Performance Report: Quarter 4 March 2019...performance • Risk Report • Internal Audit Report •...

Performance Report:Quarter 4 – March 2019

1

Reporting Our Performance – Annual Cycle

2

Quarterly:

Board Report – Strategic Measures / Surveys

Operational Performance / Risk / Internal Audit / Business Plan Delivery

/Finance

Annual:

State of CQC Report –Impact and Outcomes

(Internal)

Annual Report and Accounts

Weekly:

Operational Delivery / Activity Reporting

Monthly:

ET Report & Board Summary / SLTs –

Operational Performance and Quality Improvement

Deep Dives / Finance

Are We Delivering Our Commitments?

Are We Efficient?

Are We Consistent?

Are We Effective?

Do We Learn and Improve?

2

Reporting Our Performance – Audiences

3

SLTs ET ACGC RCG Board

Annual Performance Products

• State of CQC Report –Impact and Outcomes

• State of CQC Report /Governancestatement

• Management assurance process –summary

• State of CQC Report –Impact and Outcomes (Private)

• Annual Report and Accounts

QuarterlyPerformance Products

Operational Performance and Surveys

Performance report:Operational performance and Impact (products as for Board see last column)

• ‘Deep dives’ on performance

• Risk Report• Internal Audit Report• NAO/PAC Action Plan

and Progress Report

• ‘Deep Dives’ on Risk

• Risk Report covering those within RCG remit (e.g. Consistency) (to be agreed)

Performance report:Operational Performance and Impact:• Strategic Measures and

Surveys • Operational Performance• Risk• Internal Audit• Business Plan Delivery• Finance

Monthly Performance Products

Monthly performance report • Operational

performance

Monthly performance report to ET (and summary to Board)• Operational

performance

• N/A • N/A • Summary report on Operational performance

Purpose • OperationalPerformance Management (includes delegation of improvement priorities to Operational improvement groups – eg: CIG)

• Assurance on Operationalperformance management (and focus on improvement priorities)

• Assurance on Strategic Change delivery

• Assurance regarding risk management and assurance processes

• Assurance regarding regulatory risk management processes

• Assurance on CQC overall performance

3

Performance Annex - LegendIllustrates the operating model component

Trend: improving; deteriorating; or no change

Performance: green or red only. Measures with no target will have a white background

Manage Our Resources

Register Monitor, Inspect & Rate Enforce Independent Voice

4

Title & ContentInformation about the timescales of the dataC

Additional information relevant to the content of the graph

Graph

C= The Slide gives contextM= The slide is a performancemeasure (KPI)

Commonly Used AcronymsASC – Adult Social Care; PMS – Primary Medical Services; HSP – Hospitals; MH – Mental Health; NCSC – National Customer Service Centre; IH – Independent Health; YTD – Year To Date (Financial Year); KPI - Key Performance Indicator; Enf – Enforcement; RI – Requires Improvement; Fac Acc – Factual Accuracy

Arrow colour measures YTD performance against target

YTD performance 3%(6%) Monthly performance

Arrow direction measures trend against previous month performance

Monitor, Inspect &

Rate

Enforce

Independent Voice


Register

Sickness:

12 Month Average

Turnover:

12 Month Average

Enforcement

Actions Issued

Report Publication

Timeliness

Engagement:

Positive Coverage

Engagement:

Negative Coverage

Engagement:

CQC Themes

Applications:

NCSC Processing

Applications:

New Reg

Assessment

Applications: Var &

Can Reg

Assessment

NCSC:

Correspondence

NCSC: General

CallsNCSC: Mental

Health Calls

NCSC: Alert Triage NCSC: Concern

Triage

Alerts: Referred to

Local Authority

Alerts/Concerns:

Mandatory Action

Inspection

Timeliness: ASC

Productivity: ASC Productivity: PMS

Data From March Static Cut; 2018/19 Financial Year, unless otherwise stated

Turnover:

Avoidable Reasons

Last 12 Months

Complaints:

Acknowledged

Information

Access:

Responsiveness

Special Measures:

Current Total

Unregistered

Provider Enquiries

Notices of

Proposal: Last 12

Months

4Q+ In Breach

With Actions: ASC

4Q+ In Breach

With Actions: PMS

Inspection

Timeliness: PMS

NCSC:

Safeguarding Calls

3.8%(3.8%)

99.6%(100%)

97%(94%)

87%(87%)

70%(72%)

89%(90%)

95%(96%)

95%(97%)

NCSC:

Registration Calls

87%(86%)

94%(95%)

89%(88%)

85%(93%)

98%(99%)

72%(73%)

N/A(92%)

99%(100%)

98%(98%)

N/A(93%)

N/A(2.5%)

62%(47%)

86%(90%)

23% 94%(93%)

5641597(91)

89%(84%)

2,206(185)

447 90% 96%

10.6%

5

Monitor, Inspect &

Rate

Enforce

Independent Voice


Register

Productivity

147(147)

Finance: Pay

Forecast

KPI: 2% variance

Finance: Non-

Pay Forecast

KPI: 2% variance

Sickness: 12

Month Average

KPI: Below 5%

Turnover: 12

Month Average

No current

benchmark in

place

Turnover: Neg

Reasons Last 12

Months

Incl. work life

balance, lack of

opportunities,

better reward

package.

Complaints

Acknowledged

KPI: 3 Days

Target: 95%

Information

Access

Responsiveness

Benchmark: 90%

Based on

statutory time

limits of diff.

legislation

Applications:

NCSC

Processing

KPI: 5 days

Target: 90%

Applications:

New Reg

Assessment

KPI: NOP/NOD

sent in 50 days

Target: 80%

Includes all reg

applications

Applications:

Var/Can Reg

Assessment

KPI: NOP/NOD

sent in 50 days

Target: 90%

Includes all reg

applications

Notices of

Proposal Last 12

Months

Most cases of

NOPs are where

we are refusing

an application.

