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Slide 1: Agenda Item: 10 Ref: CM/09/04/38 BOARD MEETING – TUESDAY 16 SEPTEMBER 2009 CORPORATE PERFORMANCE REPORT FOR THE FIRST QUARTER, 2009/2010 PURPOSE 1. This paper introduces the first quarter performance report to Board, at appendix 1. RECOMMENDATION 2. The Board is asked to NOTE and COMMENT on the performance issues set out in the attached report. The format and content of the report are still being developed for the future. The Board are therefore also asked to COMMENT on further improvements needed in the reporting of performance. BACKGROUND 3. The Board has previously seen proposals with regard to a performance assessment framework. 4. The starting point for the development of the framework has been the collection of measures that demonstrate our impact, and the difference we make for people who need health and adult social care services. The architecture of the framework is based around the five priority outcomes set out in the draft strategic plan. These are: a. Ensuring care is centred on peoples' needs and protects their rights b. Championing joined-up care c. Acting swiftly to help eliminate poor quality care d. Ensuring and promoting high quality care e. Regulating effectively in partnership 5. In addition, the framework includes: f. The regulatory activities that we carry out g. The enabling activities that support the delivery of our regulatory work 1 of 40
Slide 2: Agenda Item: 10 Ref: CM/09/04/38 6. For this reporting period, we have not sought to provide indicators of progress against the five priority outcomes. However we have provided some narrative on how current activities contribute to the priority outcomes, shown at annex 2. This is for three reasons: − First, the consultation on the strategic plan will ask for comments on our priorities in making a difference for people. We need to reflect the outcomes of the consultation in populating the performance framework and being sure that we are focussed on the right issues. Our draft strategic priorities, and current proposed measures of success are also at annex 2. − Second, we are doing further work to develop our evaluation strategy, so that, in the light of the strategic plan consultation, we are able to measure progress on the outcomes that we set ourselves in a meaningful and robust way; − Third, sustainable improvement against the priority outcomes is not a ‘quick fix’, and will therefore be more informative when reporting over a longer time period. 7. For this first reporting period, we have therefore focussed more on establishing ‘baseline’ information on our key activities. The report sets out our progress in the period April-June 2009 (although in places we provide more up to date information rather than a rigid application of a cut-off). It represents both the considerable involvement of a range of colleagues across the organisation in supplying the data, and of course the substantial effort of most of the organisation in the performance that underpins this information. 8. The first page of the report seeks to highlight the key messages about performance from the information provided. However there are some general issues about the content and format of the report to highlight: − The report is still very much ‘work in progress’. We see advantages in taking an early report to the Board in ensuring an effective management grip on key activities and a clear focus on priorities. However there remain areas where the data needs further validation and where there is a need for further management attention in ensuring that we have the right performance measures in place and the right management information flows to support them. The difficulties with inherited information technology that have been reported to the Board add to this challenge; − The information available at this stage is stronger on inputs and volumes of activity than on measures of the quality of that activity and outcomes. This will be addressed as part of further developments and through the evaluation strategy. Nevertheless for 2 of 40
Slide 3: Agenda Item: 10 Ref: CM/09/04/38 each regulatory activity and enabling activity we also show the measures that we will be seeking to populate in future reporting cycles – that move us towards reporting on our quality and impact. We are doing work on the feasibility, cost and proportionality of the possible further measures. We will report back to the Board on this in due course. − The Corporate Performance Dashboard reflects the Executive Team’s judgement on progress against the expectations that we have set, although substantially informed by the underlying quantitative measures; − The finance report is a separate paper for the September Board. We will aim to have a more integrated approach in future reports; − The report has a strong focus on the delivery of the inspection work and regulatory duties inherited from the predecessor bodies. There is a separate paper to the Board on the development of the new registration system. Future reports will also look to integrate progress on key development work 9. The report is intended to be a ‘stand-alone’ document providing, principally, data - with narrative as explanation for performance where necessary. Where measures are less-developed, some aspects of the report rely more on narrative explanation. Jamie Rentoul Director of Regulation and Strategy 16 September 2009 APPENDICES I. 2009/10 first quarter corporate performance report II. Summary report of performance with regard to priority outcomes III. Performance Assessment Framework 3 of 40
Slide 4: Agenda Item: 10 Ref: CM/09/04/38 Appendix 1 CORPORATE PERFORMANCE REPORT FOR THE FIRST QUARTER, 2009/10 SECTION ONE: INTRODUCTION AND OVERVIEW The report uses a standard red, amber, green system to show performance against expectations with the following meanings: Green Amber Red Activity is on target Activity is not on target but is expected to be so in 1-2 months Activity is not on target and is being managed as a priority The key messages from the report − In the period April to July the Commission has made generally good progress against the Strategic Business Plan and Operating Plan for 2009/10. See Corporate Performance Dashboard. − In the first four months of 2009/10 the Commission has successfully maintained the inspection work and regulatory duties that it inherited from its predecessor bodies. − For the month ending July the Commission’s overall work on inspecting healthcare and social care organisations has been assessed as AMBER. However several areas of inspection activity, particularly social care organisations are assessed as GREEN. See page 10 for further details. − Inspections of hospital acquired infection in NHS organisations were behind schedule at the beginning of the year but are now close to being on track. This work has been assessed as AMBER at the end of July but is expected to be on track by the end of October. − The latest overall assessment of the Annual Health Check of NHS providers and commissioners at 27 August 2009 is AMBER. This is because the ‘Core Standards’ component was assessed as AMBER pending confirmation of additional resources to finalise this work. The remaining components involving ‘Indicators and Measurement’, ‘Quality and Financial Measurement’ and the ‘Website’ are all assessed as GREEN and on track. 4 of 40
