ANNEX A - CQC Performance, April – June, Quarter 1, 2012 Contents

Section 1

– Performance dashboard

Slide 2

Section 2

– delivery priority 1: Deliver and Improve our regulatory and other functions

Slides 3 - 8

Section 3

– delivery priority 3: Manage our organisation, people and resources

Slides 9 - 11

Section 4 –

locations

Slides 12 - 15

Levels of compliance and non-compliance - registered

Section 5 –

CQC 2012/13 equality objectives tracker

Slide 16

Section 6 –

Explanatory notes to the scorecard measures

Slide 17

Public Agenda item: 9 Paper no: CM/03/12/06

1

CQC Performance – April - June, Quarter 1 2012 – section 1, Performance dashboard

Performance dashboard

Highlights and issues: Table 1 : Operating Performance. NHS, ASC, IHC Private Ambulance and Dentist compliance inspections are below planned activity required to achieve full year targets however activity has increased in the period and improved in some areas in July (see slide 3) Table 2: Public facing and governance measures - with the exception of complaints handled within 20 days, all targets were achieved. There were almost 10% less complaints than the same period last year and handling of statutory requests for information remains strong. Stage 2 complaints within 20 days have remained red for the second month, it should be noted that these figures are based on low numbers, there have been only 25 stage 2 in the quarter, those missing the target are largely due to complex complaints, although at the end of the quarter all had been cleared. All NCSC targets were achieved in the period and continue to perform strongly. NCSC information is available on slide 6 and complaints and other information requests is on slide 11. Table 3 shows the Q1 snapshot of compliance levels across each sector, for locations additional information and a breakdown is available slides 12 to 15. Table 4: YTD the Commission has under spent by £3.1m (excluding fee income)– further details are on slides 10. Indicators that are also included in our ‘Public scorecard’ on our website are highlighted across the report in yellow and where applicable a post period update has been added to include the most recent performance information. Please note ‘trend’ performance is based on improvement in the 3 months of the quarter, not compared with Q4.

1. Operating Performance 3. Current level of compliance (locations)

NHS ASC IHC 9% Dentists Ambulance 4% 22% 19% 12% 91% 88% 96% 78% 81%

Graph 1

demonstrates the percentage of inspections completed by sector in Q1 and the relevant Q1 profiled target is given by the line: 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 5% 22% NHS 44% 14% 41% ASC 63% 6% 31% IHC 84% 2% 14% PDC 91% 2% 7% Ind Amb Compliant Non compliant w ith at least one outcome (no enf orcement) Non compliant - enf orcement Not yet subject to a completed review of compliance

2. Public facing and governance Indicator

Provider information on the CQC website updated weekly Number of calls to the NCSC Safeguarding calls answered within 30 seconds Stage 2 complaints completed within 20 working days FOI handled within deadlines % of outstanding critical and important audit actions completed

Target

100% N/A 90% 95% 95% 90%

YTD

92% 44,901 94.0% 67% 95.8% 94%

RAG and trend

G p N/A G q R p G p G p

Finance

Revenue expenditure plus depreciation variance vs. Budget

Human Resources

Establishment and Vacancy rate Turnover Sickness rate

4. Resources Target

£39.1M

Year to date (Quarter1 ) YTD Actual RAG and trend

£36M A p 15% by June 1.125% per month <5% 14.8% 1.97% 3.57% G p G p G p

2

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions 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

Scheduled inspections and compliance.

