ANNEX A - CQC Performance, Quarter 4 and Full Year 2012/13

ANNEX A - CQC Performance, Quarter 4 and Full Year

2012/13Contents

Section 1 – Scorecard summarySlide 2

Section 2 – delivery priority 1: Deliver and Improve our regulatory and other functionsSlides 3 - 7

Section 3 – delivery priority 3: Manage our organisation, people and resourcesSlides 8 - 9

Section 4 – Levels of compliance and non-compliance - registered locationsSlides 10 - 13

Section 5 – CQC equality objectives tracker Slide 14

Section 6 – Explanatory notes to the scorecard measures Slide 15

1

All measures with a tick are included in our monthly performance dashboard which is published

on our website.

Agenda item 5

Paper No: CM/03/13/04 Annex A

Q4 and Full Year YTD scorecard summary

Operating performance - Compliance inspections

Resources and audit actionsCustomer Service

Operating performance - Registration, Enforcement and MHA

Measure Target Q1 Q2 Q3 Q4 12-13

registrations within 8 weeks

90% 90% 88.2% 82.9% 82.1% 86% G

variations within 4 weeks 90% 71.8% 75.8% 72.4% 74.5% 73.6% A

% warning notices - 14 days

90% 81% 79% 79% 75% 83% G

MHA Commissioner visits

- 267 302 243 278 1,090 MI

SOAD requests allocated < 4 working days

95% N/R 100% 99.9% 99.8% - G

CI Vacancy rate <2% 12.5% 7.8% 0.4% 0% 0% G

Establishment Total

- 2,292 2,296 2,392 2,408 2,408 MI

Turnover 13.5% 2% 1.8% 0.3% 7% 7% G

Sickness rate <5% 3.6% 3.2% 4% 3.5% 3.5% G

Revenue variance vs. budget

5% See section 3 of the cover paper of this report G

% of outstanding audit actions completed

90% 97% 94% 95% 95% - G

Calls Safe guarding

90% 94.3% 94.4% 92.8% 95.6% 94.3% G

Calls Mental Health 90% 95.9% 95.5% 93.8% 96.7% 95.5% G

stage 1 complaints

<90% of

495105 96 117 107 425 G

Stage 1 proceeding stage 2

<20%20%

(21)

27%

(26)

12%

(13)

21%

(22)

20%

(83)G

stage 2

completed in < 20 days

95% 81% 67% 100% 89% 83% A

Measure Target Q1 Q2 Q3 Q4 12-131

NHS

Trusts

100%

(318)

20%

(71)

14%

(50)

39%

(137)

26%

(53)

100%

(318)G

ASC100%

(22,255)14%

(3,556)18%

(4,384)26%

(6,562)

28%

(6,987)

99.9%

(22,250)G

IHC100%

(2,120)

7%

(196)

7%

(186)

20%

(565)

39.8%

(1,101)

99.9%

(2,117)G

Dental100%

(3,546)

14%

( 499)

15%

(523)

29%

(1,023)

46.2%

(1,637)

104%

(3,682)

G

AMB 100%

(216)

5%

(16)

6%

(20)

17%

(55)

34.7%

(110)

100%

(216)G

Overall 100% (28,591)

15.2%

(4,338)

18.1%

(5,163)

29.2%

(8,342)

34.6%

(9,888)

99.9%

(28,583)G

21 2012/13 Compliance figures includes 852 locations that became inactive and deregistered after inspection (with 5 outcomes or more)

Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration

Compliance Monitoring

In 2012/13 we undertook a total of 35,371 inspections, this includes inspections where we responded to concerns raised by users or where we followed up progress in resolving non compliance identified in earlier inspections as well as those that were scheduled to be undertaken in the year. In short our overall 2012/13 business plan inspections programme for the year was achieved, compared with active locations compliance inspectors completed the programme in all but 8 locations. A full reconciliation to the 2012/13 Business Plan targets is given on the second table on the left

Note that our inspection figure of 28,583 inspections, this includes 852 locations that became inactive and deregistered after inspection (with 5 outcomes or more) these were reconciled to the overall inspection data at year end but not included in the quarterly breakdowns.

By sector:

• 100% of NHS active locations completed (318),• The ASC programme completed all but 5 active locations (22,250 completed)• The IHC programme completed all but 3 active locations (2,117 completed)• 104% of Dentist locations and;• 100% of the active ambulance locations completed.

Notable achievements by sector are detailed in the cover paper of this performance report annex.

