 Close up of glasses and pen resting on notebook and a laptop in the background
An independent review of the technology that supported our transformation has found that the primary cause of our technology failure was a failed organisational transformation. It adds that the technology used for our regulatory platform and provider portal are salvageable but required substantial development and rebuilding work.
The report sets out the scale of the problems that resulted in the failure of our technology and the impact that transformation had across CQC. It makes 23 recommendations, which can be grouped into 5 broad areas covering: culture; data and digital; governance; operating model; and change management.
The next step will be to develop an action plan to deliver the recommendations, which we plan to co-develop with CQC colleagues, providers, people who use services, and wider stakeholders. This will be presented at a future board meeting. This, along with work we are doing in partnership to develop the CQC Way and a series of regional roadshows to support our improvement work, will help us get back to delivering our purpose – to make sure people receive safe and effective care, and to help providers improve.
Our annual report sets out our activity and findings during 2023/24 from our engagement with people who are subject to the Mental Health Act 1983 (MHA), as well as a review of services registered to assess, treat, and care for people detained using the MHA.
This year’s report highlights again the issues that lack of staff, beds, and training are causing and are leading to harmful gaps in care and treatment. The demand is far outstripping capacity, leading to people being placed far from home, their family, and their friends. There aren’t enough staff to support all patients, and while many people describe healthcare workers as ‘caring’ and ‘wonderful’, there are ongoing concerns with staff numbers and training.
Young people, people from ethnic minority groups, and people from areas of deprivation face the biggest barriers to accessing care. We remain concerned that a lack of suitable community resources continues to lead to inappropriate hospitalisation of people with a learning disability and autistic people.
We are calling for national action to tackle system-wide issues in community mental health. Better funding, improved community support, and a specialised and sustainable workforce is required to ensure that people receive the care they need.
Investigations are ongoing into a cluster of Listeria monocytogenes (LM) cases linked to two mousse desserts (chocolate and vanilla, and strawberry and vanilla). These products match clinical isolates from the outbreak, and other desserts may also be affected.
The Food Standards Agency (FSA), UKHSA, and local authorities are investigating. NHS hospitals have been advised to remove these products, and care homes are also instructed not to serve the affected mousse. Schools are not impacted, as they do not serve high-risk consumer groups.
Actions Required:
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Withdraw from food service and sale all desserts at healthcare settings (regardless of brand), manufactured at B. & A. Susca Limited, Pine Street, Off Bennett Street, Hyde, Cheshire, SK14 4TG. This is a precautionary measure while investigations continue.
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Place on hold/quarantine desserts removed from service/sale, until further advice is provided by the Local Authority and FSA. Disposal is not required.
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Other Cool Delight brand desserts not from this manufacturing site are not affected. If unsure whether a product is from this site, place it on hold and contact the supplier to confirm its origin.
While LM levels in the affected products are below the legal threshold for healthy consumers, immunocompromised individuals, including hospital patients and pregnant women, are at greater risk.
For more information on Listeria, please visit this link. You can also read the FSA’s evidence to NHS food review.
Under the Health and Social Care Act 2022 CQC was given new responsibilities to assess whether integrated care systems (ICSs) are meeting the needs of their local populations. We initially paused our work on this in early 2024 to refine our approach to ICS assessments and the delay was further impacted by the General Election in July 2024 and the Dash review in October 2024.
Following uncertainty as a result of the recent government announcement that NHS England will be brought back under the Department of Health and Social Care (DHSC) along with reductions planned for ICBs, DHSC has withdrawn its request for a proposal from CQC on the future of ICS assessment activity.
This work will pause for at least six months which will allow us to focus on our 4 priorities and 5 foundational improvements.
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