Ref Indicator Target Q4 11-12 Q1 12-13 YTD Trend C01 C02 C03 C05 C04 Scheduled inspections undertaken compared to plan:

NHS

- at least 1 service per trust (291 Trusts of which there are 350 locations) 25,008

ASC

provider locations 2,764

IHC

provider locations 3,545

dental

provider locations 317

private ambulance

provider locations 23% (81 1 ) 20% (4994 1 ) 14% (388 1 ) 15% (540 1 ) 9% (29 1 ) N/A N/A reported together in 2011/12 16.1% (1433) N/A New 22% (76) 18.8% (4700) 8.86% (245) 12.2% (449) 4% (13) 22% (76) 18.8% (4700) 8.9% (245) 12.2% (449) 4% (13)      C07 Responsive inspections undertaken 342 469 469  C08 C09 C10 C11 C12 Percentage of our inspections where we talked to people about their experience of care The % of our inspections where we used one or more involvement methods or tools NEW Percentage of compliance actions followed up in under twelve weeks The % of draft compliance reports issued within 10 days (of site visit) The % of final compliance reports issued within 25 days (of site visit) 100% 100% 90% 90% N/A New N/A New N/A New 65.1% 14 days 77.0% (28days) N/A 73.8% N/R 61% 67.7% 2 N/R 73.8% Q3 61% 67.7% 2 First due N/A N/A N/A   C13 % of newly registered locations inspected found to be non- compliant First due Q2 N/A C15 % of user voice items added to QRP NEW N/A New (18%) 29601 (18%) 29601 N/A 2 1 C16 The number of thematic reviews undertaken N/A See commentary N/A This is the latest figure in respect of June, no Q1 figure has been reported but will be available for the next report RAG

A A R A R MI

N/A

MI

N/A

R A MI

N/A

A Overall inspection performance remains below planned activity

but improving. 22% of NHS inspections were completed in Q1, marginally below plan. ASC inspections increased each month in Q1 (see graph below) and achieved 94% of target in the period. There was an increase in dentist inspections to achieve 83% of target and although below plan IHC inspection figures improved significantly; there were 117 IHC inspections in April compared with 68 in May and 60 in April. Inspection activity is forecast to accelerate in Q2 as new Inspectors come on stream, however, based on Q1 performance annual targets will remain challenging .

Post period update: As of the end of July: NHS: 25% (89) completed against a target of 25% (89) ASC: 25% (6,307) completed against a target of 24% (6,025) IHC: 12% (232) completed against a target of 22% (575) Dentists: 18% (644) completed against a target of 22% (764) Ambulance: 7% (15) completed against a target of 17% (55) 2500 2000 1500 1000 500 0 April ASC Scheduled Inspections May June Thematic reviews are currently paused whilst a new governance process for approving new thematic review proposals is considered. It is anticipated that the thematic review programme will recommence in Q3. In Q1, 67.7% of final compliance reports were issued within 25 days compared with a target of 90%. This indicator is more challenging than last year and has continued to improve, it also compares favourably to the same period last year when 36.3% where issued with 28 days. Performance is being reviewed by Operations and an action plan being put in place, CRM improvements due in August are expected to considerably improve performance of this and the draft report (C11) indicator. Post period update: as of the July performance report 63% of draft reports and 68% of final reports were issued against a plan of 90%.

3

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions 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

Enforcement

Ref E01 C10 E02 E03 E05 E06 E07 E07a E09 E11A E11B Indicator The % locations where enforcement action has been taken Percentage of compliance actions followed up in under twelve weeks Percentage of warning notices issued within 14 days of identifying one is required Number of Notices of Proposal to cancel registration issued Number of suspensions Number of penalty notices served Number of warning notices served Number of locations with a warning notice served Number of notices of decision to cancel registration Number of locations de-registered voluntarily Number of providers de-registered – following CQC intervention Target 100% 90% Q4 11-12 N/A 0 0 252 N/A New 9 N/A New N/A New Q1 12-13 Report being developed due Q3 Report being developed due Q3 79.9% Report being developed due Q2 0 0 219 108 5 411 9 YTD 79.9% 0 0 219 108 5 411 9 Trend     N/A   N/A RAG

A MI MI MI MI MI MI MI

Overall in the quarter 411 locations have de-registered voluntarily and 9 have de-registered following CQC intervention, there have been 5 notices of decision to cancel a registration and 219 warning notices have been served. Following feedback from the April ET and in consultation with Legal and Operations, we have refined a number of the enforcement measures. Some of the new measures include; the number of locations where warning notices are served, the number of providers deregistered following CQC intervention and locations where enforcement action is taken as a percentage of all locations. Several of the other indicators have been made clearer. The percentage of warning notices served within 14 days declined in June to 73% compared with 80% in May bringing the overall YTD figure 79.9%. Operations are investigating the causes and will take action when identified. There have been 219 warning notices served to date, which is 33 less than Q4, however significantly higher than the same period last year and above the average quarterly figure for 2011/12 of 163, the graph below illustrates the number of warning notices served in each of the last 5 quarters. .

Post period update: Total warning notices served in the year to date for July was 261. In July there was an improvement in the number of warning notices issued within 14 days to 85% compared with 73% in June and 80% in May. Warning notices served in the last 5 quarters 300 250 200 150 100 147 200 252 219 E12 Locations where enforcement action taken as a % of all locations 0 0 0 N/A

MI

50 51 Enforcement is continued overleaf 0 Q1 - 11/12 Q2 - 11/12 Q3 - 11/12 Q4 - 11/12 Q1 - 12/13

4

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve our the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration

Enforcement continued

Ref E13b E13a E14 E15 E16 Indicator Section 31 HSCA 2008 – urgent suspension of registration ,or urgent variation or imposition of conditions Section 31 HSCA 2008 – urgent removal of conditions Non urgent variations or imposition of conditions Removal of conditions on non urgent variations or impositions Non urgent cancellation of registration

Registration

Ref Indicator Target Target Q4 11-12 N/A New N/A New N/A New N/A New N/A New Q4 11-12 Q1 12-13 2 0 0 0 N/R Q1 12-13 YTD 2 0 0 0 N/R YTD Trend     N/A Trend RAG

MI MI MI MI MI

RAG The percentage of variation BAU applications completed within 4 weeks was 71.4% in June compared with 68% in April and 74% in May. Underperformance is largely due to a number of applications being delayed by the provider. Overall most applications are handled within the target time. Operations are reviewing possible improvements to the process to try and separate those applications delayed by the provider, and so out of the control of the registration team, from applications that the team are able to manage. The Head of Registration is reviewing possible ways to improve how this measure is recorded. In the first quarter of the year there were 4,466 variation applications handled within the target time of 4 weeks. New registrations completed within 8 weeks has remained within green rating at 87.6% for the year, 3,931 applications have been handled within the 8 week target. Post period update: In July 80% of variation applications were completed within 4 weeks improving YTD performance to 73%. Performance of new applications has remained consistent at 89% 21.8% of applications were rejected in Quarter1 compared with a target of 25%. This compares favourably to performance in the same period last year when 43% were rejected. Applications validated in less than 5 days fell slightly when compared to Quarter 4 but remained significantly over target at 98.4% again an improvement on the same period last year when performance stood at 94%.

Graph - Applications completed within the 4 week variation target R01 R02 R04 Percentage of new provider and manager registration applications completed within eight weeks Percentage of applications to change a registration completed within four weeks % of applications rejected (Shared services) 90% 90% <25% 88.7% N/A New 30.7% 87.6% 70.6% 21.8% 87.6% 70.6% 21.8%    G R G June May 71% 74% 19% 16% R05 R07 R08

MI

Applications validated within 5 days - Shared services Primary medical services providers served with all Notices of Decision by 31 March 2013 Primary medical services providers served with all Notices of Decision after 31 March 2013 90% 100% N/A 99% 98.4% 98.4% Tranche not yet open Tranche not yet open  G April 0% 68% 22% 10% 20% 30% 40% 50% 60% Within target Missed target 70% 80% 90% 100%

5

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions 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

NCSC Call handling indicators

Ref NC2 NC3 NC4 NC11 Calls answered within 30 seconds Safeguarding Calls answered within 30 seconds - Mental Health Calls answered within 30 seconds Registration ‘Other’ calls answered within 30 seconds NC6 NC7 NC8 Indicator Calls abandoned - Safeguarding Calls abandoned - Mental Health Calls abandoned – Registration Target Q4 11-12 Q1 12-13 90% 98% 94% 90% 80% 80% 3% 3% 5% 98% 89.0% 92.0% 0% 0% 1% 95.9% 79.9% 76.1% 1.3% 2.7% 3.9% NC9 Calls abandoned - Other 5% 1% 4.6% YTD 94% 95.9% 79.9% 76.1% 1.3% 2.7% 3.9% 4.6% C12 Number of Whistle blowing contacts N/A N/A 1,654 1,654 Trend RAG         N/A G G G G G G G G

MI

Overall performance against NCSC measures fell slightly in Quarter 1 compared to Quarter 4 but remains within target. There were almost 45,000 calls year to date. There were 1654 whistle blowing contacts to the NCSC of which 749 were calls to the Helpline, 685 were emails and 218 letters.

In the priority areas covering safeguarding and mental health 94.0% and 95.9% of calls respectively were answered within the target time of 30 seconds, compared to 98% for both call types in Quarter 4 . Call abandonment rates remain above target despite a slight drop in Quarter1 . Performance against calls answered within time was above target. The slight drop in performance during the Quarter1 was due to one off training events for T5 , User Acceptance Training for CRM Release 18 and the NCSC staff event on values/future business objectives as well as adverse weather conditions in June.

Post period update: In July there were 17,500 calls brining the year to date total to over 62,000. Call handling remained constant with all targets being exceeded and there were a further 609 whistle blowing calls In July.

Graph – peaks and troughs in calls answered within target

Call answered within 30 seconds

Safeguarding Mental Health Registration Other 120% 100% 80% 60% 40% 20% 0% 6/4/12 13/4/12 20/4/12 27/4/12 4/5/12 11/5/12 18/5/12 25/5/12

Week ending

1/6/12 8/6/12 15/6/12 22/6/12 29/6/12

6

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model - Publication, Mental Health and Other inspections

Ref Indicator Target Q4 11-12 Q1 12-13 YTD

Publications

P1 P4 Weekly provider information on the website refreshed timely Total visits to the website 100% 79% 92% 1,148,043 1,270,862 P2 P3 Key publications are on target – State of Care; Mental Health Act Monitoring report; Annual report; reports of thematic inspections Providers feel informed about CQC regulatory system and have the information they need in order to be regulated by us 100% 100% 93.5%

‘Other ‘ inspections (controlled drugs, ionising radiation and joint inspections)

100% Provider survey to be run every six months OC3 N/R 156 OC5 OC6 OC7 Other inspections on track: pharmacy and controlled drugs Other inspections on track: ionising radiation (IR(ME)R) Joint inspections are on track – Ofsted Joint inspections are on track - HMI prisons 5 N/R 6 8 0 9 92% 1,270,862 100% N/A 156 8 0 9 OC8 Joint inspections are on track - HMI Probation N/R 2 2 Trend    N/A N/A   N/A  RAG G

MI

G

MI

G G N/A G G There have been almost 1.3m unique visits to the website in Q1, the most popular pages were the Homepage, organisations we regulate and the public section of the website. Graph 1 below illustrates the top 5 most visited areas. There were almost 19,000 downloads in June Compliance guidance the most popular with at almost 10,000. Weekly updates although below target are improving month on month and have compared strongly compared to last year. Post period update: There was a significant increase in visitors to the website in July when there were over 475,000 visitors bringing the year to date total to almost 1.75m visitors. Most visited pages and downloads remained constant. Graph – most visited areas of the CQC website 20233 20862 34499 38641 Hits' 165957 Homepage Orgs we regulate Public Reports surveys and reviews Contact us Other inspections: In Q1 there were 8 ionising radiation (IR(ME)R) inspections, 2 more than planned. No activity has been reported against Ofsted inspections, this is being followed up and feedback will be included in the next report. HMI prisons Inspections have increased compared to Q4 from 6 to 9 and there have been 2 HMI probation inspections in the period. 1 Status updated quarterly as MHA schedules are set for quarters

7

CQC Performance – April - June, Q1, 2012 – section 2, Deliver and Improve our regulatory and other functions Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model - Publication, Mental Health and Other inspections

Mental Health Operations

Ref M1 M2 M3 M10 Indicator MHA Commissioner visits - Hospital visits (Actual vs. Scheduled ) Mental Health Act complaints Percentage and number of complaints triaged within 3 working days Mental Health Act Complaints Percentage of complaints received which are responded to within 25 days Requests allocated to Second Opinion Appointed Doctors within 4 working days Target 95% 90% 90% 75% in Q1 & Q2 increasing to 95% in Q3 and Q4 Q4 11-12 106% (428) N/A New N/A New N/A New Q1 12-13 121% (277) 96% (68 of 71) 94% (187 of 198) 61% YTD 121% (277) 96% (68 of 71) 94% (187 of 198) 61% Trend     RAG G G G A Mental health measures: Overall there has been a strong start to delivery of mental health operations indicators. In Q1 there were 277 visits completed which was 121% of planned activity, this compares favourably with the same period last year when 83% of scheduled visits were completed to plan. New indicators covering performance around responding to complaints from service users relating to their service providers was also above target; 96% of complaints were triaged within 3 days and 94% were responded to within 25 days compared with a target of 90% for both indicators. A number of milestones aimed at improving processes are progressing well; a new online reporting process aimed at improving the quality and timeliness of information collected from second opinion appointed doctors and the locations they visit will be rolled out between August and October. The recruitment and induction programme of an additional 50 second opinion appointed Doctors is on track to be delivered in Q3.

A new indicator covering the efficiency with which allocation of requests for second opinion appointed doctors are made is below plan at 61% compared with a target of 75% however has improved in each on the three months in the quarter, 56% of requests were allocated within target in April, compared with 60% in May and 62% in June. This is expected to improve further as the improvement embeds. The introduction in August of an online SOAD request form we will report in Q3 SOAD measures covering medication, ECT and CTO visits. Monthly updates on progress against the MHA improvement plan will be made available in the ET performance reports and in the next quarterly Board report.

8

CQC Performance – April - June, Q1, 2012 – section 3, Manage our organisation, people and resources Priority 3 – Manage our organisation, people and resources

Human Resources

Indicator Ref HR1 Establishment Total HR1a Establishment and vacancy rate ( establishment less permanent staff ) Target 15% by June 2012 HR2 Compliance inspector vacancy rate <2% HR3 Induction and other frontline staff training on target Green HR4 HR5 HR6 All staff who are new to frontline roles successfully complete induction programme within 10 weeks of new role starting All front line staff undertake mandatory training on an annual basis.

Number of permanent staff (FTE) 95% 96% Q4 11-12 2259 17.9% N/A New N/A New N/A New N/A New HR7 No of Vacancies 404 HR7a HR8 New staff pipeline (Staff with an offer of employment) Temporary staff in established posts 28 Q1 12-13 2292 (12/13) YTD N/A 14.8% 12.5% Green 98% Green 1849 339 111 44 14.8% 12.5% Green 98% Green 1849 339 111 44 Trend   N/A N/A N/A N/A   N/A  RAG N/A

G R G G G MI MI MI MI

500 450 400 350 300 250 200 150 100 50 0 Establishment increased in Q1 to 2,292 compared with 2,259 in Q4 reflecting recruitment of additional compliance inspectors and other staff in the period. When compared to Q1 last year overall establishment has increased 16%. The Establishment and Vacancy rate is 14.8% for Q1, achieving the 15% target for the period Recruitment activity is progressing for a number of front line roles. There are 215 compliance inspector vacancies, and 6 training cohorts planned, 2 in each month between August and September, these will cover training for 157 CIs. To meet the additional recruitment a further training cohorts will take place in each of the 3 months of Q3, exact dates are being planned by HR.