Unregistered

Provider

Enquiries

Alerts of services

not assessed to

ensure they are

safe to operate

NCSC:

Correspondence

KPI: 3 days

Target: 90%

NCSC: General

Calls

KPI: 30 seconds

Target: 80%

NCSC:

Registration

Calls

KPI: 30 seconds

Target: 80%

NCSC: Mental

Health Calls

KPI: 30 seconds

Target: 90%

NCSC:

Safeguarding

Calls

KPI: 30 seconds

Target: 90%

NCSC:

Safeguarding

Alerts Triage

KPI: 1 day

Target: 95%

NCSC:

Safeguarding

Concerns Triage

KPI: 1 day

Target: 95%

Safeguarding

Alerts: Referred

to Local

Authority

KPI: 1 day

Target: 95%

Safeguarding

Alerts/Concerns:

Mandatory

Actions

KPI: 5 day

Target: 95%

Productivity

ASC/PMS KPI: 2

inspections (any

type) a month

HSP KPI:

average of 235

units a month

Target: 100%

Inspection

Timeliness: ASC

RI/I Returns: 90%

G/O Returns:

80%

1st Inspections:

80%

Inspection

Numbers:

Hospitals Units

A unit is

equivalent to 1

independent

location or 1 core

service

Inspection

Timeliness: PMS

Target: 90%

Enforcement

Actions Issued

Includes Warning

Notices, Civil

Actions and

Criminal Actions.

Actions may still

await outcomes.

Special

Measures:

Current Total

Services enter

and exit during

the month

4Q+ In Breach

With Actions:

ASC

Inspections in

progress or

scheduled and

current/recent

enforcement

4Q+ In Breach

With Actions:

PMS

Inspections in

progress or

scheduled and

current/recent

enforcement

Report

Publication

Timeliness

KPI: 50 days

Except

HSP 3+ Core

Services: 65 days

Target: 90%

Engagement:

Positive

Coverage

Target: >70%

Engagement:

Negative

Coverage

Target: <10%

Engagement:

CQC Themes

Target: >80%

Data From March Static Cut;2018/19 Financial Year, unless otherwise stated

6

Applications: Volumes received

Volume of applications received and Actual Inspector Strength

41,755 applications have been received in the last 12 monthsC


Rolling 12 months; Data from Mar cut *Actual Strength is the number of FTE in post, discounting those that are out of the business, which includes those on long-term sick, on parental leave, suspensions, and external secondments.

7

30973318

2768

3219 31203005

3522 33743041

4486 44444361

127.1

135.4

136.3137.2

134.4

138.2

137.2

132.2

138.0

138.0 138.0136.3

120

130

140

150

0

1000

2000

3000

4000

5000

6000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Applications Received Actual Strength

Are Our Registration Assessments Timely?

Volume and timeliness for completion of Registration processes by month*Year to date, 70% of New Registration applications and 89% of Variations and Cancellations have been completed within KPI, compared with 77% and 89%

respectively in 2017/18

MRegister Monitor, Inspect & Rate Enforce Independent Voice

2018/19 Financial Year; Data from Mar cut KPI: Notice of Proposal or Decision sent within 50 days *includes data where the employees’ directorate was “unspecified”8

1105 1186 1039 1100 1058 929 11101132 1007 1126 1056

1097

18352086

1559 1702 17551638

1967 19561745

196415871974

80%

90%

65%69% 68% 69% 68%

72% 73% 72% 69% 69% 69% 72%

87% 91% 91% 88% 91% 88% 90% 89% 89% 89% 88% 90%

14%9% 8% 7% 9%

5% 6% 9% 5% 5% 6% 7% 0%

20%

40%

60%

80%

100%

0

1000

2000

3000

4000

5000


New Var & Can Target (New)

Target (Var & Can) Actual (New) Actual (Var & Can)

Variance to Establishment

Rejection rate for applications

Volume of applications received by type and rejection ratesIn the last 12 months, 26% of applications have been received via the provider

portal, with the rejection rate for provider portal applications being 21% compared with 37% for applications received by other methods in the last 12 months.


Rolling 12 months; Data from Mar cut

9

Top 5 provider application rejection reasons:• Provider Section• Declaration/Data protection section• Location Section• Invalid Supporting provider/manager app• Application not required

Top 5 manager application rejection reasons:• Provider Section• Invalid Supporting provider/manager app• Application not required• Location section• Manager section(s) invalid/incomplete

1446 1594 1353 1191 1511 1364 1488 1470 1155 1546 1612 1560

4046 4300 3969 4516 4072 3883 4584 4073 3466 4707 3959 3937

26% 27% 25% 21% 27% 26% 25% 27% 25% 25% 29% 28%

33.1% 31.9%34.7% 33.6% 32.1% 32.1% 32.3% 33.5% 32.5% 32.8% 33.1%

29.6%

18.7% 19.6%22.7%

18.9%18.9% 22.5%

23.0% 23.6% 25.0%23.7% 22.9%

14.2%

38.3%36.5%

38.8% 37.5% 37.0% 35.5% 35.3% 37.1%35.0% 35.8% 37.2% 35.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

0

2000

4000

6000

8000

10000


Portal Applications Non Provider PortalOverall Rejection Rate Provider Portal Apps Rejection rateNon Provider Portal Apps Rejection rate

10539 (98%)

2028 (89%)

0 (%)

0 (%)

239 (2%)

241 (11%)

1688 (16%)

1875 (83%)

0 (%)

0 (%)

0% 50% 100% 150% 200%

ASC

PMS

Undertaken Scheduled Due not sched. Undertaken not due Scheduled not due

Inspections: Undertaken and Scheduled

Correspondence received by NCSC and timeliness of response

Year to date, NCSC has answered 86% of its correspondence promptly M


2018/19 Financial year; Data from Mar cut *HSP data is not included due to data quality issues which are currently under review

Inspections undertaken and scheduledIn 2018/19, ASC has undertaken 98% and PMS has undertaken 89% of inspections

due to be completed by the year end. In addition 3,563 inspections were undertaken which were not due until 2019/20.

10

Published Reports: CQC Timeliness & Influences


Proportion and volume of reports published within timescales

Year to date, 86% of reports have been published within KPI

2018/19 Financial Year; Data from Mar cut 11KPI: ASC, PMS & HSP 0-2 Core Services – 50 working days after last visit date; HSP 3+ Core Services – 65 working days after last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy

challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage.

4328

955 1154 1218 1141 1211 1110 1079

1348 13031439

1278

1589

249

273276

234230

180 161

164143

133

182

17379% 81% 82% 83% 84% 86% 87% 89% 90% 92%88%

90%

7% 6% 8% 7% 6% 7% 8% 6% 7% 6% 7% 7% 5%

17% 16% 17% 16% 16% 16% 16% 16% 16% 16% 15% 15%

90%

81%

8%

0%

20%

40%

60%

80%

100%

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Over. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Draft Final In KPI Out KPI % Within KPI

Enf. Fac. Acc. Target Perf. 2017-18 Enf. 2017-18

Published Reports: CQC Report Backlog


Volume and age of reports outstanding publication and per inspector

In the last 12 months, backlog has been reduced by 12%

2018/19 Previous 12 Months; Data from Mar cut

Age of reports: 0-20, 20-50, 50-75, 75+ Working Days excluding Bank Holidays; Reports in Progress: Inspection date has passed and KPI target remains 1. In Progress, Avg Reports per inspector: Total volume of reports divided by the number of Inspectors “Not in Training”(NIT).

Data excludes P4 Health & Justice locations12

*The logic behind this report continues to be reviewed to ensure accuracy, due to discrepancies which may appear through cross-directorate support on inspections and inspectors moving teams

48% 49% 49% 51% 50% 57% 56%60%

53%63% 59% 61%

37% 35% 36% 35%36% 29%

33%32%

38%27% 33% 34%

8% 8%7% 6%

6% 6%6%

4%5% 5% 5% 3%

8% 8%8%

7%8% 7%

6%5%

5% 5% 3%2%

2,590 2,5132,395

2,2722,084 2,063

2,2702,462

2,303 2,378 2,3852,268

2.38 2.28 2.18 2.03 1.88 1.84 2.02 2.20 2.20 2.13 2.08 1.96

0

1

2

3

4

5

6

0

500

1,000

1,500

2,000

2,500

3,000

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

2018 2019

0-20 20-50 50-75 75+ Reports In Progress Avg Reports per Inspector

Changes in Quality over time

CRegister Monitor, Inspect & Rate Enforce Independent Voice

Data from Mar cut13

Current and previous ratings profile of active services

62 224 392 649 752 885 1022 1,188

3,97511,355 17,605

22,240 23,527 23,879 24487 24,954

1,9264,145

5,061 4,906 4,421 4,249 4009 3,964

369 482 526 477 438 439 378 369

1% 1% 2% 2% 3% 3% 3% 4%

63%70%

75% 79% 81% 81% 82% 82%

30%

26% 21% 17% 15%14% 13% 13%

6% 3% 2% 2% 2% 1% 1% 1%

0%

20%

40%

60%

80%

100%

2015/16 - Q2 2015/16 - Q4 2016/17 - Q2 2016/17 - Q4 2017/18 - Q2 2017/18 - Q4 2018/19 - Q2 Current -March 18/19

Outstanding Good Requires Improvement Inadequate

2018/19 Financial Year; Data from Mar cut KPI: Alerts (required to be referred to the Local Authority) – 1 days to make referral

Do We Respond Promptly to Information of Concern? – CQC


Volume of Safeguarding Alerts referred to a Local Authority and timeliness of action

Year to date, response has been timely for 94% of Alerts compared to 96% of Alerts in 17/18

14

3 2 0 3 2 5 3 1 2 2 0 2

2436

29 2635 31 37

51

3237

30

40

89%

95%

100%

90%

95%

86%

93%98%

94% 95%

100%

95%

96%

95%

0

10

20

30

40

50

60

70%

75%

80%

85%

90%

95%

100%


Volume Outside KPI Volume Within KPI Alerts - Referral to LAAlerts - 2017/18 Average Target

M

Do We Respond Promptly to Information of Concern? – CQC


2018/19 Financial Year; Data from Mar cut KPI: Alerts (not required to be referred to the Local Authority) & Concerns – 5 days to undertake a mandatory action

Volume of Safeguarding Alerts and Concerns received requiring a mandatory action and timeliness of action

Year to date, response has been timely for 89% of Alerts/Concerns compared with 90% in 17/18

15

286 257 241 270 247 170 274 234 145 275 240 247

1946 2024 20452295 2168

19352176 2193

1700

22871960 1798

87% 89%

89% 89%

90%

92% 89%90% 92%

89% 89%

88%

90%

95%

0

500

1000

1500

2000

2500

3000

3500

50%

60%

70%

80%

90%

100%


Volume Outside KPI Volume Within KPIAlerts & Concerns - Mand Actions Mand Actions - 2017/18 AverageTarget

Inspections: ASC Activity




2018/19 Financial year; Data from Mar cut

Inspections undertaken and scheduled against forecast

Year to date, ASC has undertaken 12,227 inspections 62% of

inspections have been undertaken within KPI.

16

233

599 573 534 566 541 534759 769

564754

610 518

250 333 373 346 327 378

342 349

283

436

488 586

1155

1394 14361322

12371130

1202

1193

783

1181

1013916

0

200

400

600

800

1000

1200

1400

1600

1800

O/D U - Apr U - May U - Jun U - Jul U - Aug U - Sep U - Oct U - Nov U - Dec U - Jan U - Feb U - Mar

Overdue In KPI Out KPI No KPI Not scheduled Capacity

Published Reports: ASC Timeliness & Influences




2018/19 Financial Year; Data from Mar cut 17

99

691 802 890770

885 829 789

993 9481043

940

1142

182

187

197

139

169134

122

131105

91131

111

79% 81%

82%85%

84% 86%

87%

88% 90% 92% 88% 91%

17%

8% 10% 8% 7% 8% 8% 6% 8% 6% 7% 7% 6%

17% 17% 18% 17% 19% 18% 16% 18% 16% 17% 16% 15%

90%

84%

9%

0%

20%

40%

60%

80%

100%

0

200

400

600

800

1000

1200

1400




Published Reports: ASC Report Backlog



In the last 12 months, ASC backlog has been reduced by 12%

2018/19 Previous 12 Months; Data from Mar cut – Inspection Visit date 01/04/2014 onwards

Age of reports: 0-20, 20-50, 50-75, 75+ Working Days excluding Bank Holidays; Reports in Progress: Inspection date has passed and KPI target remains 1. In Progress, Avg Reports per inspector: Total volume of reports divided by the number of Inspectors “Not in Training”(NIT) at that point in time.

Data excludes P4 Health & Justice locations 18


47% 48% 49% 51% 49% 56% 60% 62%49%

66% 60% 62%

35% 33% 33% 35% 33% 30%35%

33%34%

28% 30% 32%

8% 7%6% 6%

6% 6%7%

4%5% 5% 5% 3%

8% 8%7% 7%

7% 7%6%

5%5% 5% 2% 1%

1,799 1,753 1,6971,610 1,597

1,517 1,506 1,6221,692

1,571 1,610 1,575

3.01 2.86 2.73 2.69 2.61 2.512.70 2.86

2.502.80 2.73 2.61

0

1

2

3

4

5

6

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

2018


23 88 170 335 398 513 632 792

3,018 8,684

13,050 16,120 16,845 17,106 17767 18,159

1,741 3,739

4,360 4,140 3,906 3,802 3563 3,485

318 366 373 345 312 349 302 264

0% 1% 1% 2% 2% 2% 3% 3%

59%67%

73% 77% 78% 79% 80% 80%

34%

29% 24% 20% 18%17% 16% 15%

6% 3% 2% 2% 1% 2% 1% 1%

0%

20%

40%

60%

80%

100%

2015/16 - Q2 2015/16 - Q4 2016/17 - Q2 2016/17 - Q4 2017/18 - Q2 2017/18 - Q4 2018/19 - Q2 Current -March 18/19


ASC: Changes in Quality over time


Data from Mar cut19


Published Reports: HSP Timeliness & Influences


Proportion and volume of reports published within timescalesYear to date, 58% of Hospital reports overall, 56% of those with less

than two core services and 70% of those with three or more core services have been published within KPI

2018/19 Financial Year; Data from Mar cut20KPI: ASC, PMS & HSP 0-2 Core Services (Inc IH) – 50 working days after last visit date; HSP 3+ Core Services – 65 working days after

last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage.

21

16

27 24

46 42 40 37 40 39 45

67

37

67

33 50

38

48

2413

17 14

25

30

35

45

45%

29%

52%

43%

63%

72%67%

73% 61%67%

47%

60%

44%

67% 67% 69%

60%

82%79%

75%79%

82%

69%

55%

5% 3% 4% 2% 4% 6% 4% 5%2% 1% 1%

11%4%

32%28%

21%

32%

22%26%

40%

25%

36% 33%

25% 27%

90%

30%

6%0%

20%

40%

60%

80%

100%

0

20

40

60

80

100

120


Draft Final In KPI Out KPI

% Within KPI (0-2) % Within KPI (3+) Enf. Fac. Acc.

Target Perf. 2017-18 Enf. 2017-18

Published Reports: HSP Report Backlog



In the last 12 months, HSP backlog has been reduced by 17%



Data relates to individual inspection records and average reports per lead inspector for hospital inspections not including individual core service reports21


30%27% 26% 41% 29% 41% 40% 43% 33%

47%

29% 25%

35% 44%43% 33%

47%34%

41%

41%51%

35%

48%

48%

12% 11%15%

12% 9%14%

10%

8% 10%12%

16%

15%

23%18%

16%14%

16%10%

9%

7% 6%6%

8%

12%

195

174

148130 122

134

164

204 203217

200

162

0.64 0.56 0.48 0.40 0.37 0.41 0.50 0.63 0.65 0.56 0.62 0.49

0

1

1

2

2

3

3

4

4

5

5

0

50

100

150

200

250

Ap

r

Ma

y

Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

2018


18 27 40 46 56 69

234318

395 410 448 599

194211 193 186 190 215

24 14 16 15 8 6

4% 5% 6% 7% 8% 8%

50%56%

61% 62% 64%67%

41%37% 30% 28% 27% 24%

5% 2% 2% 2% 1% 1%

0%

20%

40%

60%

80%

100%

2016/17 - Q2 2016/17 - Q4 2017/18 - Q2 2017/18 - Q4 2018/19 - Q2 Current - March18/19


HSP: Changes in Quality over time


Data from Mar cut22


213 241157 162 143 125

79 97165

209163

201 177 198

11 118 18

2032

2119

1122

2839

93101

101 93

8061

76

99

77

103103 83

367

522480 467

449

379

444

535

314

369303 332

0

100

200

300

400

500

600

Dereg O/D U - Apr U -May

U - Jun U - Jul U - AugU - Sep U - Oct U -Nov

U - Dec U - Jan U - Feb U -Mar

Deregistrations Overdue In KPI Out KPI No KPI

Indep. Prog. Dentist Prog. Not scheduled Capacity

Inspections: PMS Activity




2018/19 Financial year; Data from Mar cut

Inspections undertaken and scheduled against forecast

Year to date, PMS has undertaken 3,903 inspections 89% of inspections

have been undertaken within KPI.

23

Published Reports: PMS Timeliness & Influences




2018/19 Financial Year; Data from Mar cut 24KPI: ASC, PMS & HSP 0-2 Core Services – 50 working days after last visit date; HSP 3+ Core Services – 65 working days after last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy

challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage.

133

236

327282

328286

244 249

315 309 329299

380

34

36

40

44

37

33 22

16 1212

16

1787% 90% 88% 88%

89% 88%

92% 95%96% 96% 95%

96%

0% 2%6% 4% 5% 5%

8%4% 4% 4% 6% 6% 5%

12% 11% 11% 10% 8% 8% 9% 7% 9% 8% 10% 11%

90%85%

5%0%

20%

40%

60%

80%

100%

120%

0

50

100

150

200

250

300

350

400

450

500




56% 57% 53%53%

49%69% 63%

69%60%

70% 65%64%

37% 35% 39%

39%

42%24%

32%

28%

36%26%

32%34%

3% 5% 4%

4%

5%3%

2%

1%2% 1%

2%

1%

3% 3% 4%

4%

4%3%

3%

2%2% 2%

1%

2%

532 539 548

478

400372

424

486451 463

513

471

2.41 2.412.10

1.76 1.671.93

2.231.93

1.682.07

2.232.07

0

1

2

3

4

5

6

0

100

200

300

400

500

600

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

2018


Published Reports: PMS Report Backlog



In the last 12 months, PMS backlog has been reduced by 11%



Data excludes P4 Health & Justice locations 25


37 134 204 287 314 326 334 327

932 2,632 4,321 5,802 6,287 6,363 6272 6,196

131 314 507555 322 261 256 264

42 105 129 118 110 75 68 86

3% 4% 4% 4% 4% 5% 5% 5%

82% 83% 84% 86% 89% 91% 91% 90%

11% 10% 10% 8% 5% 4% 4% 4%

4% 3% 2% 2% 2% 1% 1% 1%

0%

20%

40%

60%

80%

100%

2015/16 - Q22015/16 - Q42016/17 - Q22016/17 - Q42017/18 - Q22017/18 - Q42018/19 - Q2 Current -March 18/19


PMS: Changes in Quality over time


Data from Mar cut26


What is the Quality of the Services Rated?


Data from Mar cut

Current ratings profile of active services

27

792

327

17

24

4

24

18,159

6,196

82

283

32

202

3485

264

70

71

15

59

264

86

5

4

1

9

3%

5%

10%

6%

8%

8%

80%

90%

47%

74%

62%

69%

15%

4%

40%

19%

29%

20%

1%

1%

3%

1%

2%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ASC

PMS

HSP Acute (NHS)

HSP (IH)

HSP MH (NHS)

HSP MH (IH)


Do Locations Rated Good Deteriorate?



Re-ratings of services previously rated Good

In the last year, 23% locations previously rated Good, that we re-

inspected deteriorated

28

1550

1 58

12114

926 153

4099

2618 35 55 1032

240 5 2 2 1028

3%0% 0% 1% 5%

21%

17%20%

28% 12%

72%

72%75% 76% 60% 81%

4%14% 8% 4% 11%

2%

0%

20%

40%

60%

80%

100%

ASC Acute Trusts MH Trust Locations IH PMS

Deteriorated to Inadequate Deteriorated to Requires Improvement

Remained Good Improved to Outstanding

2893 0 8 2

25

144434

758

942

189721

2

40

38 189

9 1 0 1 0 1

8%5% 0% 7% 4% 10%

40%58%

78% 54%

18%

16%

52%

36%

22%

37%

78% 74%

0% 2% 0% 1% 0% 0%

0%

20%

40%

60%

80%

100%

ASC Acute Trust MH Trust Locations IH PMS

Deteriorated to Inadequate Remained Requires Improvement

Improved to Good Improved to Outstanding

Do Locations Rated Requires Improvement Improve?



Re-ratings of services previously rated Requires Improvement (RI)

In the last year, 53% locations previously rated RI, that we re-inspected

improved

29

Re-ratings of services previously rated Inadequate

In the last year, 74% locations previously rated Inadequate, that we re-

inspected improved

Do Locations Rated Inadequate Improve?



30

120 2

1

4

1

37

356 5

3

4

37

47 1 0

325

0 00

0 0 0

23% 25%

100%

57%

13%37%

68% 63%

43%

50%

37%

9% 13%

0%

38%25%

0%

20%

40%

60%

80%

100%

ASC Acute Trusts MH Trust Locations IH PMS

Remained Inadequate Improved to Requires Improvement

Improved to Good Improved to Outstanding

What Enforcement Activity Do We Undertake?

Volume of enforcement actions issued each month broken down by current status and type

In the last 12 months, we have issued 2,206 enforcement actions, of which 1,213 (55%) are pending outcome.


31Rolling 12 months; Data from Mar cut

170

249

181168 188 184 175

200176

148

182 185

0

50

100

150

200

250

0

20

40

60

80

100

120

140


All Actions Pending Outcome All Actions PublishedAll Actions Completed Warning NoticesCivil Actions Criminal Actions

Volume of whistleblowing enquiries received and trend

CQC has received 8,878 whistleblowing enquiries in the last yearC

Whistleblowing volume and action taken



32

148 142 165 187 168 150 172 171 128 182 209 13442 41 28 46 19 33 55 31

2028 20 16

15 24 1512 13 14

15 1010

12 198

537 507 525567

568 517542 519

369

605 549571

46% 48% 48% 48%

42% 43% 41%

45%43% 43% 44%

38%

2% 2% 2% 2% 1% 3% 2% 2% 2% 2% 2% 2% 0%

10%

20%

30%

40%

50%

60%

0

200

400

600

800

1000

1200


Other (such as information used to support future inspections)Triggered a responsive inspectionBrought forward a planned inspectionReferred to a more appropriate organisation (such as a local authority)% where a safeguarding record has been set up (safeguarding issue identitified)% where a management review record has been set up (could result in enforcement)

What Happens to Locations in Special Measures?

Number of services entering and exiting Special Measures this month and those remaining in Special Measures at month end

C

422 in Special Measures were

carried into March from February

63 entered Special Measures in March

38 exited Special Measures in March

447 in Special Measures at the

end of March

Of those exiting


Data from Mar cut

33

249

5

Sufficient ImprovementsDeregisteredRegistration Cancelled

321 100 19 7

0% 20% 40% 60% 80% 100%

ASC PMS HSP Trusts IH

Locations in breach for more than four quarters, categorised by inspection activity or enforcement actions in progress or undertaken

against each

C

Action Against Long-Term In Breach – Adult Social Care & Primary Medical Services


Data from Feb cut – Presented One month in arrears

34

277 30

133 8

161 9

525 63

17315

3134 6

20% 22%

9% 6%

11%7%

37% 47%

12%11%

2%10% 4%

0%

20%

40%

60%

80%

100%

ASC PMS

No active or plannedinspection or enforcement

Number identified by thedirectorate as de-registering

Scheduled Inspection outsideKPI

Scheduled Inspection withinKPI

Recent Enforcement(Published within last 12months)Enforcement in progress -Started within last 12 months

Inspection in progress

24 1

242

220

6

1

582

18% 17%

18%

33%

16%

0%4%

17%

43%33%

0%

20%

40%

60%

80%

100%

ASC PMS

Of those with no action, length of time in breach

8Q+ %

7-8Q %

6-7Q %

5-6Q %

4-5Q %

Timeliness of our visits in response to requests for SOADs Year to date SOAD performance for all types of visits is 88% for the year overall

Are Mental Health Act and SOAD* visits timely?


35Data from Mar cut. SOAD = Second Opinion Appointed Doctor; ECT = Electroconvulsive Therapy; CTO = Community Treatment Orders

94%90% 90% 92% 95%

91% 89% 92% 93%89% 89%

88%

80%76%

70% 70%65%

77%71%

76%

59%

81% 81%85%

71% 60%

50%

67%

80%

100%

85%

62%

75%

100%

67%

83%

30%

40%

50%

60%

70%

80%

90%

100%

Medicines ECT CTO Target 95%

36

RAG Status of Business Plan Priorities A

End of year Update (Q4 18/19)

1. Transform Registration (Registration) The status of Priority 1 remains amber at the end of Q4 18/19. The revised Registration Transformation Programme (post June ’18) will continue to be delivered in 19/20. Two aspects of the original 18/19 business plan have not been delivered as originally planned in 18/19 but will roll over into 19/20.

Activities to be rolled over to the 19/20 business plan:• Start to implement registration for those responsible for ‘directing and controlling care: exploration

during 18/19 looked at existing information to support this work as well as how this work can be delivered practically in 19/20 and medium term.

• Develop the CQC register so that there is appropriate information for providers, our partners, and the public: considerations around development continue to be factored into Registration Transformation workstreams which continue into 19/20.

2. Ensure CQC is able to respond to changing models of care including use of new technology (Policy & Strategy)

At the end of Q4 significant progress has been made in enabling CQC to respond to changing models of care. Work has been done to keep this item on the wider health and asocial care agenda. Key achievements during 18/19 included; Engagement with DH and ALBs on wider regulatory frameworks, completing the integrated care providers (ICP) consultation (Oct 18) on how we register and hold ICPs to account as well as publishing a set of inspection prompts which focuses on assurance of safe use of triage and consultation apps in PMS. A Key project has also been established to define an approach to regulating technological innovation. 3. Develop CQC's approach to assessing the quality of care in a place (Policy & Strategy)

The status of priority 3 at the end of Q4 18/19 is Amber. A paper was provided to ET in December ’18; subsequently ET and Board have agreed to focus on taking greater account of local area issues when regulating providers . In addition we will also be developing and sharing more intelligence on quality in local areas which will be delivered through five workstreams. The Department of Health & Social Care have confirmed they will be commissioning CQC to undertake further Local System Reviews in 2019/20 (funding and scope is to be confirmed). 4. Roll-out changes to the regulation of Independent Health Providers

At the end of Q4 key work has been successfully completed to roll out changes to IH (including introduction of ratings for the first time for some). We have strengthened how we assess services at provider level. Consultation response and provider guidance to changes completed in Q1 and in Q2, ratings for comprehensive inspections began. Changes to regulation of IH providers were implemented in Q3 through aligning methodology with consultation. New inspection and provider handbooks were published and frameworks were updated. The ratings of IH started for providers which we gained the powers to rate. At the end of Q4 Inspections of IH services continue with the main focus remaining within the diagnostic imaging providers. Those IH services which had been rated previously are being inspected in line with frequency rules. Planning and alignment of methodology for inspections of independent doctors services (in line with PMS) has progressed with ratings inspections commencing in Q1 19/20. 5. Strengthen CQC's independent voice (IV) and engagement

IV process for new products is now well established and supported by good governance. Plans to carry out Discovery work to inform the development of a new website were submitted as part of the latest round of Strategic Change Committee, however website redevelopment may not be a priority for 19/20. The Share Your Experience service is now in private beta and is expected to go to GDS assessment on 11 June. The Provider Engagement Strategy has been approved by ET and implementation is underway. The Internal Engagement strategy was updated and discussed with the CEO. A review version reflecting Change Programme needs and new internal channels to ET and Board in Q1.

Business Plan Priorities

End of year update (Q4 18/19)

6. Deliver our Digital Programme

The status of priority 6 at the end of Q4 18/19 is red. A number key challenges have been faced in this area due to resource and capacity factors. Reprioritisation in Q2, saw this area of work focus on delivering critical level work in 18/19. A number of initiatives will continue into 19/20.

Activities to be rolled over to the 19/20 business plan: Monitor Discovery has now superseded the Information Exchange work around ASC PIR & GP PIC and is due to commence in March. Further work which has impacted Intelligence activity has been highlighted under priority 7. 7. Enable CQC to become intelligence driven

The status of Priority 7 at end of Q4 18/19 is amber/ red. A number of achievements have been made this year enabling CQC to become more intelligence driven; however elements of this priority were highly ambitious and will be carried forward in to the 19/20.

Activities to be rolled over to the 19/20 business plan:• CQC Insight for independent health (acute) now due to complete in Q1 due to technical issues• IHub for mental health (NHS) and development of CQC Insight for MH to will move to Q1 due to capacity.• ASC PIR and GP PIC development stopped from Q2 18/19 as current trajectory unable to achieve overall outcome.

Work has been incorporated into wider review of Monitor and Inspect & Rate which completes in Q4 18/19. • Data strategy work is behind plan with personnel changes driving the delay. The revised date to get this agreed is

end of Q1.• New NHS survey contracts remain unsigned; discussions with incumbent. Letters of intent have been extended

until the end of May to finalise contract issues. Government Legal Department are supporting to resolve contract issues. Plans will continue to be developed with new supplier during the resolution statge.

8. Develop a quality improvement culture within CQC

The status of Priority 8 at the end of Q4 18/19 is Amber. A number of activities have been completed within this priority, which incudes the recruitment of an internal improvement team and development of the QI framework. Work to procure the external partnership that will support the QI capability programme Is due to be complete at the end of Q4. In addition to the QI capability building programme for colleague will also launch in Q4.

Activities to be rolled over to the 19/20 business plan The two critical success factors for the programme going forward are 1. allocation of sufficient capacity for colleagues to participate in the structured improvement skills capability-building programme 2. active participation of SLT30 members on the 'leading for improvement' programme, testing and modelling necessary leadership behaviours to enable systematic improvement work to be successful and embed.9. Improve the experience of CQC staff

The 2018 people survey results were discussed at ET in Dec, and Board in Feb. Results tell a similar story to previous years and challenges continue around technology, communications and managing change. ET and Board have agreed a corporate action plan with ET leads to address these and will review progress quarterly. Attraction and retention: Pay negotiations have concluded and will be processed in March payroll. Workload and wellbeing: the National Wellbeing group are developing a wellbeing strategy for CQC which will be discussed at ET in May and implemented across directorates, with activity already underway in some areas.Diversity and inclusion: PD continue to work with networks to implement our action plan and KPIs around this have been included in the 19/20 business plan. We have taken part in the WRES ALB report for the 2nd year running, a publication date is yet to be confirmed. Learning and development: Shaping our future leaders launched in February. We received 192 applications for 100 places which reflect the broader diversity of our workforce.

Status of Internal Audit Actions A

Internal Audit

Audit Action Status

Completed actions and reports

Number of completed actions in Q4

21 action(s) complete H4

M7

L10

NR0

Closed audit plans in Q4

Preparation of Inspection Reports [18/19]

General Data Protection Regulation [18/19]

Customer Service (NCSC) [18/19]

Governance & Risk Management (MO, HEW, NGO) [17/18]

Experts by Experience [17/18]

Cash & Treasury Management [15/16]

163actions

Overdue High Priority Actions

Progress (this quarter qtr.) Progress (previous qtrs.) NR =Not Rated

CQC track progress of the agreed audit plans developed in response to internal audit report findings. The table below provides a summary of all open internal audit action plans (to date) and sets out the progress of completion . Individual actions within plans are rated by priority (i.e. high, ‘medium’, ‘low’ and ‘not rated’).

Audit Rating Total

Investment Appraisal, Managing Change and Benefits Realisation [16/17]

Limited

1

IT Disaster Recovery [17/18] Limited 3

Total 4

A udit YearA udit

R at ing

N o clo sed

(previo us

qtrs)

N o C lo sed

this Qtr.

T o tal N o .

C lo sed

N o . On

T rack

N o .

Overdue

T o tal

act io ns

Fee Forecasing and Grant In

A id 18/ 19 M o derate 1 1 2 1 2 5

40%

Enforcement 18/ 19 M o derate 4 2 6 5 4 1540%

Prepation of Inspection

Reports 18/ 19 Limited3 1 4 0 0 4

100%

Strategy Implementation 18/19

Business Plan 18/ 19 M o derate 4 0 4 0 2 667%

General Data Protection

Regulation (GDPR) 18/ 19 M o derate 22 1 23 0 0 23 100%

Customer Service (NCSC) 18/ 19 M o derate 5 2 7 0 0 7 100%

Governance & Risk

M anagement

(M O,HWE,NGO) 17/ 18 M o derate

6 1 7 0 0 7100%

IT Disaster Recovery 17/ 18 Limited 2 4 6 1 8 15 40%

Health & Safety (17/18) 17/ 18 M o derate 3 3 6 1 0 7 86%

Experts by Experience 2017 17/ 18 M o derate 3 2 5 0 0 5 100%

CQC Insight 17/ 18 Substant ial 1 0 1 0 1 2 50%

Strategic Implementation Plan 17/ 18 N R 7 0 7 0 1 8 88%

Inspection Ratings 16/ 17 M o derate 14 0 14 0 1 15 93%

Investment Appraisal/ Change

M anagement 16/ 17Limited

7 1 8 0 3 11 73%

Cyber Security 15/ 16 M o derate 24 0 24 0 2 26 92%

Cash & Treasury

M anagement 15/ 16 M o derate 4 3 7 0 0 7 100%

T o tal 110 21 131 8 24 163 80%

C o mplet io n P ro gress %

5%15%

80%

No On track

No Overdue

No Closed

38

Strategic and high-level risks - summary Residual Max tol Confid Update

External

R2 If a change of external environment in health and social care occurs with implications for CQC’s

role (e.g.: integration) then we could become less effective in identifying risk and ensuring the quality of

care. This includes if we are unable to define our role in line with the NHS long term plan, we will be

unable to effectively deliver our purpose.