Slide 5: Agenda Item: 10 Ref: CM/09/04/38 − The management and processing of new registrations under the Care Standards Act has been assessed as AMBER at the end of July. This is despite the progress made in overcoming the system shortcomings that the Commission inherited on the registration of social care providers. − The management of Human Resources in the Commission has been assessed as AMBER at the end of July because the Human Resources Team has still to complete activities from the Commission’s previous Transition Programme and has yet to finalise the development of People Management Policies. − The management of Information Communication and Technology (ICT) services has been assessed as AMBER at the end of July because it is continuing to manage the integration of different systems and the difficulties that were inherited from the ICAP system. 5 of 40
Slide 6: Agenda Item: 10 Ref: CM/09/04/38 CORPORATE PERFORMANCE REPORT FOR THE FIRST QUARTER, 2009/2010 CONTENTS SECTION ONE: INTRODUCTION AND OVERVIEW 1.1 Introduction 1.2 What are the key messages from the report? 1.3 Corporate Performance Dashboard THE COMMISSION’S SEVEN KEY ACTIVITIES (1) Registration of new social care and health care providers (including the work (2) (3) (4) (5) (6) (7) of the National Processing Centre) Mental Health Act visiting Inspections of providers Enforcements Commissioner reviews Comprehensive Area Assessments Reviews and Studies Page 4 4 7 8 10 12 15 17 18 19 20 23 25 27 29 THE COMMISSION’S FIVE CORPORATE ENABLING ACTIVITIES (A) Involving users and the public (B) Promoting equality, diversity and human rights (C) Engaging with those providing and commissioning care (D) Organisational Development and Human Resources (E) Using resources effectively 6 of 40
Slide 7: Agenda Item: 10 Ref: CM/09/04/38 1.3 CORPORATE PERFORMANCE DASHBOARD FOR THE FIRST QUARTER, 2009/10 RAG Status Page See appendix 2 See appendix 2 See appendix 2 See appendix 2 See appendix 2 OUTCOMES 1. Ensuring care is centred on peoples’ needs and protects their rights 2. Championing joined-up care 3. Acting swiftly to help eliminate poor quality care 4. Ensuring and promoting high quality care 5. Regulating effectively in partnership Key ACTIVITIES 1. Registration 2. Mental Health Act (MHA) 3. Inspecting Providers 4. Enforcements 5. Commissioner Reviews 6. Comprehensive Area Assessments 7. Special Reviews and Studies AMBER AMBER AMBER GREEN GREEN AMBER GREEN Page 8 Page 10 Page 12 Page 15 Page 17 Page 18 Page 19 HOW WE DO IT 1. Involve users and the public 2. Promote equality, diversity and human rights 3. Engage with those providing care and those commissioning care 4. Organisational Development and Human Resources 5. Using resources effectively AMBER AMBER AMBER AMBER AMBER Page 20 Page 23 Page 25 Page 27 Page 29 7 of 40
Slide 8: Agenda Item: 10 Ref: CM/09/04/38 Activity 1 – REGISTRATION PERFORMANCE FOR APRIL TO JULY 2009/10 Registrations of social care providers Registrations completed in 4 months Manager registrations completed in 2 months Major variations completed in 3 months Minor variations completed in 1 month Registrations/variations outstanding 4 months+ Registrations/variations outstanding 6 months+ Registrations of independent healthcare providers Registrations completed in 4 months Manager registrations completed in 2 months Major variations completed in 3 months Minor variations completed in 1 month TARGET ACTUAL 90% 90% 90% 90% <5% 0 TARGET 86.1% 65.8% 77.9% 72.9% 13.3% 54 ACTUAL 90% 90% 90% 90% 88.1% 79.9% 100.0% 26.3% What measures do we intend to report on from our Performance Assessment Framework Criteria Applications for registration are processed quickly The registration process operates well High risk applications are processed quickly The CQC makes high-quality decisions on registration As above Measure % of registrations under Care Standards Act 2000 are completed in set time period % of applicants rate the quality of CQC's information and processes as good % of high risk applications are fast-tracked in agreed time Fewer than target % of challenges against registration decisions are upheld No first registrations gave extraordinary breach in agreed time Reporting See above Tbc Quarter 2 (October) Quarter 3 (December) Quarter 3 (December) Note: − During April to July the Commission established and consolidated its processes for managing applications for registration and Notifications on social care providers within the National Processing Centre based In Newcastle. 8 of 40
Slide 9: Agenda Item: 10 Ref: CM/09/04/38 − In April the Commission inherited system shortcomings. Since then the National Operations team has worked to resolve these problems whilst at the same time successfully transferring the administration of applications for registration from regional offices to the National Processing Centre in Newcastle. − The performance levels of social care registrations have now been raised to just under agreed time limits for completion of registrations. There is still some way to go. The ICAP information system is insufficiently flexible and frequent technical difficulties result in delays and backlogs that require time, effort and resources to be diverted from routine processing of registrations. 9 of 40
Slide 10: Agenda Item: 10 Ref: CM/09/04/38 Activity 2 – MENTAL HEALTH ACT VISITING PERFORMANCE FOR APRIL TO JULY 2009/10 MHA inspection visits – April to July Planned expected number of visits in period TARGET 324 ACTUAL 351 Note: − 37% of visits were unannounced. Second Opinion Advisory Doctor (SOAD) service – April to July Number of requests for SOAD service [No target applies] Number of actions completed in target time of days Actions completed in target time of days (depending on treatment type) Number of SOAD requests relating to people treated in the community Number of actions completed relating to people treated in the community Actions completed relating to people treated in the community TARGET ACTUAL 3843 2433 63% 1161 242 20% Note: The mental health act visiting programme activity is running to plan. − The second opinion doctor service is more problematic. Since November 2008 the Mental Health Act (2007) introduced community treatment orders, with an in-built protection that a second opinion appointed doctor checks the treatment plan. − Prior to their introduction it was estimated there would be 450 such applications, compared to the near 1200 received in the first quarter. This has led to poorer response times. − Several initiatives have been developed by the Commission to deal with this pressure, for example day sessions at provider organisations as opposed to one-off visits, recruitment and appointment of additional SOADs and working with providers and professional bodies to encourage more consultant psychiatrists to apply to become a SOAD. It remains a significant issue that we are continuing to address. 10 of 40
Slide 11: Agenda Item: 10 Ref: CM/09/04/38 What measures do we intend to report on from our Performance Assessment Framework Criteria Patients view MHA visits as important in upholding their rights Services are safe Second opinions are provided efficiently CQC ensures that patients have their rights explained to them Measure % satisfaction from patient feedback Number of death reviews % of second opinions provided in agreed time % of detained patients report that they had their rights under section 132 of the Act explained to them To be reported by tbc Quarter 3 (December) Quarter 2 (October) tbc 11 of 40
Slide 12: Agenda Item: 10 Ref: CM/09/04/38 Activity 3 – INSPECTIONS OF PROVIDERS PERFORMANCE FOR APRIL TO JULY 2009/10 Social care inspections – April to July Annual Plan is currently set at : April to July Inspections Poor rated services inspected within 12 months of their last inspection Adequate services inspected within 12 months of their last inspection TARGET 14,040 4,780 100% 100% ACTUAL 4,911 96.8% 79.9% Note: − The indicator for adequate services inspected within 12 months was changed in the last year of the Commission for Social Care Inspection to be based on ‘Inspection for Better Lives’ principles, requiring a social care inspection within 2 months of the last. − Performance is hampered by the ICAP system, data issues and the change to the way this indicator is calculated although it is improving from Commission for Social Care Inspection returns and with the changes being made by Operations on the inspection of good and excellent homes, we expect performance here to improve further. Independent healthcare inspections – April to July April to July Inspections TARGET 308 ACTUAL 314 NHS hospital associated infection inspections – April to July Specialist hospital associated infection inspections completed Number of reports published in line with reduced timescales Proportion of reports published in line with reduced timescales TARGET 61 17 100% ACTUAL 49 15 90% Note: − 11 measures for improvement were highlighted in published reports in April to July. Each of these is being followed up with the trusts concerned − 6 trusts are now registered with conditions, down from the original total of 21 on 1st April and progress is being made on the remaining trusts. 12 of 40
Slide 13: Agenda Item: 10 Ref: CM/09/04/38 Annual Health Check of the NHS – April to July progress Number of NHS follow up inspection visits Proportion of NHS follow up inspection visits Proportion of NHS trusts final declarations submitted on core standards Proportion of the 701 queries from trusts that have been resolved TARGET 84 100% 100% 100% ACTUAL 84 100% 100% 98% Note: − Primary Care Trusts were inspected in their capacity as both providers. Joint Ofsted children's health services inspections – April to July Number of inspections Proportion of inspections TARGET 2 100% ACTUAL 2 100% Note: − The first two inspections were used to test and refine the methodology in preparation for the 22 remaining inspections to be completed by March 2010. Service Inspections of Adult Social Care completed – April to July Numbers of service inspections of adult social care Proportion of service inspections of adult social care TARGET 4 100% ACTUAL 4 100% Note: − User representatives (“Experts by Experience”) were included in all inspections. A further 29 inspections are planned by March 2010. Notifications processed under Ionising Radiation (Medical Exposure) Regulations (2000) – April to July Number of notifications closed versus those received TARGET (184) ACTUAL 128 (70%) Note: − There are no targets for notifications under Ionising Radiation Regulations. The Commission responds to all notifications received. 13 of 40
Slide 14: Agenda Item: 10 Ref: CM/09/04/38 Pharmacy and Controlled Drugs inspections – April to July Controlled Drugs inspections [No target applies] Number of controlled drugs inspections part of a key inspection [No target applies] Number of controlled drugs inspections part of random inspections to look at medication handling [No target applies] Number of random focussed inspections involving some form of enforcement activity [No target applies] TARGET ACTUAL 355 163 (46%) 192 (54%) 31 (16%) Note − There are no targets for completing Pharmacy and Controlled Drugs inspections. All inspections are carried out when problems are identified by an inspector and, or a referral for input from the national pharmacy team has been made by their local area manager. − Enforcement activity involves either compliance with a Statutory Notice that the Commission had served or they resulted in a Statutory Notice being served What measures do we intend to report on from our Performance Assessment Framework Criteria Inspections take full account of appropriate risks Inspected bodies consider that reviews are a fair reflection of their service CQC makes good quality ratings decisions about providers Provider findings are consistent with views of people who use service Measure % of inspections delivered in line with standard risk schedule Survey of users and the public % of appeals upheld against ratings of providers Survey of users and the public To be reported by See above Annually (March) Quarter 4 (March) Annually (March) 14 of 40
Slide 15: Agenda Item: 10 Ref: CM/09/04/38 Activity 4 – ENFORCEMENT PERFORMANCE FOR APRIL TO JULY 2009/10 Enforcement Activity – April to July [No target applies] Social care providers - Number of enforcement actions Social care providers - Number of immediate requirement notices Independent healthcare providers - Number of enforcement actions NHS providers - Number of enforcement actions Total Enforcement Activity – April to July Note TARGET ACTUAL 63 216 47 112 438 − Enforcement activity involves either compliance with a Statutory Notice that the Commission had served or they resulted in a Statutory Notice being served − Enforcement Activity for independent healthcare and NHS providers is calculated differently to that for social care providers. See details below. Details of independent healthcare enforcements– April to July Cases managed by Enforcement Team Cases managed by AIP (managed by region) Number of convictions Number of prosecutions Cases considered for prosecutions Simple Cautions Total ACTUAL 26 12 2 2 4 1 47 Details of NHS enforcement activity – April to July Preliminary enquiries / Interventions Mortality Outliers Investigations Cases on Monitoring Log Total ACTUAL 73 21 16 2 112 15 of 40
Slide 16: Agenda Item: 10 Ref: CM/09/04/38 What measures do we intend to report on from our Performance Assessment Framework Criteria Measure % of organisations which go through complete path from escalation to resolution within set time period % of organisations whose escalation proceedings exceed set time period % decisions unsuccessfully challenged on appeal % of organisations which do not return to enforcement procedures within set time period To be reported by Quarter 2 (October) Quarter 2 (October) Annual Annual Enforcement action is taken swiftly As above Enforcement action is sufficiently robust Enforcement action has a lasting impact Note: − The National Enforcement Team is receiving a steady flow of referrals for Independent Healthcare and Hospital Acquired Infection and enforcement activity. These range from requests for telephone advice, to attending Management Reviews of enforcement actions, to drafting statutory notices and preparing complex cases for prosecution. There are no annual or part year targets for carrying out numbers of enforcement actions. 16 of 40
Slide 17: Agenda Item: 10 Ref: CM/09/04/38 Activity 5 – COMMISSIONER REVIEWS PERFORMANCE FOR APRIL TO JULY 2009/10 Local Authority social care commissioning– April to July progress Annual Performance Assessment review meetings Local Authorities TARGET 114 ACTUAL 114 Note − All 152 Local Authorities are scheduled to be reviewed by October. NHS Primary Care Trust health care commissioning (part of the NHS Annual Health Check) – April to July progress Number of NHS follow up inspection visits Proportion of NHS follow up inspection visits TARGET ACTUAL Note − The Commission’s Performance Assessment Programme Board on 3 August assessed our work on NHS Primary Care Commissioning and the Annual Performance Assessment of councils as Green. What measures do we intend to report on from our Performance Assessment Framework Criteria Poor quality commissioners are inspected quickly Commissioners are held to account for the quality of commissioning decisions CQC makes good quality ratings decisions about commissioners Measure All commissioners assessed as high risk are inspected in agreed time % Overview & Scrutiny Committees and LINks agree they can use our assessments to hold commissioners accountable % of appeals upheld against ratings of commissioners To be reported by Quarter 3 (December) Annually (March) Quarter 3 (December) 17 of 40
Slide 18: Agenda Item: 10 Ref: CM/09/04/38 Activity 6 – COMPREHENSIVE AREA ASSESSMENTS (CAA) PERFORMANCE FOR APRIL TO JULY 2009/10 Comprehensive Area Assessments – April to July progress Submission of information to the Audit Commission by local deadlines TARGET ACTUAL Note − The Commission’s Performance Assessment Programme Board on 3 August assessed our work on Comprehensive Area Assessments as AMBER. What measures do we intend to report on from our Performance Assessment Framework Criteria CQC participates effectively in local CAA arrangements CAA leads to specific action on health and social care issues CQC provides good quality information to local CAAs Measure CQC submits all pieces of information required for local CAA frameworks by appropriate local deadlines Stakeholder survey Other regulators and inspectors engaged in the CAA rate the CQC as providing useful information on health and social care To be reported by See above Annually (March) Annually (March) Note − Comprehensive Area Assessment (CAA) is the new (multi-inspectorate) way of assessing how effectively local partnerships are working together to deliver local people’s priorities including but not limited to health and social care – resulting in local reports being produced for the first time this November (for performance in 2008/09). It is clearly focused on people, place and outcomes and therefore it supports strong and effective partnership working across organisations. − Guidance is being issued to staff cover the inputs that Adult Social Care Deputy Regional Directors and NHS Strategic Health Authorities might make to discussions on Comprehensive Area Assessments on the awarding of “performance assessment flags”. The Guidance also relates to our protocol on the responsibilities of staff in the Commission. − CQC Assessors are updating CQC’s analysis of performance relating to health and well being in 150 council areas. Further the performance assessment notebooks for adult social care assessments are also being completed. Finalised versions of both 18 of 40
Slide 19: Agenda Item: 10 Ref: CM/09/04/38 products are on schedule for inputting into the CAA collation process by the end of September. Activity 7 – SPECIAL REVIEWS AND STUDIES PERFORMANCE FOR APRIL TO JULY 2009/10 (at 27 August 2009) Project name LEGACY REVIEW: Children’s safeguarding LEGACY REVIEW: Use of information and impact on patient care LEGACY REVIEW: Medicines management after discharge State of Care report Stroke pathways review Meeting the healthcare needs of people living in care homes Meeting the physical health needs of those with mental health needs and learning disabilities Social services’ response to people’s first contact with them Impact of commissioning and health promotion on health inequalities Support for families with disabled children Impact of financial downturn on quality of care Project RAG GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN Project status National report published. Report ready for publication. Report ready for publication. Report due January 2010 Report due November 2010 Report due November 2010 Report publication date not yet confirmed Report publication date not yet confirmed Project being scoped. Project being scoped. Project being scoped. What measures do we intend to report on from our Performance Assessment Framework Criteria The programme of Special Reviews and Studies is implemented efficiently The programme has led to a positive change/ impact As above Measure Programme achieves agreed milestones Self-assessment by CQC further to programme evaluation Survey of stakeholders on impact and benefits of individual reviews To be reported by See above Annually (March) Annually (March) Note 19 of 40
Slide 20: Agenda Item: 10 Ref: CM/09/04/38 The three objectives of the Special Reviews and Studies programme are to: − Complete the programme of inherited (or legacy) reviews and studies − Publish the annual State of Health and Social Care Report − Establish and deliver a new programme of special reviews and studies. How (1) – Involve users and the public PERFORMANCE FOR APRIL TO JULY 2009/10 National Contact Centre (NCC) – April to July Total Calls Analysis: Received % of calls answered in 20seconds Call Types: Details to be confirmed Emails: Healthcare received Social care received Correspondence: Healthcare received Social care received April 14,745 70% n/a 931 1,640 - May 11,552 66% n/a 400 1,328 61 89 June 21,886 63% n/a 216 1,205 72 240 Quarter 1 48,183 67% n/a 1,547 4,173 133 329 What measures do we intend to report on from our Performance Assessment Framework Criteria Measure To be reported by Annually (March) Annually (March) Annually (tbc) Staff survey % of LINKs consider that CQC involves users and the public Evaluation of use of ‘Experts by Experience’ on inspections. All complaints are acknowledged and closed or referred on in agreed time Random survey of complainants to assess how they rate the way that 20 of 40 CQC has a public profile CQC involves people who use services Staff consider that CQC put people first and involve people who use services and the public CQC involves users and the public As above CQC handles complaints effectively As above Survey of public awareness of CQC Evaluation of how service users are to be involved in all our activities Annually (tbc) Annually (tbc) Tbc Annually (tbc)