Post period update: Following additional recruitment in July the number of outstanding compliance inspectors has fallen to 80. Graph – vacancies in the last 5 Quarters Vacancies Q1 -11/12 Q2 -11/12 Q3 -11/12

Time

Q4 -11/12 Q1 - 12/13 1 Actual performance is the most recent fortnight reported, therefore not an average

9

Human Resources (continued)

Ref HR10 HR11 HR12 AR1 AR2

Finance

Ref F01

CQC Performance – April - June, Q1, 2012 – section 3, Manage our organisation, people and resources Priority 3 – Manage our organisation, people and resources Resources

Indicator Turnover 2 Sickness Rate (based on calendar days) 2 Health and Safety - no. of workplace accidents Frequent usage of Activity Recording Tool (ART) by Compliance Inspectors Frequent usage of Activity Recording Tool (ART) by Registration Assessors Indicator Revenue expenditure plus depreciation variance vs. Budget (excluding fee income) Target 1.125% per month <5% Q4 11-12 1.7% 3.2% 85% 85% 4 N/A N/A Q1 12-13 1.97% 3.57% 4 N/A N/A Target 5% Full year 11-12 £149.4M v 157.7M (5%) Q1 12-13 £36M v £39.1M

(8%) 3 YTD 1.97% 3.57% 4 68.4%

1

71.6%

1

YTD £36M v £39.1M

(8%) 1 Actual performance is the most recent fortnight reported, therefore not an average 2 The rolling year average ( July 2011- June 2012) for Turnover is 7.42% and 4.11% for the sickness rate 3 Excludes fee income Trend      Trend RAG  RAG

G G MI A A A

Revenue expenditure plus depreciation Quarter1 shows an under spend of £3.1m (8% excluding fee income) consisting of staff costs of £1.8m, non Staff Costs of £0.7m and depreciation of £0.6m.The year to date underspend is in line with the £3.2m underspend forecasted in May’s report. Additional finance measures are being discussed and will be added to the next set of monthly reports. Post period update: including July expenditure year to date underspend is £3.7m – excluding fee income (£52.9m versus £49.2m) Usage of the Activity Recording Tool (ART) remains below target in the last reported fortnight but has improved significantly since April, 68% of compliance inspectors and 72% registration assessors were using the system compared with a target of 85%. Weekly MI is now sent to regions and this has had an impact on ART usage. Regional activity is given in the graphs below.

Compliance Inspector ART usage by region - latest

Graphs – most recent two weeks usage of ART, 6 July CQC Central North South London 0% 10% 20% 30% 40%

Performance

50% 60% 70% 80%

Registration Assessor ART usage by region - latest

CQC North Central South London 0% 10% 20% 30% 40% 50%

Performance

60% 70% 80% 90%

10

CQC Performance – April - June, Q1, 2012 – section 3, Manage our organisation, people and resources Priority 3 – Manage our organisation, people and resources Resources and Governance

Corporate governance (complaints and statutory requests for information)

Ref Indicator Target Q4 11-12 GL01 Number of stage 1 corporate complaints received across the organisation 10% less than 2011/12 122 GL02 GL04 Stage 1 Corporate complaints upheld Of the initial stage 1 complaints received the number proceeding stage 2 <20% N/A New N/A New GL05 GL03 Of those closed , the number of stage 2 reviews completed in 20 working days No of stage 2 complaints upheld 95% 67% N/A New GL06 GL07 GL08 GL08a No of stage 2 complaints referred for independent investigation Information access requests closed within deadline No. of Parliamentary Ombudsman enquiries made of CQC No. of Parliamentary Ombudsman investigations made of CQC 95% 0 98.4% 8 0 Q1 12-13 105 7 20% (21) 67% 5 0 95.9% (304) 12 0 YTD 105 7 20% (21) 67% 5 0 95.9% (304) 12 0 Trend  N/A N/A  N/A     RAG

MI MI

G R

MI MI

G

MI MI

There were 105 stage one complaints received in Q1, in comparison with 122 in Q4 last year. The majority of these complaints recorded were about dealings with CQC mostly inspection or NCSC staff, other complaints related to or administrative processes and policies and procedures. The percentage of stage 2 complaints completed within the timescale of 20 working days remained constant at 67% when compared to Q4. There were 25 closed of these 17 were within the timescale. Most complaints over the timescale relate to complex complaints requiring additional information from the complainants. Performance in handling statutory requests started the year well, all targets for FOI, DPA and information sharing were achieved. 304 or 95.9% of requests were closed in Quarter 1 compared to a quarterly average of 351 or 98.4% in 2011/12. The scorecard shows a slight fall in percentage terms for the KPI for compliance with FOIA and DPA and information sharing statutory deadlines. This was partly due to resource and demand issues, and partly due to additional care being taken over several disclosures. Approval has been obtained to recruit an extra member to the Information Access Team to address resource issues.

Post period update: Including July there have been 142 stage 1 complaints year to date. 100% of stage 2 complaints were completed in under 20 days improving year to date performance to 75%.

Graph – handling for statutory requests for information

Handling Statutory Requests Quarter 1

GL09 GL10 GL11 Of closed requests proportion closed within deadline - Freedom of Information Of closed requests proportion closed within deadline - Data Protection Of closed requests proportion closed within deadline - Info Sharing 95% 95% 95% 98% 100% 100% 95.8% (236) 92.9% (28) 98% (40) 95.8% (236) 92.9% (28) 98% (40)    G G G Freedom of Information Information Sharing GL14 GL12 Urgent cancellations of registration (under section 30 of the HSCA 2008) Percentage of outstanding critical and important audit actions completed 90% 0 N/A New 0 94% 0 94%  

MI

G Data protection 90.0% 91.0% 92.0% 93.0% 94.0% 95.0% 96.0% 97.0% 98.0% 99.0%

Performance 11

CQC Performance – April - June, Q1, 2012 – section 4, levels of compliance and non compliance at registered locations Number of locations in each sector that meet essential standards of quality and safety By sector – location level

50% 40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 73% 5% 22% NHS 44%

CQC Performance – April - June, Q1, 2012

The graph to the left illustrates levels of compliance across all

– compliance outcomes

that were non compliant with at least one outcome and 93 locations were non compliant and subject to enforcement action. The table below gives a break down of actual numbers of locations that are non-compliant and subject to enforcement in the period.

63% 84% 91% 14% 41% ASC 6% 31% IHC 2% 14% PDC 2% 7% Ind Amb NHS ASC IHC

Non compliant – enforcement

2 87 4 PDC Ind Amb 0 0 Total 93 Compliant Non compliant w ith at least one outcome (no enforcement) Non compliant - enforcement Not yet subject to a completed review of compliance

12

CQC Performance – April - June, Q1, 2012 – section 4, compliance outcomes

Levels of compliance and non-compliance - registered locations

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

Introduction to this set of graphs: This data relating to the time locations have been non compliant is new. We have introduced it to inform our work on monitoring compliance, follow up non compliance particularly where it has lasted for a long period. The tables show how many non-compliant locations there are each quarter grouped by the time they have been non compliant i.e. less that one quarter, between one and two quarters, to up to more than four quarters. Each quarter the information is updated to show how many of those locations still remain non compliant. See the graph below for illustration. The regions within the Operations directorate are using this useful and important new report to follow-up all outstanding areas of non-compliance. Operations has began by focusing on those outliers who have been non-compliant for more than a year. Our analysis highlights cases where inspectors are working closely with the provider to support a return to compliance in the future. In some cases follow-up inspections have identified non-compliance with further regulations, leading to a longer period of non-compliance. The data has also shown that in a few instances some providers are now compliant, but the inspector has not yet updated the system. We are correcting this. Operations plan to run this new report monthly to ensure we keep a tight grip on all non-compliant providers. The data will also help inspectors to ensure we meet the target to follow-up non-compliance within 12 weeks of when an action plan shows the area of non-compliance has been addressed.

