ANNEX A - CQC Performance, Quarter 3, 2012

ANNEX A - CQC Performance, Quarter 3, 2012

Contents

Section 1 – Scorecard summarySlide 2

Section 2 – delivery priority 1: Deliver and Improve our regulatory and other functionsSlides 3 - 8

Section 3 – delivery priority 3: Manage our organisation, people and resourcesSlides 9 - 10

Section 4 – Levels of compliance and non-compliance - registered locationsSlides 11 - 14

Section 5 – CQC 2012/13 equality objectives tracker Slide 15

Section 6 – Explanatory notes to the scorecard measures Slide 16

1

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

on our website.

Q3 and YTD scorecard summary

Operating performance - Compliance inspections

Resources and audit actionsCustomer Service

Operating performance - Registration, Enforcement and MHA

Measure Target Q1 Q2 Q3Year to

DateTrend RAG

registrations within 8 weeks

90% 88% 88% 83% 86% G

variations within 4 weeks 90% 70% 76% 74% 73% A

% warning notices - 14 days

90% 81% 79% 79% 84% G

MHA Commissioner visits

95% 121% 106% 82% 101% G

SOAD requests allocated < 4 working days

95% N/R N/R 100% 100% N/A G


DateTrend RAG

CI Vacancy rate <2% 13% 8% 0.4% 0.4% G

Front line staff mandatory learning

72% 42% 31% 29% 34% R

Sickness rate<5% 3% 3% 4% 4% G

Revenue variance vs. budget

5% - 8% - 8% -6% - 6% A

% of outstanding audit actions completed

90% 97% 94% 95% 95% G


DateTrend RAG

Calls in 30 sec. Safe guarding

90% 94% 94% 93% 94% G

Calls in 30 sec. Mental Health

90% 96% 96% 94% 95% G

stage 1 complaints

<10% of 2011/12 105 96 117 318 G

Stage 1 complaints proceeding stage 2

<20%20%

(21)

27%

(26)

12%

(13)19% (60) G

stage 2

completed in < 20 days

95% 67% 100% 77% 81% A


DateTrend RAG

NHS inspections

65%

(226)

20%

(71)

14%

(50)

39%

(137)

73%

(258) G

ASC inspections

59%

(14,847)

14%

(3,556)

18%

(4,384)26%

(6,562)58%

(14,502) A

IHC inspections

46%

(1,279)

7%

(196)

7%

(186)

20%

(565)

34%

(947) R

Dental inspections

57%

(2,010)14% (499)

15%

(523)

29%

(1,023)

58%

(2,045) G

Private Ambulance inspections

56%

(177)

5%

(16)

6%

(20)

17%

(55)

27%

(86) R

2

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

As at 31st December we were 75% of the way through the financial year and had completed 55.7%, (17,838) of our inspection delivery plan compared with a year to date profiled plan of 58% (18,539).

Against the number of active locations we have met 61.6% of plan over the first 3 quarters, which leaves over 38% of plan to be inspected in Q4.

As of 27th January there were 28,943 active locations (i.e. excluding those that made up the business plan target, but have since deregistered). This leaves 8,020 inspections to be completed in the next 9 weeks. Over the year productivity has improved significantly and additional resources have been made available in support of the programme delivery, however Q4 will be particularly challenging. The graph below illustrates the percentage of the plan by sector that must be delivered in Q4 to meet the overall business plan target. The second table on the left demonstrates the latest position (as at 27th January 2013 and compares the current weekly run rate and the required weekly run rate.)

1 This is the profiled target to date- annual target is given numerically in the cells to the left2 Based on including inspections from Q1,Q2 and Q3 that had less than 5 outcomes.

CQC Performance – Q3, 2012 – 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

Q312-13

YTD Trend RAG

C01

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

65%

(226)

20%

(71)

14%

(50)

39%

(137)

73%

(258) G

C02

25,008 ASC provider locations

59%

(14,847)

14%

(3,556)

18%

(4,384)

26%

(6,562)

58%

(14,502) A

C03

2,764 IHC provider locations 46%

(1,279)

7%

(196)

7%

(186)

20%

(565)

34%

(947) R

C05

3,545 dental provider locations

57%

(2,010)

14%

(499)

15%

(523)

29%

(1,023)

58%

(2,045) G

C04

317 private ambulance provider locations

56%

(177)

5%

(16)

6%

(20)

17%

(55)

27%

(86) R

N/AOverall performance against programme

58%

(18,539)

14%

(4,338)

16%

(5,163)

26%

(8,342)

56%

(17,838) A

Compliance Performance by sector

20%

7% 7%

39%

20%

29%

42% 42%

14% 14%

4%

14%18% 15%

5%

26%

18%

26%

73%

66%

0%

10%

20%

30%

40%

50%

60%

70%

80%

NHS ASC IHC Dental Private Amb.