CQC Performance – Q4, and full year 2012/13 – section 2, Deliver and Improve our regulatory and other functions

3

Compliance Monitoring Inspections ( with 5 outcomes or more ) completed

Ref Indicator TargetQ1

12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY

12-131

FY

11-12RAG

C01

NHS - at least 1 service per trust (291 Trusts - 350 locations)

100% 71 50 137 533181

(100%)109 G

C02

25,008 ASC provider locations

100% 3,556 4,384 6,562 6,98722,2501

(99.9%)9,8182

G

C03

2,764 IHC provider locations 100% 196 186 565 1,101

2,1171

(99.9%G

C05

3,545 dental provider locations 100% 499 523 1,023 1,637

3,6821

(104%)1,432 G

C04

317 private ambulance provider locations 100% 16 20 55 110

2161

(100%)- G

Overall 100% 4,338 5,163 8,342 9,888 28,5831 11,359 G

1 2012/13 Compliance figures includes 852 locations that became inactive and deregistered after an inspection had been undertaken (with 5 outcomes or more). The overall Dentists amount includes an additional 136 inspections performed that were above target, the full year target is 35% of all Dentist locations. 2The figure for 11-12 is ASC and IHC combined

2012/13 Inspections undertaken and reconciliation to Business Plan

NHS ASC IHC DEN AMB TOTAL

a. Inspections 311 21,489 2,048 3,682 201 27,731

b. Inactive locations 16 2,078 403 0 61 2,558

c. Inspected and then de-registered 7 761 69 0 15 852

d. Dormant 6 675 98 0 38 817

e. Biennials 0 0 117 0 0 117

f. Prisons 0 0 26 0 0 26

g. Out of scope 10 0 0 0 2 12

Total (a-g) 350 25,003 2,761 3,682 317 32,113

Business Plan 350 25,008 2,764 3,546 317 31,985

Variance 0 -5 -3 136 0 128


QRP, Thematic Reviews and compliance

C30 Total user voice items on QRP - 29,601 40,951 48,7031 52,815 52,815 N/A MI

C16 Number of thematic reviews undertaken 3 - - - - 3 - G

Commentary:

Almost 5% of all of our completed scheduled inspections included Experts by Experience - There were 1,408 site visits that involved an Expert by Experience a significant increase compared with 506 or 3% in 2011/12. There were 1,760 responsive inspections undertaken this year compared to 2,589 in 2011/12, although a decrease of 829 it was expected given the rise in the number of scheduled inspections that have taken place this year in comparison to last year (over double).

72.2% of final compliance reports were completed within 25 working days compared with a plan of 90%, draft reports were also significantly under plan and 69% for the year. The underperformance can mostly be attributed to prioritisation of inspections but also to this indicator not reflecting the complexity of some reports, particularly at NHS Trusts.

There were 3 thematic reviews completed during 2012/13 covering: Dementia, Hospital discharge arrangements , Access to secondary care. CQC carried out a review of hospital data looking at outcomes for people with dementia in hospital. The key findings were that almost a third of hospital admissions involving people with dementia did not include a record of their dementia, despite the fact that it had been identified in the past. Home care - There were are 250 home care services that provided care to more than 26,000 people, during the review more than 4,600 people were contacted and 738 people were visited in their own homes. The review found that 74% of the services were meeting all five of the standards that our inspectors checked.

The number of total user voice QRP items in 2012/13 is 52,815 of these there were 40,102 NHS data items, 11,215, ASC data items and 1,498, IHC data items. In 2012/13, a project was undertaken to increase the volume and coverage of information submitted to CQC. The volume of 'people's voice' data items increased by 38% in NHS QRPs, 209% in adult social care and 33% in IHC. In February we launched a redesign of the QRP for ASC and IHC, incorporating new pages that clearly set out the regulatory history, correspondence and data relating to 'people's voice'. Inspectors feed back has been very positive.

This year 86% of all new applications were processed in under 8 weeks against a target of 90%. Although below plan this year’s performance represents a significant improvement compared to the overall percentage processed within 8 weeks last year which was 73%.Variation BAU applications within 4 weeks also ended the year under plan at 74%.


4

Scheduled Inspections and Experts by Experience

RefIndicator

TargetQ1

12-13

Q2

12-13

Q312-13

Q412-13

FY 12-13

FY 11-12

RAG

C07Responsive inspections undertaken

- 488 489 393 390 1,760 2,589 MI

C09 % of site visits that involve Experts by Experience 6% N/R N/R N/R N/R

4.9%

(1,405)

3%

(506)A

C16The % of draft compliance reports issued within 10 days (of site visit)

90% 64.8% 64% 72.5% 70.7% 69.3% 57.3% R

C17

The % of final compliance reports issued within 25 days (of site visit)

90% 73.6% 65.9% 74.3% 73.3% 72.2% 66.4% R

Registration


12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY

12-13

FY

11-12RAG

R01

Percentage of new provider and manager registration applications completed within eight weeks 1 90% 90% 88.2% 82.9% 82.1% 86% 72.8% G

R02

Percentage of applications to change a registration completed within four weeks 1

90% 71.6% 75.8% 72.4% 74.5% 73.6% - A

R04% of applications rejected (Shared services)

<25% 23.1% 24% 25.8% 35% 27% 35.3% A

R05

Applications validated within 5 days - Shared services 90% 98.4% 98.8% 98.6% 92.3% 97% 91% G