Location been non compliant for: Less than one quarter More than one quarter but less than two quarters More than two quarters but less than three quarters More than three quarters but less than one year Over one year Q4 2011/12

35

28%

30

24%

30

24%

20

16%

12

9%

Q1 2012/13

21

18%

29

25%

22

19%

19

16%

25

22% 35 30 25 20 15 10 5 0 There were 35 non compliant locations in Q4 2011/12 29 of them were still non compliant at the end of Q1 2012/13 <1 quarter >1 but <2 quarters >2 but <3 quarters >3 but <4 quarters Position at the end of Q4 11/12 Position at the end of Q1 12/13

13

CQC Performance – April - June, Q1, 2012 – section 4, compliance outcomes

Levels of compliance and non-compliance - registered locations

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

Location been non compliant for: Less than one quarter More than one quarter but less than two quarters More than two quarters but less than three quarters More than three quarters but less than one year Over one year Q4 2011/12

1168

36%

1010

31%

607

19%

355

11%

149

5%

Q1 2012/13

969

26%

1057

28%

793

21%

500

13%

422

11% 1200 1000 800 600 400 200 0 <1 quarter > 1 but < 2 quarters > 2 but < 3 quarters > 3 but < 4 quarters Position at end of Q4 2011/12 Position at end of Q1 2012/13

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CQC Performance – April - June, Q1, 2012 – section 4, compliance outcomes

Levels of compliance and non-compliance - registered locations

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

Location been non compliant for: Less than one quarter More than one quarter but less than two quarters More than two quarters but less than three quarters More than three quarters but less than one year Over one year Q4 2011/12

145

56%

62

25%

29

12%

12

5%

0

0%

Q1 2012/13

171

44%

132

34%

53

14%

23

6%

8

2% 160 140 120 100 80 60 40 20 0 <1 quarter >1 but <2 quarters >2 but <3 quarters >3 but <4 quarters Position at the end of Q4 11/12 Position at the end of Q1 12/13

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CQC Performance – April - June, Q1, 2012 – section 5, deliver our equality objectives All priorities – corporate equality objectives

Equality actions are included in Directorate Business plans, and successful delivery is achieved

Ref Indicator Target Q4 11-12 Q1 12-13 YTD EQ1 EQ2 Embed equality across all our regulatory and corporate activities 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 Green rating N/A new N/A new Green Green Green Green EQ3 Improve information and intelligence that we hold about health and social care providers in order to better identify risks to equality Green rating N/A new Green Green Trend N/A N/A N/A EQ4 EQ5 EQ5 EQ6 EQ7 EQ8 EQ9 Involve a diverse range of people who use services in our work Increase the uptake of accessible information for easy to read. Large print and 6 community language downloads.

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

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 Improve the diversity profile of CQC's workforce so it is representative of the communities we serve Improve the percentage of staff who say that they feel safe from harassment and are treated equally at work Improve the percentage of staff who have the knowledge, skills and tools to embed equality and human rights in their work.

Green rating Green rating Green rating Green rating Green rating Green rating Green rating N/A new N/A new N/A new N/A new N/A new N/A new N/A new Green 17644 24 Green To be reported in Q2 To be reported in Q2 Green Green 17644 24 Green N/A N/A Green N/A N/A N/A N/A N/A N/A N/A RAG G G G G G G G N/A N/A G Commentary: At the start of the financial year the commission published our internal equality objectives. All of the objectives have been embedded in the reporting cycle and will be included in the quarterly reports to the ET and Board. All objectives were rated as green and on track to be achieved for the year. Notable progress in Q1 included an action (as part of EQ2) on the evaluation of EDHR in reviews of compliance to identify where the Commission need to carry out development work to ensure that the Commission identifies and responds appropriately to EDHR issues in compliance monitoring the evaluation is on track.

Further information will be included in the mid year performance report.

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CQC Performance – section 6, understanding the scorecard

Compliance

A 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.

Complaints

The 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.

Enforcement

We 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.

Equality

Setting 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.

Finance

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

Human Resources

The 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

Publication

The 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 Inspections

The 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.

Registration

To 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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