Perfo

rman

ce

Q1 Q2 Q3 Q4 Required

747,303

1,421

1,191

179Actual number of active locations remaining to be

inspected

Latest Position of Inspection Activity and run rates (as at 27th January 2013)

Sector YTD YTD

target DifferenceCurrent weekly

Run rate

Required weekly run

rate Variance

NHS 269 261 8 4 7 -3

ASC 16,973 17,633 -660 619 629 -10

IHC 1,240 1,784 -544 86 130 -44

Dentist 2,329 2,507 -178 104 109 -5

Ambulance 112 228 -116 9 17 -8

CQC 20,923 22,413 -1,490 822 891 -69


Scheduled Inspections and compliance


12-13

Q2

12-13

Q3

12-13YTD Trend RAG

C07Responsive inspections undertaken

- 485 502 393 1,380 MI

C11The % of our inspections where we used one or more involvement methods or tools

- 61% 81% 84% 75% MI

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

90% 61% 64% 73% 68% R

C17

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

90% 68% 65% 74% 71% R

C30 Total user voice items on QRP - 34,355 40,951 48,703 48,703 MI

C16 The number of thematic reviews undertaken

3 1 0 1 2 G

C19 The % of providers and locations in each sector that are meeting essential standards of quality and safety

-

See Graphs Slide 11-14

MI

C24a Inspection Judgements - the % change to non compliant

- MI

C24b Inspection Judgements - the % change to compliant

- MI

C24c Inspection Judgements - the % no change to compliant

- MI

C24d Inspection Judgements - Average time period for change to compliant

-190.1 Days

192.5

Days

198

Days

198

DaysN/A

MI

C24e Inspection Judgements – the % of non compliant for 2 quarters

-

See Graphs Slide 11-14

MI

C24e Inspection Judgements – the % of non compliant for 3 quarters

- MI

Commentary:

The Regulatory Risk Committee has agreed to 4 thematic reviews this year covering:

• Dementia• NHS data quality • Experiences of people waiting for NHS treatment and;• Physical health needs of people with a learning disability.

The review of dementia started in September and the remaining reviews are on track to report in March 2013.

The number of user voice QRP items is 48,703 this is an increase of 42% or 14,348 since Quarter1.

Although draft and final report timeliness has improved in comparison to Q2 when it was 64% and 65% respectively performance remains below plan for this year. The graphs below demonstrates that the plan for final reports was met in April, performance declined until September and then started to show improvement. The increase in performance is partly due to release 19 of CRM which provides detailed MI for compliance managers.


4

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

The % of draft compliance reports issued within 10 working days

The % of final compliance reports issued within 25 working days

target

RefIndicator Target

Q1

12-13

Q2

12-13

Q3

12-13YTD Trend RAG

E12Locations where enforcement action taken as a % of all locations

- 0 N/R N/R N/R N/A MI

E07

Number of warning notices served

- 177 198 276 651 MI

E02

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

90% 81.2% 78.9% 78.8% 83.8% A

E04Number of Notices of Proposal served to vary / remove / impose a condition. - N/R N/R N/R N/R N/A MI

E05Number of suspensions

- 0 0 0 0 MI

E09Non urgent cancellations of registration 0 0 0 0 MI

E11ANumber of provides cancelled voluntarily

- 402 418 365 1185 MI

E11B Number of providers de-registered due to CQC intervention - 9 12 20 41 MI

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

E13b

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

- 0 0 3 3 MI

E13a Section 31 HSCA 2008 – urgent removal of conditions

- 0 0 0 0 MI

E14 Non urgent variations or imposition of conditions

- 1 3 4 8 MI

E15 Removal of conditions on non urgent variations or impositions

- 0 0 0 0 MI

Commentary:

The number of warning notices increased by 39% (or 78) in Q3 compared with Q2. Year to date there have been 651 warning notices issued compared to 396 for the same period last year an increase of 64%. The percentage of warning notices that are issued within 14 days of identifying one is required has remained fairly constant between Q2 and Q3 at 78.9% and 78.8% respectively. Year to date the figures is 83.8%.