1 Excludes 5 days NCSC processing from receipt of the application, 97% are processed within 5 days by NCSC.


12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY

12-13

FY

11-12RAG

E07

Number of warning notices served - 183 199 276 252 910 638 MI

E02

Percentage of warning notices issued within 14 days of identifying one is required

90% 81% 79% 79% 75% 83% N/A A

E05Number of suspensions

- 0 0 0 0 0 1MI

E09Non urgent cancellations of registration 6 2 3 11 22 -

MI

E11ANumber of providers cancelled voluntarily - 402 419 363 324 1,508 - MI

E11B Number of providers de-registered due to CQC intervention

- 9 12 20 34 75 -MI

GL13 Prosecutions concluded with a favourable result - 1 0 0 0 1 1 MI

E13b

Section 31 HSCA 2008 – urgent suspension of registration ,or urgent variation or imposition of conditions

- 0 0 3 3 6 0 MI

E13a Section 31 HSCA 2008 – urgent removal of conditions

- 0 0 0 0 0 - MI

E14 Non urgent variations or imposition of conditions - 1 3 5 6 15 MI

E15 Removal of conditions on non urgent variations or impositions

- 0 0 0 0 0 - MI

Commentary:

The number of warning notices increased 42% (or 272) in 2012/13 compared with 2011/12. This year there have 910 warning notices issued compared to 638 for the same period last year.

Year to date there have been 910 warning notices served and 6 section 31 urgent suspensions of registration or urgent variation or imposition of conditions. Compared with last year there has been a significant increase (42%) in the number of warning notices served - there were 638 last year. Our business plan target was to serve 90% of warning notices within 14 days of identifying one is required. For the year 83% have been within plan

There were 1,508 providers that cancelled registration, of these 75 locations that have de-registered since April 2012 were due to CQC intervention.

Notable legal action during the year included use of Section 30 of our Health and Social Care Act 2008 powers, to cancel the registration of a Nottinghamshire care home owner to stop them from being able to run a residential home to protect the safety and welfare of residents. CQC took this action because it had serious concerns about the service and the risks to the people using it.



5

Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model - Other inspections and mental health

‘Other ‘ inspections

O7 HMI prisons -11 11 13 13 48 MI

Commentary:

Mental Health Act Operations

There were 1,090 MHA Commissioner visits undertaken in 2012/13, this compares with 1,502 in 2011/12. Although a reduction when compared with last year this is still over and above scheduled MHA Commissioner visits for this year.

Overall SOAD performance was below plan, in 2012/13, 712 or 70% SOAD medicines visits have been attended within 10 working days of receipt of request. There have been 344 of 68% of SOAD Electroconvulsive Therapy (ECT) visits and, 68% Community Treatment Order visits were done within target. Recruitment is on going to increase the number of available doctors. The SOAD leadership has been strengthened to include a Principle SOAD.

Notable working with partners included Mental Health Act Commissioners worked with HMI Constabulary and HMI Prisons on a joint review of the use of police custody in nine police areas. The findings will be published in a joint national report.

There were 671 or 87% of MHA Complaints were triaged with 3 working days, which is marginally below plan. There were 796 or 71% MHA complaints responded to within 25 days, a significant decline when compared with Q1 and Q2 performance of 94% and 100% respectively.

Information for ‘other’ inspections has been requested and will be included when received and reconciled.


7

Mental Health Operations

Ref IndicatorTarget

Q1

12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY12-13

FY 11-12

RAG

M1MHA Commissioner visits undertaken

- 267 302 243 278 1090 1502 MI

M2SOAD medicine visits attend within 10 working days of receipt of request

75% N/R74%

(319 of 432)

67% (393 of

589)N/R

70%(712 of 1,021)

-A

M3SOADS ECT visits - those identified as required, attend before second treatment

75% N/R90%

(78of 87)

83% (194 of 113)

N/R 62% (172 of

200)

-A

M4SOADS CTO visits- where the opinion is needed before the end of the month

75% N/R72% (31

of 43)

62% (32

of 52)N/R

66% (63 of

95)- A

M5

Requests entered within 4 working days of receipt to allocate to SOADS 75% N/R

100%(1030 of

1030)

99.9%(3,358 of

3,362)

99.8%(3,370 of

of 3,378)

99.8%(7,758

of 7,770

N/A G

M6MHA Complaints - % and number of complaints triaged within 3 working days

90% 93%

(78 of 84)

98% (187 of

191)

94%(221 of

236)

71%(185 of

260)

87%(671 of

771)

N/AG

M6A

MHA Complaints - % received which are responded to within 25 days

90%94%(83

of 84)

100% (191 of

191)

67%(159 of

236)

33% (63 of 189)

71% (496 of

700)N/A A

Commentary: The National Customer Service Centre (NCSC) achieved all service targets in 2012/13. There were over 201,000 calls handled in 2012/13 compared to 213,000 in 2011/12 a reduction of 5.6%. In the prioritised areas of calls relating to Safeguarding and Mental Health 94.3% and 95.3% respectively were answered within 30 seconds compared to a target of 90%. There were 8,634 Whistle blowing contacts received across CQC during 2012/13; the number of contacts increased gradually from 1,725 in Q1 to 2,579 in Q4. The increase in Q4 is possibly linked to media attention of the Francis report.

