was due to racial or other discrimination. However, most participants felt that there was no discrimination or unfairness in the way they were treated.

What does the information we collect tell us about how we listen and respond to concerns?

CQC does not collect demographic or protected characteristic information from people who raise concerns. This means we can't use this information to show whether certain groups are experiencing poorer care or discrimination. It also means we cannot currently check whether people experience discrimination when we handle their concerns.
We are unable to easily or confidently report on how many concerns we have received from members of the public and how we have acted on them, as we do not accurately or consistently collect this data. For example, where there is an option to record action taken in response to information received through our 'Give Feedback on Care' service, the most common option chosen is 'unspecified'.
Most concerns raised with us by members of the public are categorised as Priority 3 meaning there may have been a breach of fundamental standards (see Receiving information and triage for more information on how we prioritise information of concern). Where data is available to indicate how CQC has responded to those concerns, the most common response is either 'unspecified' or 'no further action'. This means that we do not have assurance that some Priority 3 concerns about potential breaches of fundamental standards are being acted on appropriately.
Our capacity and capability to analyse qualitative information from the public is not fully developed, although plans are in place to make this possible.
CQC does not collect or monitor levels of satisfaction among the public and care workers about the process of raising a concern.

Recommendations

Aim 1: The public, workers of services registered with CQC, and other stakeholders trust CQC to listen to and act on their feedback and concerns in an inclusive manner.

We recommend that CQC should:

Make clear how our Contact Transformation programme will deliver on the commitments in the CQC and the Public Engagement Strategy relevant to this review. This includes improvements in how information of concern is captured, prioritised, stored and analysed, and the customer service we provide back to individuals who raise concerns with CQC.
Develop and publish externally an agreed organisational approach to the customer service the public and organisations that represent them, and people working in care services can expect when they share concerns about care with us. This includes all direct channels (webform, telephone, email, letter, face-to-face), as well as how we will offer a feedback loop to keep them informed about how their concern is being assessed and acted on.
Consider offering different levels of customer service response, depending on the severity of concerns being raised, the vulnerability of the person raising them, and the type of service involved.
Develop a clear, transparent, easily reportable process for tracking how each concern raised by members of the public and organisations that represent them, and people working in care services has been triaged, assessed and acted on. This will enable a feedback loop to individuals, effective reporting, accountability and quality assurance.
Introduce a process to understand the public's experiences of sharing concerns about care with us, so we can continually improve this key area of our work.
Measure both the timeliness of how concerns raised by members of the public are responded to, and whether the action has mitigated the presenting risk, and implement a quality assurance system for this.
Based on the above new processes and protocols, develop new, clear information for the public to enable them to understand what they can expect when they raise concerns with us, as well as our response.
Consider further investment to increase public awareness and understanding of CQC's role in this area, particularly among people from ethnic minority groups and disabled people. This will help establish and maintain public trust and confidence and increase CQC's access to people's experiences of care.

Aim 3: CQC has a culture in place, supported by effective policies, processes and practices, to listen to, act on, and respond to information of concerns about care from workers of services and others. It does this in a way that is free from institutional or interpersonal discrimination.

We recommend that CQC should:

Review and improve our information capture and prioritisation processes to help us better understand and report on the volumes and types of concerns about care received from members of the public and the action we have taken in response. This includes capture of demographic and protected characteristics. This work also includes introducing an audit process to make sure this information is accurately recorded.
Urgently address the constraints on how we can analyse concerns raised by the public and workers in care services, including how the data is captured and stored. This will support the above recommendations and ensure all information of concern is appropriately assessed and acted on.

Aim 6: Relevant CQC colleagues feel confident, skilled and empowered to handle whistleblowing and information of concerns about care.

We recommend that CQC should:

Review available staff resources to make sure these are sufficient to enable both effective monitoring of services and responsive on-site inspections when there are early indications of deterioration in quality or of the emergence of a closed culture (shared recommendation with section 1).
Review internal guidance, training and wider activity to create a stronger positive culture across the organisation that enables us to deliver outstanding customer service to members of the public raising concerns about care with us. This work should include specific focus on discrimination recognising different approaches that may be needed. This is in line with our strategic ambition for regulation that advances equality and protects people's human rights.