Slide 21: Agenda Item: 10 Ref: CM/09/04/38 CQC handled their complaint Note: The Commission’s approach towards engaging users and the public is set out in “Voices into Action”. Ensuring regulatory activity and outputs of the Commission reflect involvement agenda i) Maintaining the 9/10 programme − Involvement activity in inspections by experts by experience and in Mental Health Act visiting is continuing, although at a lower level than planned in registered social care services. − Input to 08/09 Annual Health Check programme on CS17 as needed − Revised payments and reimbursements policy prepared. − Developing further contacts with Local Involvement Networks, Overview and Scrutiny Committees and Foundation Trust Governors. ii) Developments − Registration, special reviews and studies and periodic review have had substantial input on involvement with plans checked and challenged ensuring we take people’s views into account and devising ‘methods’ focusing on what matters to people. − Convening an internal group on how we use what users tell us to ensure the different parts of our system produce coherent regulatory outputs that are both helpful and reflect what people have told us. − Establishing diverse reference panels and an online forum to inform our plans. − Starting to benchmark how well providers and commissioners involve people, including children and young people, who use their services. Establishing the reputation of the Commission for leading excellence in involvement by example − The development of the Registration programme has successfully involved people in a range of ways. Public and user involvement in the pre-consultation workshops 21 of 40
Slide 22: Agenda Item: 10 Ref: CM/09/04/38 Public and user involvement in the major programme of consultation events (nine regional, three national) - around fifteen percent of all participants were public and/or user representatives, including people from Local Involvement Networks, Foundation Trust governors and self advocacy organisations. 15 smaller meetings with ‘seldom heard’ groups. These sessions were for people who don’t find written communication or big meetings user-friendly. We used the ‘easy read’ version of the draft guidance as a discussion aid, people told us that this was helpful and made things very clear. Feedback from the groups was that they appreciated the way we had included them and they felt that the consultation was genuine consultation going on. Online panel, where a cross section of people could have a say on the guidance, in a ‘big conversation’ with each other. Around 120 people took part. Publicity via magazine articles – Drink & Drugs News, British Journal of Health Services Management - - - − Collaborating with other bodies about involvement issues – recently met involvement teams from Department of Health, NHS Institute and General Dental Council The National Contact Centre (NCC) manages all interactions with external stakeholders and manages inbound and outbound telephone, email contacts and non regulated organisations’ correspondence. Growth in the volume of calls is due to increased awareness of the “03000 616161” contact number and forwarding of predecessor commissions’ lines to this number. Call numbers are forecast to increase further in Quarter 2 specifically in line with the consultation on Registration ‘Guidance About Compliance.’ The percentage of calls answered in 20 seconds is fluctuating between 60% and 70%. Several technical faults resulting of telephone down time have impacted on the overall figures. 22 of 40
Slide 23: Agenda Item: 10 Ref: CM/09/04/38 How (2) – Promote equality, diversity and human rights PERFORMANCE FOR APRIL TO JULY 2009/10 Age profile of permanent staff – at 31 July Age profile in 10 year bands Age 20-29 Age 30-39 Age 30-39 Age 30-39 Age 30-39 Total 10% 18% 34% 32% 6% 100% Ethnic profile of permanent staff – at 31 July Asian / Asian British Black / Black British Chinese / Other Ethnic Group Mixed Unknown White Total Ethnic profile 4% 5% 2% 2% 4% 83% 100% Gender profile of permanent staff – at 31 July Gender profile Female Males Total 72% 28% 100% What measures do we intend to report on from our Performance Assessment Framework Criteria We are recognised as a diversityfriendly organisation CQC staff are committed to EDHR CQC is a discrimination-free workplace CQC has a diverse staff profile Measure Achieve target level in Stonewall Index (and other analogues) Achieve % score for commitment to EDHR in staff survey No complaints of discrimination upheld Achievement of agreed targets for staff diversity To be reported by Annually (March) Annually (tbc) Annually (March) Annually (March) Note: − The Commission’s Steering Group for the Single Equality and Human Rights Scheme is established and all Directorates are engaged. 23 of 40
Slide 24: Agenda Item: 10 Ref: CM/09/04/38 − A programme of consultation meetings with external stakeholders has begun. Consultation on the future model for ‘staff diversity networks’ was completed on 11 August 2009. Proposals will be developed on next steps. − Equality impact assessments (EIA) in several policy areas have been completed. The equality impact of the published guidance about registration compliance has commenced. − A cross-directorate working group on the development of the Commission's own EIA tools and processes has completed its first draft, reporting to the Methods Committee on 23rd September 2009. − An Equalities and Diversity Monitoring Group has been established to develop monitoring and analysis processes that will ensure the Commission is compliant with equalities legislation. − We continue to work with the Audit Commission on the equalities input to the Comprehensive Area Assessment process. Regular meetings with the Equalities and Human Rights Commission (EHRC) have continued, and work is taking place to agree a memorandum of understanding. 24 of 40
Slide 25: Agenda Item: 10 Ref: CM/09/04/38 How (3) – Engage with those providing care and those commissioning care PERFORMANCE FOR APRIL TO JULY 2009/10 What measures do we intend to report on from our Performance Assessment Framework Criteria Clinical and social care staff working in regulated bodies consider our regulation as important to their work Publish consultation on CQC's 5 year strategy (2010/15) Publish consultation on proposed 2010/11 topic reviews and period reviews Measure Survey of organisations assess CQC as a good organisation to work with To agreed deadline To agreed deadline To be reported by Annually (March) tbc tbc Note: Our engagement with providers and commissioners focuses on building support for the Commission among this group and ensuring they have an understanding of our key corporate priorities, at two main levels. 1. Corporate messages about the process of registration and regulation – what they need to know, and be engaged with, in order to be effectively regulated by the Commission 2. Messaging about the health and adult social care system – using the findings of our work to promote national, and regional, priorities and to drive improvements in services. − First quarter activity has focused on consultation on the guidance about compliance and the new registration system. All health and adult social care providers received individual letters about the consultation; key providers were also sent consultation packs. All providers were able to respond to the consultation by post, email or online and many took part in national and regional consultation events. − A monthly e-newsletter continues to be sent to all NHS trusts keeping them informed about the work of the Commission and regulatory activity. In addition, our monthly stakeholder bulletin is sent to many social care and independent healthcare providers to keep them updated on our work. During the next quarter we will be launching a new monthly e-bulletin for all providers, containing bespoke information for each sector. 25 of 40
Slide 26: Agenda Item: 10 Ref: CM/09/04/38 − Alongside these publications we have also had a presence at key external conferences and events; for example the NHS Confederation Annual Conference; where key opinion formers are targeted to ensure our messages reach this audience. In June we also held a dinner meeting with the NHS Confederation, attended by senior members of staff from the Commission and around 20 Confederation members. − To help improve engagement with providers, and to support the registration process, a reference group is being set up that will involve a wide range of health and social care providers. The group will initially be set up to test the products being developed for registration but it will also act as a channel to obtain provider input and support on a range of issues. 26 of 40
Slide 27: Agenda Item: 10 Ref: CM/09/04/38 How (4) – ORGANISATIONAL DEVELOPMENT AND HUMAN RESOURCES PERFORMANCE FOR APRIL TO JULY 2009/10 Human Resources – April to July Number of permanent staff Number of permanent staff new starters Number of permanent staff leavers Proportion of permanent staff leavers (turnover rate) TARGET ACTUAL 1,969 32 143 7% Note: − Of the 143 staff that left the Commission as at July 2009, 59 were redundancies without pension, and 31 were redundancies with pension. − 65 planned redundancies will result from the implementation of the Voluntary Redundancy Programme for Operations Inspectors by the end of December 2009. What measures do we intend to report on from our Performance Assessment Framework Criteria Staff consider CQC is improving the quality of care Stakeholders view our staff as credible, knowledgeable and customer-focused Staff understand how their objectives link to CQC objectives The action plan following the staff survey is implemented CQC effectively manages its human resources As above As above As above Measure To be reported by Annually (tbc) Annually (March) October October October October October See above Staff survey Survey of stakeholders % reviews of staff objectives completed by target dates % compliance with agreed actions following staff survey Monthly full time equivalent staff within headcount limit % sickness absence rate across CQC % vacancy rate across CQC Staff turnover rate 27 of 40
Slide 28: Agenda Item: 10 Ref: CM/09/04/38 Note: − In this first quarter, the Human Resources Team has worked to identify and address staff concerns, build the basic employee deal, manage and complete staffing transition activity, and identify the priority areas for human resource support looking ahead. Projects underway include: Terms and Conditions of Employment Employment Offer People Management Policies Pay Proposal for 2009/10 Employee Relations Environment (recognising Trade Unions) − In addition four additional transition projects are underway: Improve work force control through headcount (and budget) data and planning Completion of office closures and moving staff to home working arrangements Delivery on the Commission for Social Care Inspection remit to reduce the Inspector population by 65 full time equivalent posts under the “Inspecting for Better Lives Inspection” implementation Procurement of a new CQC Payroll system for next year The following have also been put in place. Local Area Manager Assessment and Development Centres Competency Framework Performance Appraisal Framework Induction Programme Training Suite 2009 Recruitment Policies and Process 28 of 40
Slide 29: Agenda Item: 10 Ref: CM/09/04/38 How (5) – Effective use of resources PERFORMANCE FOR APRIL TO JULY 2009/10 Performance of ICT systems – April to July System availability against the agreed standard operating times of 08:00 - 18:00 Monday to Friday TARGET 100.00% ACTUAL 99.91% Note − The ICT team has stabilised the ICAP information system. However the overall rating on ICT remains at AMBER because of the ICAP system What measures do we intend to report on from our Performance Assessment Framework Criteria Measure To be reported by See finance report See finance report See finance report See finance report Annually (March) See above Tbc Tbc Our staffing budget is spent efficiently As above As above As above We demonstrate that our benefits exceed our costs We have an efficient IT service As above As above Monthly staff spend within budget Monthly revenue spend within budget Monthly capital spend within budget Annual forecast spend within budget Evaluation of ICT benefits ICT achieve agreed service levels Staff satisfaction survey of ICT service Evaluation of ICT benefits 29 of 40
Slide 30: Agenda Item: 10 Ref: CM/09/04/38 Appendix 2 PROGRESS ON CQC’S FIVE PRIORITY OUTCOMES The five priority outcomes are drawn from the draft five-year strategy 2010-15 which is being published for consultation, and is shown in tabular format below. The draft includes some suggested outcome measures, but we expect that to change and be refined in the light of the consultation. In parallel, we will also need to assess how we can report on progress against the outcomes and measures. This will include existing data sets but potentially also new data collection (for example, a stakeholder survey). We will also need to look at how often we would expect to have new data to report on progress – for example some of the measures may reflect annual data collection. As such, for this first reporting period a short narrative commentary for each outcome is provided. Furthermore, there is substantial work currently being undertaken on the priority outcome areas (each led by a Director) to help clarify our priorities and success measures. This will be tested further through the consultation period. 1. Ensuring care is centred on peoples’ needs and protects their rights: − We want people to be able to shape their own care around their needs, and to have a voice. As part of this, they need access to timely, relevant and accurate information so that they can make informed choices about their care. Our work here principally relates to: − Our business as usual activities relating to inspections, periodic reviews, Mental Health Act visits and providing second opinion services − Our work with stakeholder groups – notably in consulting on our proposals for registration − Our work in taking forward ‘voices into action’ which sets out how we involve people who use health and adult social care services in everything we do and in making sure that services involve people and respond to their views. − Maintaining and updating our website and publishing activities, ensuring the timely publication of reports and other information. Our work has a particular focus on safeguarding: − With regard to Safeguarding Children our review reported in July that NHS services showed variable performance around their statutory responsibilities. The findings, including indications of the quality of partnership working across health and other agencies, will contribute to assessments of trusts under the Annual Health Check; and to the 3-year programme of joint inspection of children's services with Ofsted and other inspectorates. − With regard to safeguarding adults we have reviewed the safeguarding policies inherited from the predecessor commissions, and developed protocols for how safeguarding alerts will be managed, including clarifying the interface between 30 of 40
Slide 31: Agenda Item: 10 Ref: CM/09/04/38 the national processing centre, our contact centre, our regional teams and central teams. Operational safeguarding leads have been recruited and regional 'champions' identified and the CQC adult safeguarding lead has engaged with key stakeholders including the ADASS, adult safeguarding network, Action on Elder Abuse, and the NHS safeguarding group. 2. Championing joined-up care: − We want to champion better coordination and integration of health and social care so that the services people receive are joined up and their experience is good. We want commissioners and providers of care to work together, and with people who use services, so that people’s outcomes are improved Our work includes: − Our engagement with and assessment of councils and NHS organisations to inform the annual performance assessment, the annual health check and our input to the Comprehensive Area Assessments − Our programme of special reviews and studies underway: how well is the health and social care ‘pathway’ working for people who have a stroke and their carers and people with dementia; meeting the health needs of people in care homes; meeting the physical health needs of people with mental health problems and learning difficulties in hospital and residential care; and child and adolescent mental health services. − We have undertaken a substantial amount of development work in planning for 2010/11 looking at how we take forward our unique perspective as the regulator of health and social care in monitoring and assessing the integration and coordination of health and social care services through registration and assessment of the quality and safety of care. The results of this development activity will be set out to the board as part of our 2010/11 strategy and planning presentations. 3. Acting swiftly to help eliminate poor quality care: − People have a right to expect that if a service falls below essential quality and safety standards for registration, this is identified and swift action is taken. We want to have a major impact on these poorer services and will focus particularly on the weakest performers that have failed to improve - approximately the lowest 10%. Our work includes the following: − Our regional teams have completed a sweep of all registered organisations and NHS organisations to establish the level of risk and ensure that a Commission baseline is established on the basis of a common approach. This information is reviewed routinely at the executive level. 31 of 40
Slide 32: Agenda Item: 10 Ref: CM/09/04/38 − Our screening team continues to analyse large and complex information sets relating to providers’ performance. Outliers are followed up in all cases. − The national enforcement team continues to receive a flow of referrals for independent healthcare, healthcare associated infection, and ionising radiation (or IR(ME)R) enforcement activity - ranging from requests for simple telephone advice and attending case reviews to drafting statutory notices and preparing complex cases for prosecution. − All referrals are prioritised according to risk and checked to ensure that appropriate regional action has been taken prior to escalation. − Our regional enforcement teams’ work has now been expanded to deal with independent healthcare referrals ensuring a swift, proportionate and consistent response to all instances of poor quality services regulated by the Commission. 4. Ensuring and promoting high quality care: − People access and experience registered services of high and improving quality that put them first and champion their rights. Where we identify care that is improving, we will promote this so that other providers can learn from what is working well. Our activities here include: − inspection activity, including the publication of Quality Ratings; − our performance assessment activities relating to the forthcoming annual health check, annual performance assessment of councils and the joint-inspectorate comprehensive areas assessment (CAA) will provide accounts of the performance of NHS providers and local authority and NHS Primary Care Trust (PCT) commissioners − we are publishing a number of reports which set expectations for high quality care − work is underway on the State of Health and Social Care report to be published early next year Our performance here is shown in the report at appendix 1. 5. Regulating effectively in partnership: We will work with other organisations to ensure that the benefits that we bring to service users outweigh our costs, and those incurred by others in meeting our expectations. − A paper on ‘better regulation’ is part of the agenda of this meeting of the board. − A series of ‘risk summits’ with other oversight and regulatory bodies in each region is planned for the Autumn to share information on areas of concern and agree on follow-up action 32 of 40
Slide 33: Agenda Item: 10 Ref: CM/09/04/38 − We are holding a large-scale consultation exercise with the public and regulated organisations on the “Guidance about compliance with the Health and Social Care Act 2008 (Registration Requirements) Regulations 2009. To date we have received over 300 written responses to the consultation. We have commissioned a survey of key stakeholders in November to December in order to get feedback on our approach to registration. − We have commissioned a major survey of key stakeholders for early 2010 to gather feedback on the way that the Commission is perceived in its first 9 months. − We are publishing our five-year strategy in early autumn in the form of a consultation. We will be meeting with each of our key stakeholders and carrying out a number of events to ensure we receive comprehensive feedback. 33 of 40
