Letter to House of Commons Health Committee 15 October 2016
To Health Committee, 15 October 2016
Dear Dr Wollaston and colleagues,
Unheeded deaths warnings. Neglect and a care home owner with criminal convictions. Indefensible CQC.
I write to submit additional evidence for the next CQC accountability hearing.
The CQC remains insufficiently accountable, insufficiently sighted on critical risks and sentinel events, and unfit to safeguard vulnerable service users. It needs to be replaced
Almost a year ago, Public Accounts Committee found that the CQC was still an ineffective regulator, that it had not adhered reliably to its own policy on safeguarding, that it did not handle data well or provide the public with adequate data about regulated services, and that it did not listen enough to service users and whistleblowers. Regarding CQC accountability, the committee found that despite previous criticism in 2012, the CQC’s framework for monitoring its own performance was still inadequate:
“….the Commission does not yet have the quantified performance measures, linked to explicit targets, that are needed to show whether it is satisfactorily performing its statutory duties…only 6 out of the 37 performance measures included in it have specific, quantified, targets”
Also a year ago, The Bureau of Investigative Journalism and the Independent revealed that the CQC had not inspected 9 out of 23 care homes where coroners’ warning reports had been issued about deaths. David Behan acknowledged that these failures were ‘indefensible’ and promised to make improvements, including analysis of coroners’ intelligence.
New analysis on coroners’ warnings about care homes
I have updated the work, and cross-checked coroners’ Reports to Prevent Future Deaths (PFDs) against CQC inspection records. There was no published evidence that CQC had inspected 18 out of 66 homes despite coroners’ warnings. Where CQC had inspected, its response was slow and erratic. I have summarised my findings in a paper that I have published here, with supporting data:
It shows that the CQC was sent 31 of the 66 care home PFDs, 11 of which were directly addressed to CQC as a named respondent. There was no published CQC response to 9 of the PFDs. In one of two cases where CQC was specifically criticised by the coroner, there was no published response by CQC. I have been unable to find any published analysis by CQC of coroners’ intelligence.
Ivy Atkin, Autumn Grange and CQC’s lack of learning
CQC’s ongoing failures have again been highlighted by the profoundly shocking death of 86 year old Ivy Atkin who died weighing 3 st 13 lb, only twenty days after CQC issued a favourable report on her care home, Autumn Grange.
CQC inspection report on Autumn Grange care home 2 November 2012:
This inspection report was published on the same day that CQC carried out an unannounced re-inspection of Autumn Grange as a result of a member of staff blowing the whistle only three days after starting work at the care home. In addition to the horrific neglect of Ivy Atkins, other residents at Autumn Grange also suffered severely and were found to have unexplained injuries. ITV news reported that other staff also came forward and alleged mistreatment, including assault. A ‘culture of neglect’ was described, thus raising a question of whether the dysfunction had been present for some time:
The coroner has now concluded that Ivy Atkin was unlawfully killed, and that CQC failed to inspect the care home effectively. 
The care home owner was jailed in February for corporate manslaughter. During the course of the recent inquest, the coroner expressed concern that he had three criminal convictions:
“A coroner has questioned how a care home boss was able to run the business where pensioner Ivy Atkin lived before she died – even though he had three criminal convictions…
…The inquest heard on Thursday that home director Yousaf Khan was convicted of criminal damage in 1989, a public order offence for punching and kicking a person in a restaurant in 1998 and drink-driving in 2000.” 
Despite obvious and serious questions about CQC’s handling of the issues relating to Autumn Grange, the CQC told me that it had not undertaken any internal review of its actions, and implied that there was no need to do so because its processes are “better than ever”. This correspondence with CQC is attached.  The inspector responsible for the inspection 7 weeks before Ivy Atkin’s death maintained at the inquest that she had not “missed anything” and that care homes can go “downhill quickly”. In a discussion yesterday about Ivy Atkin’s death, a CQC Non Executive Director responded thus to a campaigner’s concerns that CQC is reactive and not sufficiently proactive: “Er, this was 4 years ago”.
I find this attitude by CQC deeply shocking, set against the cruel death that befell Ivy Atkin. There is much rhetoric from the Secretary of State that the CQC is a new organisation under his stewardship. However, even the previous CQC regime undertook an internal review after abuse at Winterbourne View was exposed. The severity of the failings at Autumn Grange was much greater than at Winterbourne View, yet the current CQC regime has not seen fit to properly hold itself to account.
The history of serial failure by the CQC to safely regulate care homes and provide the public with accurate information – highlighted 22 times by Private Eye since 2010 – is summarised in this comprehensive report by the campaigning charity Compassion In Care: http://www.compassionincare.com/node/229
CQC value for money
The Mazars report on Southern Health NHS Foundation has raised serious doubts about the accuracy of CQC’s so-called ‘intelligent monitoring’, which is a cornerstone of CQC’s purported ‘transformation’. Moreover, a £273,908 CQC inspection  of Southern Health in 2014 did not report on the hundreds of uninvestigated unexpected deaths, later identified by Mazars’ investigation.
After seven years of failure by CQC and frequent refusal to investigate key matters (CQC disclosed by FOI that it had undertaken only 6 Section 48 investigations since inception ) I contend that the CQC’s approach does not work, is not safe and is poor value for money.
The hundreds of millions spent every year on CQC – on a ‘transformation’ that is not actually evident – would surely be better spent on leaner, focused, and professionalised investigation services, such as that which revealed the grave care failings at Mid Staffordshire:
I note that the Healthcare Safety Investigation Branch (HSIB) has now been created to carry out healthcare investigations, but its currently slender funding results in inadequate capacity. It has an intended rate of only 30 investigations a year, and the Department of Health advised that this capacity may even reduce. 
CQC’s latest National Guardian for whistleblowing has extolled the virtues of cheerfulness: https://minhalexander.com/2016/10/10/hooray-henrietta/
However, CQC unfortunately gives the health and care workforce little cause to smile.
Dr Minh Alexander
cc Public Accounts Committee
Public Administration and Constitutional Affairs Committee
Keith Conradi Chief Investigator, HSIB
 Public Accounts Committee. CQC inquiry. December 2015
 Elderly people put at risk as watchdog fails to act on warnings of ‘fatally negligent’ care homes. Melanie Newman and Oliver Wright, The Independent, 2 September 2015
 Ivy Atkin death: ‘Unlawful killing’ over care resident death, BBC 13 October 2016 http://www.bbc.co.uk/news/uk-england-nottinghamshire-37649387
 Owner of the care home where Ivy Atkin stayed before her death had three criminal convictions, Jemma Page, Nottingham Post, 14 October 2016
 Correspondence February and March 2016 with CQC, about whether it had undertaken an internal review on its inspection activities at Autumn Grange
 FOI disclosure about the cost and details of a CQC inspection on Southern Health:
 FOI disclosure by CQC about the number of Section 48 inspections undertaken since CQC’s inception:
 FOI disclosure by the Department of Health about HSIB: