Transcript Complete MOR report

ANNEX A - CQC Performance,
Quarter 3, 2012
Contents
Section 1 – Scorecard summary
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 - 10
Section 4 – Levels of compliance and non-compliance - registered
locations
Slides 11 - 14
Section 5 – CQC 2012/13 equality objectives tracker
Slide 15
Section 6 – Explanatory notes to the scorecard measures
Slide 16
 All measures with a tick are included in our
monthly performance dashboard which is published
on our website.
1
Q3 and YTD scorecard summary
Operating performance - Compliance inspections
Operating performance - Registration, Enforcement and MHA
Measure
Target
Q1
Q2
Q3
Year to
Date
Trend
RAG
Measure
NHS
inspections
65%
(226)
20%
(71)
14%
(50)
39%
(137)
73%
(258)

G
ASC
inspections
59%
(14,847)
14%
(3,556)
18%
(4,384)
26%
(6,562)
58%
(14,502)

A
registrations
within 8 weeks
variations
within 4 weeks
IHC
inspections
46%
(1,279)
7%
(196)
7%
(186)
20%
(565)
34%
(947)

R
Dental
inspections
57%
(2,010)
14%
(499)
15%
(523)
29%
(1,023)
58%
(2,045)

G
Private
Ambulance
inspections
56%
(177)
5%
(16)
6%
(20)
17%
(55)
27%
(86)

R
% warning
notices - 14
days
MHA
Commissioner
visits
SOAD
requests
allocated < 4
working days
Target
Q1
Q2
Q3
Year to
Date
Trend
RAG
90%
88%
88%
83%
86%

G
90%
70%
76%
74%
73%

A
90%
81%
79%
79%
84%

G
95%
121%
106%
82%
101%

G
95%
N/R
N/R
100%
100%
N/A
G
Resources and audit actions
Customer Service
Measure
Calls in 30
sec. Safe
guarding
Target
90%
Q1
94%
Q2
94%
Q3
93%
Year to
Date
94%
Trend

RAG
G
Calls in 30
sec. Mental
Health
90%
96%
96%
94%
95%

G
stage 1
complaints
<10% of
2011/12
105
96
117
318

G
Stage 1
complaints
proceeding
stage 2
<20%
20%
(21)
27%
(26)
12%
(13)
19%
(60)
stage 2
completed in
< 20 days
95%
67%
100%
77%
81%


Measure
CI Vacancy
rate
Front line staff
mandatory
learning
Target
Q1
Q2
Q3
Year to
Date
Trend
RAG
<2%
13%
8%
0.4%
0.4%

G
72%
42%
31%
29%
34%

R
<5%
3%
3%
4%
4%

G
5%
- 8%
- 8%
-6%
- 6%

A
90%
97%
94%
95%
95%

G
Sickness rate
G
Revenue
variance vs.
budget
A
% of
outstanding
audit actions
completed
2
CQC Performance – Q3, 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
Compliance Monitoring
Compliance Monitoring Inspections (with 5 outcomes or more) completed
Ref
C01

C02

C03

C04

N/A
Q3
12-13
YTD
Trend
RAG
65%
(226)
20%
(71)
14%
(50)
39%
(137)
73%
(258)

G
Against the number of active locations we have met 61.6% of plan
over the first 3 quarters, which leaves over 38% of plan to be
inspected in Q4.
59%
(14,847)
14%
(3,556)
18%
(4,384)
26%
(6,562)
58%
(14,502)

A
46%
(1,279)
7%
(196)
7%
(186)
20%
(565)
34%
(947)

R
57%
(2,010)
14%
(499)
15%
(523)
29%
(1,023)
58%
(2,045)

G
As of 27th January there were 28,943 active locations (i.e.
excluding those that made up the business plan target, but have since
deregistered). This leaves 8,020 inspections to be completed in the
next 9 weeks. Over the year productivity has improved
significantly and additional resources have been made
available in support of the programme delivery, however Q4 will
be particularly challenging. The graph below illustrates the percentage
of the plan by sector that must be delivered in Q4 to meet the overall
business plan target. The second table on the left demonstrates the
latest position (as at 27th January 2013 and compares the current
weekly run rate and the required weekly run rate.)
56%
(177)
5%
(16)
6%
(20)
17%
(55)
27%
(86)

R
NHS - at least 1 service per
trust (291 Trusts - 350
locations)
2,764 IHC provider locations

C05
Target
Q2
12-13
Indicator
25,008 ASC provider
locations
3,545 dental provider
locations
317 private ambulance
provider locations
Overall performance against
programme
As at 31st December we were 75% of the way through the financial
year and had completed 55.7%, (17,838) of our inspection
delivery plan compared with a year to date profiled plan of
58% (18,539).
Q1
12-13
58%
(18,539)
14%
(4,338)
16%
(5,163)
26%
(8,342)
56%
(17,838)

Compliance Performance by sector
80%
A
70%
YTD
NHS
269
261
ASC
16,973
17,633
Difference
Required weekly
run rate
Variance
8
4
7
-3
-660
619
629
Performance
Sector
Current weekly
Run rate
IHC
1,240
1,784
-544
86
130
-44
Dentist
2,329
2,507
-178
104
109
-5
Ambulance
112
228
-116
9
17
-8
CQC
20,923
22,413
-1,490
822
891
-69
50%
179
1,421
73%
66%
1,191
42%
42%
39%
40%
30%
20%
-10
7,303
74
60%
Latest Position of Inspection Activity and run rates (as at 27th January 2013)
YTD
target
Actual number of active
locations remaining to
be inspected
26%
20%
14%
26%
18%
14%
10%
29%
20%
18%
15%
14%
5%
7% 7%
4%
0%
NHS
ASC
IHC
Dental
Private Amb.
Q1 Q2 Q3 Q4 Required
1
This is the profiled target to date- annual target is given numerically in the cells to the
left
2 Based on including inspections from Q1,Q2 and Q3 that had less than 5 outcomes.
3
CQC Performance – Q3, 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
Commentary:
Scheduled Inspections and compliance
Ref
Indicator
Target
Q1
12-13
Q2
12-13
The Regulatory Risk Committee has agreed to 4 thematic reviews
this year covering:
Q3
12-13
YTD
Trend
RAG
• Dementia
• NHS data quality
• Experiences of people waiting for NHS treatment and;
• Physical health needs of people with a learning disability.
C07
Responsive inspections undertaken
-
485
502
393
1,380

MI
C11
The % of our inspections where we
used one or more involvement methods
or tools
-
61%
81%
84%
75%

MI
The review of dementia started in September and the remaining
reviews are on track to report in March 2013.
C16
The % of draft compliance reports
issued within 10 days (of site visit)
90%
61%
64%
73%
68%

R
The number of user voice QRP items is 48,703 this is an increase
of 42% or 14,348 since Quarter1.
The % of final compliance reports
issued within 25 days (of site visit)
90%
68%
65%
74%
71%

R
C17

C30
Total user voice items on QRP
-
34,355
40,951
48,703
48,703

MI
C16
The number of thematic reviews
undertaken
3
1
0
1
2

G
C19
The % of providers and locations in
each sector that are meeting essential
standards of quality and safety
-
Inspection Judgements - the % change
to non compliant
-
C24b
Inspection Judgements - the % change
to compliant
-
C24c
Inspection Judgements - the % no
change to compliant
-
C24d
Inspection Judgements - Average time
period for change to compliant
-
C24e
Inspection Judgements – the % of non
compliant for 2 quarters
-
C24a
Although draft and final report timeliness has improved in
comparison to Q2 when it was 64% and 65% respectively
performance remains below plan for this year. The graphs below
demonstrates that the plan for final reports was met in April,
performance declined until September and then started to show
improvement. The increase in performance is partly due to release
19 of CRM which provides detailed MI for compliance managers.
target
110.0%

MI

MI

MI

MI
100.0%
90.0%
80.0%
See Graphs Slide 11-14
70.0%
60.0%

MI

MI
be
r
be
r
De
ce
m
be
r
No
ve
m
be
r
ay
Ju
ly
Oc
to
MI
Se
pt
em
N/A
Ju
ne
198
Days
M
198
Days
Ap
ril
192.5
Days
Au
gu
st
190.1
Days
50.0%
The % of draft compliance reports issued within 10 working days
The % of final compliance reports issued within 25 working days
See Graphs Slide 11-14
C24e
Inspection Judgements – the % of non
compliant for 3 quarters
-
4
CQC Performance – Q3, 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
Commentary:
Indicator
E12
Locations where enforcement action
taken as a % of all locations
E07
Number of warning notices served


Percentage of warning notices issued
within 14 days of identifying one is
required
E04
Number of Notices of Proposal served
to vary / remove / impose a condition.
E02
E05
E09
Number of suspensions
Target
Q1
12-13
Q2
12-13
Q3
12-13
YTD
Trend
RAG
-
0
N/R
N/R
N/R
N/A
MI
-
177
198
276
651

MI
90%
81.2%
78.9%
78.8%
83.8%

A
-
N/R
N/R
N/R
N/R
N/A
MI
-
0
0
0
0

MI
0
0
0
0

MI
Non urgent cancellations of registration
Number of provides cancelled
voluntarily
-
402
418
365
1185

E11B
Number of providers de-registered due
to CQC intervention
-
9
12
20
41

GL13
Prosecutions concluded with a
favourable result
-
1
0
0
1

MI
E13b
Section 31 HSCA 2008 – urgent
suspension of registration ,or urgent
variation or imposition of conditions
-

MI
E11A

There were almost as many warning notices issued in the first three
quarters of 2012/13 (651) than all 4 quarters of 2011/12, when there
were 658. So far this year an average of 72 warning notices are issued
each month, compared to an average of 55 per month last year. The
graph below illustrates the number of warning notices issued on
a quarterly basis since Q1, 2011/12.
Notable legal action in Q3 included use of Section 30 of our Health and
Social Care Act 2008 powers, to cancel the registration of a
Nottinghamshire care home owner to stop them from being able to run a
residential home to protect the safety and welfare of residents. CQC took
this action because it had serious concerns about the service and the
risks to the people using it.
3,798 locations that have de-registered since April 2012 of these 41
were due to CQC intervention.
MI
Warning Notices Issued
MI
300
250
0
0
3
Section 31 HSCA 2008 – urgent
removal of conditions
-
E14
Non urgent variations or imposition of
conditions
-
1
3
4
E15
Removal of conditions on non urgent
variations or impositions
-
0
0
0
E13a
The number of warning notices increased by 39% (or 78) in Q3
compared with Q2. Year to date there have been 651 warning notices
issued compared to 396 for the same period last year an increase of
64%. The percentage of warning notices that are issued within 14
days of identifying one is required has remained fairly constant between
Q2 and Q3 at 78.9% and 78.8% respectively. Year to date the figures is
83.8%.
0
0
0
3

MI
8

MI
0

MI
0
Performance
Ref
200
150
100
50
0
Q1 2011/12
Q2 2011/12
Q3 2011/12
Q1 2012/13
Q2 2012/13
Q3 2012/13
Q4 2011/12
5
CQC Performance – Q3, 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
Commentary:
Registration
Ref
R01

R02

Indicator
Target
Percentage of new provider and
manager registration applications
completed within eight weeks
Percentage of applications to
change a registration completed
within four weeks
90%
Q1
12-13
Q2
12-13
Q3
12-13
87.7%
87.6%
82.5%
YTD
85.9%
Tren
d
RAG

G
New provider and manager applications completed within 8 weeks
remains within plan at 85.9% year to date. Meeting the 4 week target for
variation applications remains challenging. The graph below illustrates
the weekly performance over the period from May 2012 to December 2012,
although performance has improved from 65% at the beginning of May to
80% in December it remains below the 90% target.
Manager variation applications completed within 4 weeks
90%
70%
75.8%
74.3%
73.1%

A
Improvement Line
90%
85%
R04
R05

Applications validated within 5 days
- Shared services
<25%
90%
21.8%
98.4%
22.9%
98.8%
26.3%
98.5%
23.7%
98.6%

G

G
80%
75%
70%
65%
60%
55%
2
/1
/12
14
2
/1
/11
16
Tranche 5 Update (Latest Position as at 11th January 2013)
50%
2
/1
/10
19
G
2
/1
/09
21
N/A
2
/1
/08
24
N/R
4,784
(59.8%)
2
/1
/07
27
N/R
4,784
(59.8%)
2
/1
/06
29
20% by
Q3
2
/1
/06
01
Primary medical services providers
served with all Notices of Decision
by 31 March 2013 (Update as at
11th January 2013).
2
/1
/05
04
R07
% of applications rejected (Shared
services)
Time
Delivery of tranche 5 continues to progress and remains on track to achieve plan. The first six
batches have closed a further two batches remain open; these will close on 4th February and 4th
March. Overall, the number of providers that have submitted an application is 7,644.Year to date the
figure stands at 1,539 or 20%. All non compliant applications will be subject to additional scrutiny by
assessors. Year to date there have been 4,784 (or 62.6%) providers in receipt of their Notices of
Decision.
6
CQC Performance – Q3, 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 - Other inspections and mental health
Commentary:
‘Other ‘ inspections (controlled drugs, ionising radiation and joint inspections )
Ref
Indicator
Target
OC3
Other inspections on track: pharmacy
and controlled drugs
-
OC5
Other inspections on track: ionising
radiation (IR(ME)R)
-
OC6
Joint inspections are on track – Ofsted
-
OC7
Joint inspections are on track - HMI
prisons
-
OC8
Joint inspections are on track - HMI
Probation
-
Q1
12-13
Q2
12-13
Q3
12-13
YTD
Trend
RAG
156
231
230
617

MI
8
6
5
19

MI
3
0
N/R
N/R
N/A
N/A
11
18
9
38

MI
2
0
N/R
N/R
N/A
MI
RAG
Mental Health Operations
Ref
Indicator
M1
MHA Commissioner visits - Hospital
visits (Actual vs. Sch.)
M2
M3
SOADS medicine visits attend within
10 working days of receipt of request
SOADS ECT visits - those identified as
required ,attend before second
treatment
Target
Q1 12-13
Q2 12-13
Q3 12-13
YTD
Trend
95%
121%
(277 of 229)
106%
(321 of 301)
81%
(244 of 300)
101%
(842 of
830)