There were almost as many warning notices issued in the first three quarters of 2012/13 (651) than all 4 quarters of 2011/12, when there were 658. So far this year an average of 72 warning notices are issued each month, compared to an average of 55 per month last year. The graph below illustrates the number of warning notices issued on a quarterly basis since Q1, 2011/12.

Notable legal action in Q3 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.

3,798 locations that have de-registered since April 2012 of these 41 were due to CQC intervention.



5

Warning Notices Issued

0

50

100

150

200

250

300

Perfo

rman

ce

Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2011/12

Q1 2012/13 Q2 2012/13 Q3 2012/13

Registration

RefIndicator Target

Q1

12-13

Q2

12-13

Q3

12-13YTD

Trend

RAG

R01

Percentage of new provider and manager registration applications completed within eight weeks 90% 87.7% 87.6% 82.5% 85.9% G

R02

Percentage of applications to change a registration completed within four weeks

90% 70% 75.8% 74.3% 73.1% A

R04% of applications rejected (Shared services)

<25% 21.8% 22.9% 26.3% 23.7% G

R05

Applications validated within 5 days - Shared services 90% 98.4% 98.8% 98.5% 98.6% G

R07

Primary medical services providers served with all Notices of Decision by 31 March 2013 (Update as at 11th January 2013).

20% by Q3

N/R N/R4,784(59.8%)

4,784(59.8%)

N/A G

Tranche 5 Update (Latest Position as at 11th January 2013)

Delivery of tranche 5 continues to progress and remains on track to achieve plan. The first six batches have closed a further two batches remain open; these will close on 4th February and 4th March. Overall, the number of providers that have submitted an application is 7,644.Year to date the figure stands at 1,539 or 20%. All non compliant applications will be subject to additional scrutiny by assessors. Year to date there have been 4,784 (or 62.6%) providers in receipt of their Notices of Decision.



Commentary:

New provider and manager applications completed within 8 weeks remains within plan at 85.9% year to date. Meeting the 4 week target for variation applications remains challenging. The graph below illustrates the weekly performance over the period from May 2012 to December 2012, although performance has improved from 65% at the beginning of May to 80% in December it remains below the 90% target.

6

Manager variation applications completed within 4 weeks

50%

55%

60%

65%

70%

75%

80%

85%

90%

Time

Improvement Line

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 (controlled drugs, ionising radiation and joint inspections)


12-13

Q2

12-13

Q3

12-13YTD Trend RAG

OC3Other inspections on track: pharmacy and controlled drugs

-156 231 230 617 MI

OC5Other inspections on track: ionising radiation (IR(ME)R)

-8 6 5 19 MI

OC6Joint inspections are on track – Ofsted

-3 0 N/R N/R N/A N/A

OC7 Joint inspections are on track - HMI prisons

-11 18 9 38 MI

OC8 Joint inspections are on track - HMI Probation

-2 0 N/R N/R N/A MI

Mental Health Operations

Ref Indicator Target Q1 12-13 Q2 12-13 Q3 12-13 YTD Trend RAG

M1 MHA Commissioner visits - Hospital visits (Actual vs. Sch.) 95%

121%(277 of

229)

106%(321 of

301)

81%(244 of

300)

101%(842 of 830)

G

M2 SOADS medicine visits attend within 10 working days of receipt of request

Q2 75%N/R

66%(219 of

330)

M2 – M4 are

reported one

quarter in arrears to

ensure data

accuracy

66%(219 of

330)N/A A

M3 SOADS ECT visits - those identified as required ,attend before second treatment

Q2 75%N/R

42% (23 of 55)

42% (23 of

55)N/A R

M4 SOADS CTO visits- where the opinion is needed before the end of the month

Q2 75% N/R59%

(30 of51)

59%(30 of

51)N/A R

M5 Requests entered within 4 working days of receipt to allocate to SOADS

Q2 75% N/R N/R99.8%

(2,132 of 2,136)

99.8%(2,132 of

2,136N/A G

M6 MHA Complaints - % and number of complaints triaged within 3 working days

90% 96.4%

(81 of 84)

98.6%(209 of 212)

93%(238 of

255)

96% (528 of

551) G

M6A MHA Complaints - % received which are responded to within 25 days

90% N/R94%

(83 of 84 )

100% (212 of 212)

99% (295 of

296) G

Commentary:

Mental Health Act Operations - planned MHA Commissioner visits remain ahead of schedule for the year to date - against a planned programme of 830 inspections in the first 9 months of the year, 842 have been completed. All complaint targets are also on track, year to date of 551 complaints about providers, 528 were triaged within 3 working days.