In April 2012, a Safety Escalation Team was set up to make sure that all high-risk information received into the NCSC is triaged and processed efficiently, consistently and quickly. The NCSC was recognised for its customer service during 2012/13 by the ‘UK top 50’ call centres programme. This is the first year the Centre entered the programme and have been ranked 36th

.Publications, web and communication

There were 6m visits to the website during 2012/13, a 25% increase compared with 4.8m in 2011/12 The most visited unique pages were:

• Reports surveys and reviews , 240,116 views, • Contact us , 225,847 views• Jobs, 202,073 views.

Some of the most popular downloads were:

• Guidance about compliance, 109,693 • Judgement framework, 20,417, • Applications to register, 13,724.

All key publications were published on target, notably, Deprivation of Liberty Safeguards annual report, Mental Health Act annual report, CQC Care update 2, Homecare themed inspection report and Dignity and Nutrition reviews on ASC and NHS.


Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Information and publication

NCSC Call handling indicators


12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY

12-13

FY

11-12RAG

NC2

Calls answered within 30 seconds - Safeguarding

90% 94.3% 94.4% 92.8% 95.6% 94.3% 94% G

NC3

Calls answered within 30 seconds - Mental Health

90% 95.9% 95.5% 93.8% 96.7% 95.5% 94% G

NC4Calls answered within 30 seconds - Registration

80% 79.9% 85.7% 81.8% 87.6% 83.8% 84% G

NC1‘Other’ calls answered within 30 seconds

80% 75.6% 83.7% 75.8% 83.7% 79.7% 85% G

NC6 Calls abandoned - Safeguarding 3% 1.3% 0.7% 1.4% 0.5% 1.0% 1% G

NC7 Calls abandoned - Mental Health 3% 2.7% 0.8% 5.1% 2.2% 2.7% 3% G

NC8 Calls abandoned – Registration 5% 3.2% 1.9% 5.3% 2.0% 3.1% 3% G

NC9 Calls abandoned - Other 5% 4.6% 2.2% 4.3% 2.7% 3.5% 3% G

C12 Number of Whistle blowing contacts N/A 1,725 2,047 2,283 2,579 8,634 n/a MI

8

Publications

P1Weekly provider information on the website refreshed timely

100% 92% (12 of

13)

92% (12 of

13)

100% (13 of

13)

100% (11 of

11)

96% (48 of

50)N/A G

P4Total visits to the website -

1,27m1,401,95

21,52m 1,8m 6m 4,8m

MI

P2Key publications are on target – State of Care; MHA Monitoring report; etc.

Green 100% 100% 100% 100% 100% 100% G

P3Survey: Providers informed and have the information to be regulated by us 1

-95.6% 95.6% N/A MI

Priority 3 – Manage our organisation, people and resources

Human Resources

Ref IndicatorTarget

Q1

12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY12-13

FY 11-12

RAG

HR1 Establishment Total - 2,292 2,296 2,392 2408 2,408 2,259 N/A

HR1a

Establishment and vacancy rate ( establishment less permanent staff )

<5% 14.8% 9% 3.1% 2.18% 2.18% 17.9% G

HR2 Compliance inspector vacancy rate <2% 12.5% 7.8% 0.4% 0% 0% - G

HR3a

New compliance inspectors complete full induction programme within 12 weeks of start date

100% 100% 100% 100% 100% 100% - G

HR4a

Staff Complete mandatory e-learning per annum and refresh it annually

95%N/R N/R 65% 70% 70% - R

HR5a

Frontline staff complete role specific mandatory learning per annum and refresh it annually

95% 42% 31% 29% 35% 35% - R

HR6 Number of permanent staff (FTE) - 1,849 2,015 2,188 2,243 2,243 1,855 MI

HR7 No of Vacancies - 339 339 73 60 60 404 MI

HR7a

New staff pipeline (Staff with an offer of employment) - 74 74 74 39 39 - MI

HR8Temporary staff in established posts

- 50 53 53 52 52 28 MI

HR10 Turnover2

13.5%

2% 1.8% 0.3% 7% 7% 8.1% G

HR11

Sickness Rate (based on calendar days) 2 <5% 3.6% 3.2% 4% 3.54% 3.54 3.2% G

HR12

Health and Safety - no. of workplace accidents - 4 11 11 33 33 28 MI

Commentary:

Sickness rates and turnover remained low throughout the year and were well within tolerances for the full year targets to be achieved. There was a marginal increase in the overall illness rate to 3.65% of all working days lost to illness, compared with 3.2% last year while turnover reduced to 7.1% this year compared with 8.1% last year.

In February, the staff survey ‘pulse check’ results were published, notably there were some improvements since the staff survey in 2012:• There is an overall satisfaction rate of 58%, up 10%• Significant increase in CQC changing for the better 15% increase; • people committed to CQC’s future direction up 13%; • And 10% more would recommend CQC as a good place to workMandatory training completion remains low at the end of March 2013. The current mandatory compliance rate overall, and specifically for CIs and RAs requires further investigation to understand the organisational and operational constraints which may be impacting on completion of mandatory training or the effective recording of mandatory training having been completed. These investigations will be undertaken by the end of June 2013. What will also help us establish a contemporary and accurate picture is the skills audit that CIs and RAs will be undertaking in the next few weeks enabling CQC to audit its own records against those that staff hold. Our full training needs analysis work will result in a much more effective list of mandatory training that will be a key part of our new Academy.

At the beginning of the financial year there was a vacancy rate of almost 25% for compliance inspectors, following a successful recruitment campaign this has been reduced to zero and a full complement of 955 compliance inspectors are now in place with all training cohorts having been completed.

HR led in sourcing and training the inspectors and with other areas managed significant risks to quickly turnaround and deploy the Inspectors across the country. The HR team also managed a quick turnaround for the recruitment and training of over 150 Bank Inspectors that helped deliver our challenging inspection commitments.

CQC Performance – Q4, and full year 2012/13 – section 3, Manage our organisation, people and resources

9

Priority 3 – Manage our organisation, people and resources and governance

Corporate governance (complaints and statutory requests for information) and Finance

RefIndicator Targe

tQ1

12-13

Q2

12-13

Q3

12-13

Q4

12-13

FY12-13

FY11-12

RAG

GL01

Number of stage 1 corporate complaints received across the organisation

<10% of

11/1298 94 115 107 414 495 G

GL02

Stage 1 Corporate complaints upheld

- 7 8 3 2 20 N/A MI

GL03

Of the initial stage 1 complaints received the number proceeding stage 2 <20%

20%(21)

27% (26)

12%(14)

21%(22)

20%(83)

N/A G

GL05

Of those closed , the number of stage 2 reviews completed in 20 working days 95% 81% 67% 100% 89% 83% 81% A

GL0

4No of stage 2 complaints upheld

- 5 2 0 3 10 N/A MI

GL07

Parliamentary Ombudsman enquiries

- 12 3 11 4 30 29 MI

GL08

Of closed requests proportion closed within deadline - Freedom of Information

95% 95.8% 97.1% 97.7% 98%97.2% (801)

97.1%

(1,103)G

GL09

Of closed requests proportion closed within deadline - Data Protection

95% 92.9% 100% 84% 94.696% (143)

96%

(118)G

GL10

Of closed requests proportion closed within deadline - Info Sharing

95% 98% 94.7% 92.9% 100%96.5%(165)

98%

(182)G

GL12

% of outstanding critical and important audit actions completed

90% 97% 94% 1 95% 95% 95% N/A G

GL14

Urgent cancellations of registration (under section 30 of the HSCA 2008)

- 0 0 1 0 1 N/A MI

F01 Revenue expenditure plus depreciation variance vs. Budget (excluding fee income)

5%The cover paper of this report includes a breakdown of the financial

position for the full year

Commentary:

In 2012/13 we received 414 stage one complaints compared with 495 during 2011/12 a decrease of 16% compared with a planned reduction in complaints of 10%.

Complaints progressing to stage 2 ended the year at 20% compared with our threshold of 20%. Overall 83 complaints progressed to stage 2.

Stage 2 complaints handled in under 20 days ended the year at 83% overall within plan, which represents just 14 complaints not within plan, often due the complex nature of the complaint or the requirement of information from a range of sources.

Statutory requests for information

There have been 1,148 requests for statutory information this year,1,107 or 96.4% were completed within the statutory deadlines compared to 1,403 or 97.8% in 2011/12. The majority, 803, were freedom of information requests, although significantly down from last year when there were 1,103.

Audit actions

The percentage of outstanding audit actions in 2012/13 was 95% which exceeded the 90% target.

CQC Performance – Q4, and full year 2012/13 – section 3, Manage our organisation, people and resources

10

Number of locations in each sector that meet essential standards of quality and safety

CQC Performance – April - June, Q1, 2012 – compliance outcomes

By sector – location level

The graph to the left illustrates levels of compliance across all sectors. This graph should be viewed as a ‘snapshot’ at a given point across a range of variables, for example, which outcomes are reviewed and when, therefore it is not possible to make a perfect and direct comparison quarter on quarter. However by means of an overview, a comparison with other quarterly snapshots demonstrates that - at the end of Q4 there were 23,479 or 47.4% compliant locations compared with 13,218 or 32.5% in Q1, an increase of 10,261. There are 20,794 or 42% locations have not yet had an inspection (compared with 23,306 in Q1) and 5,281 or 10.7% were non compliant with at least one outcome.

Adult Social Care has the highest percentage of compliant organisations at 67.3%, Independent Healthcare has 55.2% and Independent Ambulances has 44.4%, although across all the sectors there are locations that are yet to be reviewed.

Year to date there have been 910 warning notices served to 578 providers, 75 locations have de-registered following intervention by the CQC and there have been 6 urgent suspensions of registration, or urgent variation or imposition of conditions using Section 31 powers.

CQC Performance –Q4, and full year 2012/13 – section 4, levels of compliance and non compliance at registered locations

11

44.4%

55.2%

32.5%

39.2%

0.1%

67.3%

11.5%

8.5%

6.2%

3.8%

0.0%

17.7%44.1%

36.3%

61.3%57.0%

99.9%

15.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

IndependentAmbulance

IndependentHealthcare

Org

NHSHealthcare

Organisation

PrimaryDental Care

PrimaryMedicalServices

Social CareOrg

Compliant Non compliant Not yet reviewed

CQC Performance – Q4, and full year 2012/13 – section 4, compliance outcomes

NHS locations non-compliant with one or more outcomes, by age

The following graphs show , for the NHS, for Adult Social Care, and for other providers, the period of time that they have been non-compliant. This data includes locations consistently non-compliant with a single outcome and locations that were non-compliant at the beginning of several quarters but with different outcomes. Some of the latter group may have returned to compliance during a quarter, only to become non-compliant again by the time the data is captured at the beginning of the next quarter.

In Q4 2011/12 there were 128 NHS trust locations that were non complaint compared to 134 in Q4 2012/13. A general increase in the numbers of NHS locations non-compliant for less than one quarter from 34 in Q4 2011/12 to 39 in Q4 2012/13, whilst there has been a been an increase (from 13 to 30) in the number non-compliant for over one year (although this number has been broadly stable since Q2 and should be considered in the context of a significant increase in inspection activity). The following two slides are in the same layout as this slide and illustrate the levels of compliance at ASC (slide 12) and IHC, Ambulance and dentist locations (slide 13).

Levels of compliance and non-compliance - registered locations

12

Note that these slides must be viewed in the context of time lags between inspection and final publication of the report and also the lag to re-inspection following identification of non-compliance

Location been non compliant for:

Q4 Q1 Q2 Q3 Q4

2011/12 2012/132012/13 2012/13

2012/13

Over one year

13 25 31 29 30

10% 22% 28% 22% 22%

More than three quarters but less

than one year

26 19 11 11 5

20% 16% 16% 8% 11%

More than two quarters but less

than three quarters

24 22 18 11 15

19% 19% 16% 8% 11%

More than one quarter but less

than two quarters

31 29 18 26 45

24% 25% 16% 20% 34%

Less than one quarter

34 21 34 54 39

27% 18% 30% 41% 29%

Total non compliant in period 128 116 112 131 134

22 18

1115

1325

31 29 30

26

19 1111 5

24

31

29

18

2645

3421

3454

39

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 11/12 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13

Non Compliant >4 qtrs Non Compliant < 4 qtrs Non Compliant < 3 qtrs

Non Compliant < 2 qtrs Non Compliant < 1 qtr

ASC locations non-compliant with one or more outcomes, by age


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Q4 Q1 Q2 Q3 Q4

2011/12 2012/13 2012/13 2012/13 2012/13

Over one year

178 432 765 953 933

5% 12% 20% 23% 21%


than one year

372 500 624 501 359

11% 13% 16% 12% 8%


than three quarters

656 783 694 501 526

20% 21% 18% 12% 12%


than two quarters

1,078 1,070 771 710 1210

32% 29% 20% 17% 27%


1,065 956 1,052 1529 1437

32% 26% 27% 37% 32%

Total non compliant in period 3,349 3,741 3,906 4,194 4,465

656

783

694501

526

933953765432

178

359501624

500

372

1,210710

7711,070

1,078

1,4371,5291,052956

1,065

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 11/12 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13



The following graph shows Adult Social Care for the period of time that they have been non-compliant. In Q4 2011/12 there were 3,349 providers non compliant compared to 4,465 in Q4, 2012/13. There was an increase from those providers that are non compliant for less than one quarter; 1,065, Q4 , 2011/12 to 1,437 in Q4 2012/13, however the percentage remains constant at 32%. The proportion of providers that are non compliant over one year has increased from 178 or 5% in Q4 2011/12 to 933 or 21% in Q4 2012/13. It is important to note that during the same period the number of compliance inspections ( with 5 or more outcomes) has increased from 9,818 (although this combines both ASC and IHC) to 22,250 , an increase of 127%.

