The nature of standards

Accepted in principle.
The Department of Health will consult on regulations which introduce fundamental standards of care and a clearer focus on governance arrangements for complying with them. These will be reflected in the Care Quality Commission’s new approach to inspection. The Care Quality Commission has powers to access any information that it deems necessary to carry out its functions, and through its checks on governance (including information governance), can assure that hospitals provide it with accurate information on how they are providing care that is safe, effective, caring, responsive and well-led. However, in order that the public can find information in one place, it is the Care Quality Commission rather than each provider that should publish information about providers’ performance, which it will do via ratings. Placing this information with the Care Quality Commission will allow the public to make informed comparisons and decisions about the care provider they choose. The Care Quality Commission’s ratings will report on overall quality, which will be broader than fundamental and enhanced standards.
The Care Quality Commission consulted over summer 2013 on what should be considered fundamental standards of care. The Department will consult on regulations which will set these fundamental standards in legislation. The final set of standards is likely to cover areas such as: care and safety of patients and service users; abuse, including neglect; respecting and involving service users; nutrition; consent; governance; cleanliness and safety of premises and equipment; staffing; fitness of directors; and duty of candour. In parallel with the Department’s consultation on the regulations, the Care Quality Commission will consult on statutory guidance that it will take into account in enforcement, including prosecution, and issue a handbook to provide clarity on how it awards ratings. The regulations should come into force during 2014 and will also streamline and make clearer other requirements on providers, including governance arrangements for complying with fundamental standards.
The Care Quality Commission started implementing its new approach to hospital inspection in September 2013. The approach is based around judging five dimensions of quality, one of which is how well-led a service is. This includes the governance and leadership of culture of the service. In December 2013 the Care Quality Commission will set out information in more detail in guidance, so that there is transparency in how it will rate acute hospitals. This will build on the proposals in A new start – Consultation on changes to the way the Care Quality Commission regulates, inspects and monitors care by providing more detail on:
• what the five questions that the Care Quality Commission inspects* will cover
• the definition of each level of the rating scale (outstanding, good, requires improvement inadequate)
• key lines of enquiry that will always be followed to ensure consistent ratings
• indicators and data that contribute to the rating, and any methods or rules for aggregating them
• how judgements are made from inspection findings and data, to place a provider in a ratings band.
New Chief Inspectors of General Practice and Adult Social Care took up post at the Care Quality Commission in October 2013. They will spearhead the extension and development of the new inspection approach that has started in hospitals, to their respective sectors, and together will ensure that the Care Quality Commission is providing assurance that health and adult social care services join up seamlessly from the perspective of people who use services. The Deputy Chief Inspector of Mental Health will report to the Chief Inspector of Hospitals on how this applies to mental health services.
*Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

In 2014/15, Monitor and CQC introduced the Well-led framework, a national set of comprehensive governance – including quality governance – guidelines which provider boards were required to follow. The framework underpinned CQC Well-led reviews and Monitor/NHS Improvement approaches to governance. It was a regulatory requirement that foundation trusts used this framework to assess their governance on a regular basis. It has been revised on several occasions since and has been applicable to all trusts since April 2024.

CQC and NHS England jointly developed and published new well-led guidance for NHS trusts and foundation trusts under the Single assessment framework which became applicable to all trusts from April 2024.

The NHS provider licence, first introduced for NHS foundation trusts in 2013, included a condition covering provider governance (FT4). This condition required organisations to meet specific standards as set by DHSC, Monitor, CQC or NHS England. The licence was extended to NHS trusts from April 2023 and has been modified, following a statutory consultation to reflect current statutory policy requirements.

Please see also response to recommendation 13 (Fundamental Standards).

New Fundamental Standards regulations come into force for all providers of health and social care in April 2015. The fundamental standards are:

• care and treatment must be appropriate and reflect service users’ needs and preferences.
• service users must be treated with dignity and respect.
• care and treatment must only be provided with consent.
• care and treatment must be provided in a safe way.
• service users must be protected from abuse and improper treatment.
• service users’ nutritional and hydration needs must be met.
• all premises and equipment used must be clean, secure, suitable and used properly.
• complaints must be appropriately investigated and appropriate action taken in response.
• systems and processes must be established to ensure compliance with the fundamental standards (good governance).
• sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed.
• persons employed must be of good character, have the necessary qualifications, skills and experience, and be able to perform the work for which they are employed.
• A health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity (Duty of Candour).

Under the leadership of the Chief Inspector of Hospitals, the Care Quality Commission started piloting its new inspection model in 18 acute trusts in September 2013. A summary of the findings from these inspections was published by March 2014. Since April 2014 all acute NHS trusts inspections have used the new methodology. By December 2015, the Care Quality Commission will have inspected all NHS Hospitals using its new methodology.

In January 2014, the Care Quality Commission began testing its new inspection model in mental health, community services and NHS general practice out of hour’s services. In April 2014, the first new-style inspections started in 200 general practices and in adult social care. Between April and June 2014, the Care Quality Commission consulted on how it planned to change the way it regulates, inspects and rate care services. The resulting changes come into effect in April 2015 and consultation handbooks were issued for the seven types of provider: acute, mental health and community hospitals; NHS GP and out of hours services; residential, community and hospice adult social care services. The handbooks set out for each type of provider:

• what the Care Quality Commission look at on an inspection.
• how the Care Quality Commission judge what 'good' care looks like.
• how the Care Quality Commission rate care services to help people judge and choose care if they want to.
• how the Care Quality Commission use information to help decide when and where to inspect.

From April 2014, the Care Quality Commission began rating hospitals’ quality of care in bands ranging from outstanding to inadequate. The full roll out of ratings for hospitals, and ratings for social care and GPs began to be used from October 2014. Ratings give patients and the public a fair, balanced and easy to understand assessment of how well a provider is performing.

This recommendation was accepted by the Government in principle.

Requirements for good governance systems were implemented via reg. 17 of the Health and Social Care Act 2008 (Regulated Activities)) Regulations 2014, in force from April 2015. The regulations also introduced a duty of candour.