SOAD indicators, M2 to M4, are reported one quarter in arrears to ensure data accuracy. The short- term- type contract relationship the CQC has with SOADs means that they will often complete a visit but not update the report on time. Q2 performance reflects only August and Septembers activity, the online forms that replaced the old manual reporting were delayed in being set up and as a result reporting against these measures (which were new and were not tracked manually) has been delayed.

Overall SOAD performance was below plan, recruitment is on going to increase the number of available doctors. During the most recent recruitment process there were 80 SOAD candidates and of these 9 were successful at interview and attended an induction training session. The SOAD leadership will be strengthened to include a Principle SOAD and Operational manager to ensure robust challenge to the quality of second opinions provided. In Q2, 219 out of 330 SOAD medicines visits have been attended within 10 working days of receipt of request. 23 SOAD Electroconvulsive Therapy (ECT) visits out of 55 were attended within plan and, 30 out of 51 Community Treatment Order visits were done before the planed period of one.


7

Commentary:

NCSC call handling and quality - there have been almost 150,000 calls to the National Customer Service Centre in the first 9 months of the year, and all call handling targets are on track. The quality of service has been recognised by the ‘UK top 50’ call centres programme. This is the first year the Centre entered the programme and have been ranked 36th. Feedback from has been used to identify improvements to customer service with a view to incorporating benchmarks into the work of the NCSC.

Call Volumes increased in Q3, partly due to calls from providers of primary medical services asking for assistance with their registration applications. Call Performance is consistently good across a range of indicators and is on track year to date.

Publications, web and communication

Year to date there have been almost 4.2m visits to our website of which almost 2.7m were unique visits. The ‘reports’ section of our website has been the most visited area in the first 9 months of the year. The most visited pages were; ‘reports surveys and reviews’ with 133,425 views, ‘contact us’ with 126,775 and the Job page with 107,630 views. The most popular downloads were ‘guidance about compliance’ with 82,639 downloads, the ‘Judgement framework’ ,15,867 and ‘table of statutory notifications under the Health and Social Care act’ ,11,412.

All key publications have been published on target .Notably, the State of Care report was published during Q3, and received substantial and positive media attention.


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

12-13YTD Trend RAG

NC2

Calls answered within 30 seconds - Safeguarding

90% 94% 94.4% 92.8% 93.7% G

NC3

Calls answered within 30 seconds - Mental Health

90% 95.9% 95.5% 93.8% 95% G

NC4Calls answered within 30 seconds - Registration

80% 79.9% 85.7% 81.8% 82.5% G

NC1‘Other’ calls answered within 30 seconds

80% 95.2% 95% 75.8% 78.6% G

NC6 Calls abandoned - Safeguarding 3% 1.3% 0.7% 1.4% 1.1% G

NC7 Calls abandoned - Mental Health 3% 2.7% 0.8% 5.1% 2.9% G

NC8 Calls abandoned – Registration 5% 3.9% 1.9% 5.3% 3.7% G

NC9 Calls abandoned - Other 5% 4.6% 2.2% 4.3% 3.7% G

C12 Number of Whistle blowing contacts N/A 1,654 2,025 2,246 5,925 N/A MI

Publications

P1Weekly provider information on the website refreshed timely

100% 92% (12 of 13)

92% (12 of 13)

100% (13 of 13)

94.8% (37 of 39) A

P4 Total visits to the website - 1.3m 1.4m 1.5m 4.2m MI

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

Green Green Green Green Green G

P3

Providers feel informed about CQC and have the information they need to be regulated by us