IHC, Primary Dental Care and Independent Ambulance, locations non-compliant with one or more outcomes, by age


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Q4 Q1 Q2 Q3 Q4

2011/12 2012/13 2012/13 2012/13 2012/13

Over one year

1 8 28 45 77

<1% 2% 7% 10% 11%


than one year

13 23 48 73 57

5% 6% 12% 16% 8%


than three quarters

31 53 118 83 46

12% 14% 31% 18% 7%


than two quarters

68 137 101 63 146

26% 35% 26% 13% 22%


145 166 91 205 352

56% 43% 24% 44% 52%

Total non compliant in period 258 387 386 469 678

1 828 45 77

13 23

4873 57

3153

118 83

46

68

137

101

63

146

145

166

91

205352

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 11/12 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13



The following graphs show IHC, Primary Dental Care and Independent Ambulance providers, for the period of time that they have been non-compliant. There were 258 providers non compliant in Q4 2011/12 compared to 678 in Q4 2012/13. There was an increase from those providers that are non compliant for less than one quarter 145, Q4 , 2011/12 to 352 in Q4 2012/13, or from 56% to 52%. The proportion of providers that are non compliant over one year has increased from 1 or 0.4% in Q4 2011/12 to 77 or 11% in Q4 2012/13. It is important to note that during the same period the number of compliance inspections (with 5 or more outcomes) has increased significantly.

All priorities – corporate equality objectives

RefIndicator Target FY

12 -13

FY

11-12

EQ1Embed equality across all our regulatory and corporate activities Green G -

EQ2

Ensure that, we identify and respond appropriately when providers do not meet the equality aspects of the essential standards of quality and safety

Green A -

EQ3

Improve information and intelligence that we hold about health and social care providers in order to better identify risks to equality

Green G -

EQ4Involve a diverse range of people who use services in our work Green G -

EQ5a

Increase the uptake of accessible information that we provide to help make informed choices about services – web downloads

Green G -

EQ5b

Increase the uptake of accessible information that we provide to help make informed choices about services requests to accessible communications

Green G -

EQ6

Monitor whether people detained under the Mental Health Act have their rights to equality under the Act and Code of Practice protected through our monitoring functions, and actively seek improvements where we uncover shortcomings

Green G -

EQ7Improve the diversity profile of CQC's workforce so it is representative of the communities we serve

Green G -

EQ8Improve the percentage of staff who say that they feel safe from harassment and are treated equally at work

Green A -

EQ9 Improve the percentage of staff who have the knowledge, skills and tools to embed equality and human rights in their work.

Green G -

Commentary: Below is an update of the equality objectives performance. Objective 1: The ET and Board received quarterly updates covering our equality objectives as part of the overall performance governance of CQC.

Objective 2: The work to evaluate the regulatory response and make recommendations for future practice has been completed and the findings reported to the Executive Team. Actions have been identified for 13/14 to address gaps and improve the overall response. Amber because although the issues are identified, improvement actions have not been completed yet and many need to be integrated into the Strategy programme work projects.

Objective 3: Information is currently available relating to protected characteristics has been reviewed, a strategy for ongoing monitoring and development of new data sources is currently being drafted. Information on cases of unlawful discrimination have been sourced and communicated to compliance inspectors. The Intelligence directorate has developed a clear project plan, with appropriate resources, to improve the information and intelligence that we hold to better identify risks to equality for organisations that we regulate. This work is well developed though not completed.

Objective 4: Speak-Out Network members made up of a diverse range of local community groups and were significantly involved in the Strategy Review consultation, along with members of the Equality Voices Group and Experts by Experience. There has been a similar level of engagement with the developing Statement of User Involvement.

Objective 5: The number of web downloads for the CQC for Easy reads, Large print and alternative languages totalled 68,577 in 2012/13. , this is due to the number of Corporate publications published since January 2013 including CQC response to the Francis report, the Strategic Review and Dignity and Nutrition review into both Care homes and Hospitals.

Objective 6: MHA Commissioners from two regions are currently piloting the equality monitoring formal methodology during their visits to patients who are detained under the Mental Health Act. This work will be evaluated and then used more widely during 2013/14.

Objective 7: Analysis of equality monitoring suggest that there is little movement in the staff profile. However, some action has been taken to improve the data that CQC hold and to look at positive action measures to improve the number of black and minority ethnic staff in senior grades. Learning and development and the Race Equality Network are working together to develop opportunities for career development for Black and Minority ethnic staff. Objective 8: A revised Bullying & Harassment Policy has been published which includes reference to accessing the 25 Dignity at Work Advisors. This is additional to the work of an external expert. This is rated amber to reflect that monitoring of this work will be reflected in the staff survey later in 2013.

Objective 9: Work on methods for domiciliary care agencies and community based services has included developing feedback methods to meet a range of communication needs - giving inspectors better tools to ensure a diverse range of people who use services can give us their views. In developing judgement framework impact examples, we have included specific case studies around equality aspects of our standards, for example in relation to GP services. These are available to both inspectors and providers.

CQC Performance – Q4, and full year 2012/13 ,– section 4, equality outcomes

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A document with public to technical definitions of our corporate measures has been completed and is available on the intranet. This section is intended as an accessible guide to the overall performance areas in this report.