Slide 34: Agenda Item: 10 Ref: CM/09/04/38 34 of 40
Slide 35: Agenda Item: 10 Ref: CM/09/04/38 Appendix 3 Activity one: Registration Performance criteria A1.1 A1.2 A1.3 A1.4 A1.5 Applications for registration are processed quickly The registration process operates well High risk applications are processed quickly The CQC makes high-quality decisions on registration As above Key performance measure % of registrations under Care Standards Act 2000 are completed in set time period % of applicants rate the quality of CQC's information and processes as good % of high risk applications are fast-tracked in agreed time Fewer than target % of challenges against registration decisions are upheld No first registrations gave extraordinary breach in agreed time Activity two: Mental Health Act (MHA) Visits Performance criteria A2.1 A2.2 A2.3 A2.4 A2.5 Patients view MHA visits as important in upholding their rights Services are safe Second opinions are provided efficiently CQC ensures that patients have their rights explained to them Patients view MHA visits as important in upholding their rights Key performance measure % satisfaction from patient feedback Number of death reviews % of second opinions provided in agreed time % of detained patients report that they had their rights under section 132 of the Act explained to them % satisfaction from patient feedback 35 of 40
Slide 36: Agenda Item: 10 Ref: CM/09/04/38 Activity three: Inspections of providers Performance criteria A3.1 A3.2 A3.3 A3.4 Inspections take full account of appropriate risks Inspected bodies consider that reviews are a fair reflection of their service CQC makes good quality ratings decisions about providers Provider findings are consistent with views of people who use service Key performance measure % of inspections delivered in line with standard risk schedule Survey of users and the public % of appeals upheld against ratings of providers Survey of users and the public Activity four: Enforcements Performance criteria A4.1 A4.1 A4.1 A4.1 Enforcement action is taken swiftly As above Enforcement action is sufficiently robust Enforcement action has a lasting impact Key performance measure % of organisations which go through complete path from escalation to resolution within set time period % of organisations whose escalation proceedings exceed set time period % decisions unsuccessfully challenged on appeal % of organisations which do not return to enforcement procedures within set time period 36 of 40
Slide 37: Agenda Item: 10 Ref: CM/09/04/38 Activity five: Commissioner Reviews Performance criteria A5.1 A5.2 A5.3 Poor quality commissioners are inspected quickly Commissioners are held to account for the quality of commissioning decisions CQC makes good quality ratings decisions about commissioners Key performance measure All commissioners assessed as high risk are inspected in agreed time % Overview & Scrutiny Committees and LINks agree they can use our assessments to hold commissioners accountable % of appeals upheld against ratings of commissioners Activity six: Comprehensive Area Assessments (CAA) Performance criteria A6.1 A6.2 A6.3 CQC participates effectively in local CAA arrangements CAA leads to specific action on health and social care issues CQC provides good quality information to local CAAs Key performance measure CQC submits all pieces of information required for local CAA frameworks by appropriate local deadlines Stakeholder survey Other regulators and inspectors engaged in the CAA rate the CQC as providing useful information on health and social care Activity seven: Special Reviews and Studies Performance criteria A7.1 A7.2 A7.3 The programme of Special Reviews and Studies is implemented efficiently The programme has led to a positive change/ impact As above Key performance measure Programme achieves agreed milestones Self-assessment by CQC further to programme evaluation Survey of stakeholders on impact and benefits of individual reviews 37 of 40
Slide 38: Agenda Item: 10 Ref: CM/09/04/38 How (1): Involve users and the public Performance criteria H1.1 H1.2 H1.3 H1.4 H1.5 H1.6 H1.7 CQC has a public profile CQC involves people who use services Staff consider that CQC put people first and involve people who use services and the public CQC involves users and the public As above CQC handles complaints effectively As above Key performance measure Survey of public awareness of CQC Evaluation of how service users are to be involved in all our activities Staff survey % of LINKs consider that CQC involves users and the public Evaluation of use of ‘Experts by Experience’ on inspections. All complaints are acknowledged and closed or referred on in agreed time Random survey of complainants to assess how they rate the way that CQC handled their complaint How (2): Promote equality, diversity and human rights Performance criteria H2.1 H2.2 H2.3 H2.4 We are recognised as a diversity-friendly organisation CQC staff are committed to EDHR CQC is a discrimination-free workplace CQC has a diverse staff profile Key performance measure Achieve target level in Stonewall Index (and other analogues) Achieve % score for commitment to EDHR in staff survey No complaints of discrimination upheld Achievement of agreed targets for staff diversity 38 of 40
Slide 39: Agenda Item: 10 Ref: CM/09/04/38 How (3): Engage with those providing care and those commissioning care Performance criteria Clinical and social care staff working in regulated bodies consider our regulation as important to their work Publish consultation on CQC's 5 year strategy (2010/15) Publish consultation on proposed 2010/11 topic reviews and period reviews Key performance measure Survey of organisations assess CQC as a good organisation to work with To agreed deadline To agreed deadline H3.1 H3.2 H3.3 How (4): Organisational Development and Human Resources Performance criteria H4.1 H4.2 H4.3 H4.4 H4.5 H4.6 H4.7 H4.8 Staff consider CQC is improving the quality of care Stakeholders view our staff as credible, knowledgeable and customer-focused Staff understand how their objectives link to CQC objectives The action plan following the staff survey is implemented CQC effectively manages its human resources As above As above As above Staff survey Survey of stakeholders % reviews of staff objectives completed by target dates % compliance with agreed actions following staff survey Monthly full time equivalent staff within headcount limit % sickness absence rate across CQC % vacancy rate across CQC Staff turnover rate Key performance measure 39 of 40
Slide 40: Agenda Item: 10 Ref: CM/09/04/38 How (5): Effective use of resources Performance criteria Our staffing budget is spent efficiently As above As above As above We demonstrate that our benefits exceed our costs We have an efficient IT service As above As above Key performance measure Monthly staff spend within budget Monthly revenue spend within budget Monthly capital spend within budget Annual forecast spend within budget Evaluation of ICT benefits ICT achieve agreed service levels Staff satisfaction survey of ICT service Evaluation of ICT benefits 40 of 40