-

No data :survey to be run in Q2

95.6%No data: survey run six monthly

95.6% NA MI

8

Priority 3 – Manage our organisation, people and resources

Human Resources


12-13

Q2

12-13

Q3

12-13YTD

Trend

RAG

HR1 Establishment Total - 2,292 2,2962,39

22,39

2 N/A

HR1a

Establishment and vacancy rate ( establishment less permanent staff )

5% by Dec. 2012

14.8% 9% 3.1% 3.1% G

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

HR3a

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

100% 100% 100%100%

100% G

HR4a

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

72% by

Dec 2012

N/R N/R 65% 65% G

HR5a

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

72% 42% 31% 29% 29% R

HR6Number of permanent staff (FTE)

- 1,849 2,0152,18

82,18

8 MI

HR7 No of Vacancies - 339 339 73 73 MI

HR7a

New staff pipeline (Staff with an offer of employment)

- 111 74 74 74 N/A MI

HR8 Temporary staff in established posts - 44 50 53 53 MI

HR10

Turnover2 <1.125% per

month

2% 1.8% 0.3% 1.4% G

HR11

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

HR12

Health and Safety - no. of workplace accidents

- 4 11 11 26 MI

Commentary:

Vacancies and establishment - establishment increased in Q3 to 2,392 compared to 2,292 in Q1 reflecting the significant programme of recruitment of additional compliance inspectors.

The Compliance inspector vacancy rate has improved significantly from 12.5% in Q1 to 0.4% in Q3 against a target of 2%. There is now a pipeline of candidates in place to fill future Compliance Inspector vacancies in all regions. The establishment and vacancy rate reflects the increase in staff, having improved from 14.8% in Q1 to 3.1% in Q3. overall vacancies have reduced from 339 in Q1 to 73 in Q3 a reduction of 78%.

Compliance Inspector and Registration Assessor mandatory learning remains below target. HR is investigating this and a comprehensive skills audit will seek to understand the organisational mandatory training requirements and make recommendations for delivering improvements.

Turnover and sickness rate

Turnover improved significantly in Q3 to 0.3% compared to 1.8% in Q2 and year to date it stands at 0.3%. The sickness rate has increased marginally from 3.6% in Q1 to 4% in Q3, although performance remains within the 5% target.

1 Actual performance is the most recent fortnight reported, therefore not an average 2 The rolling year average ( Sept 2011- Sept 2012) for Turnover is 7.2% and 4% for the sickness rate3 The annual target is 96%, the monthly target is cumulative and 8% per month

CQC Performance – Q3, 2012– 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 Target Q1

12-13

Q2

12-13

Q3

12-13

YTD Trend RAG

GL01

Number of stage 1 corporate complaints received across the organisation

10% less than

2011/12

105 96 117 318 G

GL02

Stage 1 Corporate complaints upheld -

7 (7%)

8(8%)

3 (3%)

18 (3%)

N/A MI

GL03

Of the initial stage 1 complaints received the number proceeding stage 2

<20%20%(21)

27% (26)

12%(13)

19%(60) G

GL05

Of those closed , the number of stage 2 reviews completed in 20 working days

95% 67% 100% 77% 81% A

GL04

No of stage 2 complaints upheld

- 5 2 0 7 N/A MI

GL07Information access requests closed within deadline 95%

95.9% (304)

97.3% (268)

92.6%(263)

96.1%(835) G

GL08Parliamentary Ombudsman enquiries

- 12 3 11 26 MI

GL09Of closed requests proportion closed within deadline - Freedom of Information

95%95.8%(236)

97.1%(189)

97.5%(175)

97% (600) G

GL10Of closed requests proportion closed within deadline - Data Protection

95%92.9%(28)

100% (37)

84% (34)

92% (99) G

GL11Of closed requests proportion closed within deadline - Info Sharing

95%98% (40)

94.7%(42)

93.1%(54)

95.3%(136) G

GL14

Urgent cancellations of registration (under section 30 of the HSCA 2008) - 0 0 1 1 MI

GL12 Percentage of outstanding critical and important audit actions completed

90% 97% 94% 1 95% 95% G

F01 Revenue expenditure plus depreciation variance vs. Budget (excluding fee income) 5%

£36M v £39.1M

(8%)

£81.3M v

£74.9M(8%)

£123.8Mv

116.9M(6%)

£123.8Mv

116.9M

(6%)

A

Commentary:

Complaint handling - Year to date there have been 318 stage one complaints, this is a decrease of 15% or 55 compared to the same period last year, when there were 373 stage one complaints received. The majority of complaints were from members of the public and service users. The number of stage 1 complaints proceeding to stage 2 decreased in Q3 to 13.

77% of stage 2 complaints in Q3 were closed within 20 working days compared with 100% in Q2. Year to date 81% of these complaints were closed against a target of 95%. There have been a number of complex stage 2 complaints considered by the Corporate Complaints team. Due to a small number of complaints received the percentage fall in Q3 only equates to 1 complaint.

Statutory requests for information

There have been almost 869 requests for statutory information in the first 9 months of the year. 835 or 96.1% were completed within the statutory deadlines. The majority, 619, were freedom of information requests. There were 143 information sharing request and 108 data protection Act requests. All measures are on track to achieve their 2012/13 business plan targets.

Audit actions

In the first 9 months of the year 95% of audit actions raised, were due to be completed by the end of December against a target of 90%.

Revenue expenditure

Year to date revenue expenditure shows an under spend of £6.9m (excluding fee income or 6%) consisting of staff costs of £5.4m, depreciation of £1.9m and an overspend on Non staff costs of £0.4M .

CQC Performance – Q3, 2012– section 3, Manage our organisation, people and resources

1 This figure is correct as of the last reported update in respect of year to date performance to August 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 Q3 there were 20,133 compliant locations compared with 17,292 in Q2. 16,156 locations have not yet had an inspection (compared with 23,306 in Q1) and 4,795 were non compliant with at least one outcome. Year to date there have been 651 warning notices served to 422 providers, 41 locations have de-registered following intervention by the CQC (compared to 21 in Q2) and there have been 3 urgent suspensions of registration, or urgent variation or imposition of conditions using Section 31 powers.

CQC Performance –Q3, 2012 – section 4, levels of compliance and non compliance at registered locations

11

19.8%

43.5%30.0% 28.2%

0.7%

60.3%6.3%

5.9%

6.0%2.7%

0.7%

16.6%73.9%

50.6%64.0% 69.1%

98.6%

23.2%

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 – Q3, 2012 – section 4, compliance outcomes

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

Non compliance is broken down by sector and period. On the table on the left, the column ‘Q4 2011/12’ demonstrates the number that were non compliant by age at the end of that quarter. The row ‘less than one quarter’ shows that there were 34 non compliant NHS locations at the end of Q4, tracking this group by following the arrow shows that the number of these that were non compliant fell in Q1 2012/13 to 29 and then again to 14 in Q2 2012/13 and 11 in Q3 2012/13. The graph illustrates the total number of locations that were non compliant in each quarter. There was a decrease in total non compliant locations in Q1 and Q2 and then an increase in Q3, this may or may not be related to the increase in inspections in Q3. 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. Further analysis is being undertaken to review the movements in compliance, evaluate the effectiveness of actions, non compliance across outcomes and the variation across sectors.

The following two slides are in the same layout as this slide and illustrate the levels of compliance at ASC (slide 13) and IHC, Ambulance and dentist locations (slide 14)

Levels of compliance and non-compliance - registered locations

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Location been non compliant for:

Q4 Q1 Q2 Q3

2011/12 2012/132012/13 2012/13

Over one year13 25 16 29

10% 22% 14% 22%

More than three quarters but less than one year

26 19 5 11

20% 16% 5% 8%

More than two quarters but less than three quarters

24 22 14 11

19% 19% 13% 8%

More than one quarter but less than two quarters

31 29 28 26

24% 25% 25% 20%

Less than one quarter34 21 49 54

27% 18% 44% 41%

Total non compliant in period 128 116 112 131

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

3421

49 54

31

29

2826

24

22

14

11

26

19

5

11

1325

1629

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 Q1 Q2 Q3

Non compliant <1 qtr Non compliant <2 qtrs Non compliant <3 qtrs

Non compliant <4 qtr Non compliant >4 qtr1

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


131 The increase in ASC Q4 to Q1 is due to a small difference in the time range between the two sets of data used for the report.