ComplianceA key part of our regulatory work is carrying out inspections to determine whether services are meeting the government standards. Our inspections focus on the outcomes that we expect people to experience when they use a service and assess the care, treatment and support they receive. Inspections include information from a range of sources including service users, the public, commissioners and other regulators. The measures in this section monitor the commitments we made to inspect services this year.

Our inspections of NHS Trusts include inspecting acute hospitals. The term 'acute' is used when referring to active care or treatment (usually in secondary care) to adults, children, or both, that requires urgent or emergency care, usually within 48 hours of admission or referral from other specialties, and includes recovery time from surgery.

Our publication ‘How CQC regulates’ was published alongside our business plan and explains the types of inspection we undertake:

• Scheduled inspections are planned by CQC in advance and can be carried out at any time.

• Follow up inspections are made when we want to check whether the provider has made improvements we are requiring them to make

• Responsive inspections are where inspectors inspect because of a specific and immediate concern.

• Themed inspections are where we look at a particular type of care or issue across one or more care sectors, for example dignity and nutrition in NHS hospitals, or care for people with a learning disability in both care homes and hospitals.

ComplaintsThe CQC welcomes comments and suggestions about performance and the conduct of staff, including complaints about the CQC. Every complaint is investigated, and the feedback used to develop and improve the Commissions services. These measures demonstrate the volume, efficiency and overall effectiveness of how complaints are handled.

CQC Performance – section 6, understanding the scorecard EnforcementWe have a variety of enforcement powers available to us where we find a service is not meeting one or more of the standards. When we exercise these powers we do so in a proportionate way, considering the effect on the public and those who use services. This suite of powers enables us to take swift, targeted action where services are failing the people who use them. We report in our scorecard on the enforcement actions we have taken. A detailed description of our enforcement actions is available on our website.

One of the most often used of our enforcement powers is a Warning notice. A warning notice tells a 'registered person' that they are not complying with a condition of registration, requirement in the Act or a regulation or any other legal requirement we think is relevant. They can be published if the provider has been given the opportunity to make representations and where those representations if made are not upheld. Our enforcement powers also include suspending or cancelling the service’s registration, or prosecution.

EqualitySetting equality objectives is a requirement for public sector bodies under the Equality Act 2010 specific duties regulations. The objectives that we have set for the CQC are stretching and they focus on the biggest equality challenges that we face. The objectives are listed here and are reported quarterly, they will track delivery of supporting work against each objective.

Experts by ExperienceExperts by Experience are people who have experience of using or caring for people who use health, social care and mental health services.

FinanceOur finance measures cover high level expenditure against budget and how effective the Commission is at collecting fees due.

Human ResourcesThe indicators in this area demonstrate the overall key human resources performance areas and cover, vacancy rate, staff turnover, the sickness rate and the Commission's establishment

PublicationThe Commission publishes information about the services it regulates on the CQC website. It also produces a number of publications each year covering reports, surveys, themed inspections, reviews and studies. These measures indicates how well the Commission is in getting information to people in a timely way.

Mental Health We protect the rights of people being treated under the Mental Health Act. Our aim is to improve the outcome for every person who uses care services commissioned under the Act. Indicators in this area cover, Commissioner visits, second opinion appointed doctor service and complaints from service users about providers. Commissioner's visit wards that detain people under the Mental Health Act. They meet patients and ensure staff use their powers appropriately. These measures track the Commission's performance against the number of visits planned. The SOAD service safeguards the rights of patients detained under the Mental Health Act who refuse the treatment prescribed to them or are deemed incapable of consenting. The role of the SOAD is to decide whether the treatment recommended is clinically defensible and if consideration has been given to the views and rights of the patient.

National Customer Service Centre The National Customer Service Centre (NCSC) is the first point of contact for members of the public, service users and providers. Other InspectionsThe Commission has the power to inspect a range of other specific areas, all of the measures in this area track our delivery of inspection activity against our plan. IR(ME)R - the Ionising Radiation (Medical Exposure) Regulations, our inspections monitor the use of ionising radiation for medical exposure. Controlled drugs covers a range of areas including assessing and overseeing how health and social care providers manage controlled drugs. The Pharmacy team supports Compliance function in specific activities relating to controlled drugs. There are also a number of joint inspections were the CQC work with other regulators, for example a 3 year programme of inspections covering all local authority areas in terms of their provisions for child safeguarding and looked after children with Ofsted, and joint inspections with HM Inspectorate of Prisons and HM Inspectorate of Probation.

RegistrationTo be registered with the CQC, providers must meet the essential standards of quality and safety for each regulated activity they provide at each location. Providers will not be registered if they cannot declare full compliance. These measures capture the efficiency of the Commission in processing these applications.

The Quality and Risk Profiles (QRP) gather key information about care providers that helps inspectors to see where risks lie and prompt them to take a closer look. It is also an essential tool for providers and commissioners to monitor performance in their own services.

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ANNEX A - CQC Performance, Quarter 4 and Full Year 2012/13

Documents

Transcript of ANNEX A - CQC Performance, Quarter 4 and Full Year 2012/13