9 ↑ 12 M Risk increased from 4. Risks to CQC of new NHSI/E

operating model – short and longer term - identified and

discussions ongoing on how to manage these with the

relevant NHS National Director.

R17 NEW If a general election is called, then there could be a period of uncertainty regarding investment in

CQC’s change programme

9 npc 12 M

R16 If EU exit affects access of EU nationals to UK employment; and Government resourcing, then this

could: impact on providers’ ability to provide good quality care, due to recruitment issues; impact on

CQC’s ability to recruit people; impact on the ability of CQC to obtain capital funding for our change

programme

9 npc 12 M CQC readiness plan for no deal EU exit is in place. We will

continue to review this in light of developments in the

coming weeks/months to ensure readiness in case it needs

to be put into action.

Deliver our operating model, and evolve it

R1 If we do not have impact in encouraging improvement innovation and sustainability in care, then

people who use services are at risk because poor quality care does not improve; the development of

Innovative or Technology based care is hampered by inconsistent regulation

12 ↔ 12 M A key project has been established to define an approach

to regulating technological innovation.

R3 If we do not effectively implement and evolve our Operating Model then people who use services

are at risk of harm or providers can successfully challenge us, and our model will not be relevant in a

changing landscape.

6 ↔ 4 M Regulatory risk framework reviewed, improved and

launched March 2019. Work commenced April on 5

consistency workstreams

R7 If we fail to implement an effective approach to regulating place-based and emerging new models

of care, we could become less effective and relevant in identifying risk and ensuring the quality of care

8 ↔ 12 M Discussion underway on resources required in order to

respond to external landscape changes in order to remain

relevant as a regulator.

R12 If a difficult to replace Adult Social Care provider fails and CQC hadn’t spotted it to give early

warning to local authorities, then people who use services are at risk because their care services

become inoperable.

8 ↔ 12 M MO Team has been restructured to improve resilience and

share best practice.

Change and improvement

R4 If we do not effectively collect & process information, then the public will not be helped to make

decisions about care & our staff & stakeholders won’t have quality information to make regulatory

decisions.

12 ↓ 12 M Rating improved from 16. Some improvements in areas of

the Intelligence driven work activities, although some areas

remain behind plan and work is ongoing to address this.

R5 If the changes in our Strategy are not well supported by IT technologies/ systems, then critical

products will be delivered late; will not be effective; or be over budget.

12 ↓ 12 M Digital Portfolio now better resourced with progress made

around FITS programme and O365 and planning and

prioritisation of Digital initiatives concluded for 19/20.

R13 If we do not have the capacity or capability to effectively deliver change and quality improvement

in CQC then we will not realise the benefits envisaged in our Strategy16 ↔ 12 M Work on resourcing underway which will further define

delivery. Robust strategy in place for securing and

managing resources across the portfolio and phased

delivery plan being put in place.

Our people

R6 If we fail to improve the experience of our people then morale and well-being of our people will be

affected, and we will not be able to recruit right people with the right skills in the right places4 ↓ 4 H ET and Board have agreed a corporate action plan with ET

leads to address these and will review progress quarterly.

Strategic & High Level Risk

39

Strategic and high-level risks - summary Residua

l

Max tol Confi

d

Manage our organisation effectively

R8 If we fail to address the Health, Safety and Well-being needs of CQC people then they could be injured

or suffer ill health.4 ↓ 4 H The safety monitoring system has been selected. This

will be deployed as part of the roll out of the new

Samsung phones.

R9 If we are unable to deliver our programme of commitments as a result of CQC’s own capacity

issues, then people who use services are at risk and providers and public will not have trust in CQC.

6 ↔ 12 M KPIs for delivery and recruitment monitored and no

material issues

R10 If we are unable to reduce our costs in line with our reduced budget or our fees are not received in a

timely way then we will be unable to deliver our functions and we will not provide VFM.

4 ↔ 8 M Risk mitigation is operating effectively and has been

enhanced as capital expenditure is now reported on

monthly

R14

a

If we are unable to deliver our IT technologies and systems due to stability issues then critical work

will not be delivered

8 ↔ 4 M Mitigating any stability issues with systems by

including the business non-functional requirements

into future provisioning requirements

R14

bIf we are unable to deliver our IT technologies and systems due to Cyber security attacks, then

critical work will not be delivered or data security breached.

6 ↓ 4 M Will consider if changes to this risk are required in light

of work on new digital services environment.

R15 If we do not successfully deliver our future IT services programme, which is to secure our future digital

services provider, then we will not be able to operate.

5 npc 10 M Programme Director and Programme Managers

recruited. Design Partner procured and work

progressing on TOM design and sourcing strategy.

R11 If we are not protecting or securely managing our information, then loss of personal/ confidential data

will cause harm/distress to individuals; and people are unwilling to share information with CQC.4 ↔ 4 M The Information Governance Group regularly reviews

information risk and we have not identified a

significant change in our risk profile over the last year

Strategic & High Level Risk

Risk rating key:

Very High (25) Risk increased ↑

High (15-20)

Medium (5-12) Risk decreased ↓

Low (2-4)

Very Low (1) Risk unchanged ↔

Performance Report: Quarter 4 March 2019...performance • Risk Report • Internal Audit Report •...

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