Q4 Q1 Q2 Q3

2011/12 2012/132012/13 2012/14

Over one year178 432 460 953

5% 12% 12% 23%

More than three quarters but less

than one year

372 500 489 501

11% 13% 13% 11%

More than two quarters but less

than three quarters

656 783 663 501

20% 21% 17% 12%

More than one quarter but less than

two quarters

1,078 1,0701 1,039 710

32% 29% 27% 17%

Less than one quarter

1,065 956 1,255 1529

32% 26% 32% 37%

Total non compliant in period

3,349 3,741 3,906 4,194 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

1065956

1255 1529

1078

10701039 880

656

783 663 674

372

500 489452

178432 460 659

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 Q1 Q2 Q3



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

2011/12 2012/132012/13 2012/13

Over one year

1 8 20 45

<1% 2% 5% 10%

More than three quarters but less

than one year

13 23 38 73

5% 6% 10% 16%

More than two quarters but less

than three quarters

31 53 114 83

12% 14% 30% 18%

More than one quarter but less

than two quarters

68 137 116 63

26% 35% 30% 14%

Less than one quarter

145 166 98 205

56% 43% 25% 44%

Total non compliant in period 258 387 386 469

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

145166

98

205

68

137

116

70

3153

114 92

13 2338

68

1 8 20 34

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q4 Q1 Q2 Q3



All priorities – corporate equality objectives

RefIndicator Target Q1

12-13

Q2

12-13

Q3

12-13

YTD Trend RAG

EQ1Embed equality across all our regulatory and corporate activities

Green rating

Green Green Green 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 rating

N/A N/A N/A N/A N/A N/A

EQ3

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

Green rating


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

Green rating


EQ5

Increase the uptake of accessible information for easy to read. Large print and 6 community language downloads.

Green rating

17,644 16,143 15,759 49,566 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 rating

Green Green Green Green N/A G

EQ7

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

Green rating

1st report

Q2Amber Green Green N/A A

EQ8

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

Green rating

1st report

Q2Amber Amber Amber N/A A

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

Green rating

Green Amber Amber Amber N/A A

This is the third update against the equality objectives. Notable progress compared to the objectives has been included below as well as risks and issues to delivery.

Objective 1: The ET and Board received quarterly updates covering our equality objectives as part of the overall performance governance of CQC.Objective 2: A plan from the evaluation of equality and human rights in compliance reviews was carried out in Q3 and will be implemented from Q4. Objective 3: A project plan, governance group and monitoring have been established to deliver this priority - identified work streams are currently on course. A reference group was set up and analytical resources allocated to deliver pilot of quantative indicators for the NHS. The report on availability of equality information on priorities and actions for next stage of work has been completed. Work is ongoing on the new mental health minimum dataset and on the multi-agency design of learning disability data collection set.Objective 4: Work is underway to monitor diversity of CQC involvement mechanisms and address gaps including: monitoring Speak Out network areas of interest in line with protected characteristics (Speak Out includes many of the seldom heard equality groups such as refugees, transgender people and gypsies and travellers) eQuality Voices recent recruitment of 10 new members to fill identified gaps including transgender people, carers of older people and refugees, Acting Together - Support organisations carry out equality monitoring and we are investigating best ways to bring this together and identify gaps for future expert by experience recruitment Objective 7: An analysis of staff profile has recently been completed for our annual equality information report (including for the first time analysis by pay grade). Work is underway with staff equality networks on the equality action plan arising from the staff survey may identify action we need to take in relation to making the profile more representative. 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: This objective is rated as amber overall to reflect the significant work required in this area following the 2012 staff survey. To assess work to date a proposed ‘pulse check’ for 500 staff of 20 questions is being prepared and will be presented to ET in late February. Work is underway to identify specific action required to take around bullying and harassment for particular staff groups, such as disabled staff, through the Staff Survey Equality Action Plan development. In Q3 HR appointed named officers for staff to talk to, during bullying and harassment week and they are planning other actions to improve support to staff who feel that they have been bullied or harassed.Objectives 9: Staff undertake equality training at the induction, this takes the form of an interactive session called equally yours, which includes updates to focus upon inclusion and using external networks. There is further work to improve the guidance that was identified following feedback, this means that some of the work will be delivered slightly later than planned.

CQC Performance – Q3, 2012,– 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.

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. These measures demonstrate the level of efficiency of the NCSC in terms of the speed at which we respond to the calls we receive and how they are prioritised, as well as the volume of calls we respond to.

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.

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Documents

ANNEX A - CQC Performance, Quarter 3, 2012