G
N/R
66%
(219 of 330)
66%
(219 of
330)
N/A
A
N/R
42%
(23 of 55)
N/A
R
59%
(30 of 51)
N/A
R
Q2 75%
Q2 75%
M2 – M4 are
reported
one quarter
in arrears to
ensure data
accuracy
42%
(23 of 55)
M4
SOADS CTO visits- where the opinion
is needed before the end of the month
Q2 75%
N/R
59%
(30 of51)
M5
Requests entered within 4 working
days of receipt to allocate to SOADS
Q2 75%
N/R
N/R
99.8%
(2,132 of
2,136)
99.8%
(2,132 of
2,136
N/A
G
90%
96.4%
(81 of 84)
98.6%
(209 of 212)
93%
(238 of 255)
96%
(528 of
551)

G
90%
N/R
94%
(83 of 84 )
100%
(212 of 212)
99%
(295 of
296)

G
M6
M6A
MHA Complaints - % and number of
complaints triaged within 3 working
days
MHA Complaints - % received which
are responded to within 25 days
Mental Health Act Operations - planned MHA
Commissioner visits remain ahead of schedule for
the year to date - against a planned programme of 830
inspections in the first 9 months of the year, 842 have
been completed. All complaint targets are also on
track, year to date of 551 complaints about providers,
528 were triaged within 3 working days.
SOAD indicators, M2 to M4, are reported one quarter
in arrears to ensure data accuracy. The short- term- type
contract relationship the CQC has with SOADs means
that they will often complete a visit but not update the
report on time. Q2 performance reflects only August
and Septembers activity, the online forms that replaced
the old manual reporting were delayed in being set up
and as a result reporting against these measures (which
were new and were not tracked manually) has been
delayed.
Overall SOAD performance was below plan, recruitment is
on going to increase the number of available doctors.
During the most recent recruitment process there were
80 SOAD candidates and of these 9 were successful at
interview and attended an induction training session. The
SOAD leadership will be strengthened to include a
Principle SOAD and Operational manager to ensure robust
challenge to the quality of second opinions provided. In
Q2, 219 out of 330 SOAD medicines visits have been
attended within 10 working days of receipt of request. 23
SOAD Electroconvulsive Therapy (ECT) visits out of
55 were attended within plan and, 30 out of 51
Community Treatment Order visits were done before
the planed period of one.
7
CQC Performance – Q3, 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 – Information and publication
Commentary:
NCSC Call handling indicators
Ref
NC2

NC3

Indicator
Q1
12-13
Target
Q2
12-13
Q3
12-13
YTD
Trend
RAG
Calls answered within 30 seconds Safeguarding
90%
94%
94.4%
92.8%
93.7%

G
Calls answered within 30 seconds Mental Health
90%
95.9%
95.5%
93.8%
95%

G
NC4
Calls answered within 30 seconds Registration
80%
79.9%
85.7%
81.8%
82.5%

G
NC1
‘Other’ calls answered within 30
seconds
80%
95.2%
95%
75.8%
78.6%

G
NC6
Calls abandoned - Safeguarding
3%
1.3%
0.7%
1.4%
1.1%

G
NC7
Calls abandoned - Mental Health
3%
2.7%
0.8%
5.1%
2.9%

G
NC8
Calls abandoned – Registration
5%
3.9%
1.9%
5.3%
3.7%

G
NC9
Calls abandoned - Other
5%
4.6%
2.2%
4.3%
3.7%

G
C12
Number of Whistle blowing contacts
N/A
1,654
2,025
2,246
5,925
N/A
MI
Weekly provider information on
the website refreshed timely
P4
Total visits to the website
P2
Key publications are on target –
State of Care; MHA Monitoring
report; etc.
P3
Providers feel informed about CQC
and have the information they
need to be regulated by us
Call Volumes increased in Q3, partly due to calls from
providers of primary medical services asking for assistance
with their registration applications. Call Performance is
consistently good across a range of indicators and is on
track year to date.
Publications, web and communication
Year to date there have been almost 4.2m visits to our
website of which almost 2.7m were unique visits. The
‘reports’ section of our website has been the most visited
area in the first 9 months of the year. The most visited pages
were; ‘reports surveys and reviews’ with 133,425 views,
‘contact us’ with 126,775 and the Job page with 107,630
views. The most popular downloads were ‘guidance about
compliance’ with 82,639 downloads, the ‘Judgement
framework’ ,15,867 and ‘table of statutory notifications under
the Health and Social Care act’ ,11,412.
All key publications have been published on target .Notably,
the State of Care report was published during Q3, and
received substantial and positive media attention.
Publications
P1
NCSC call handling and quality - there have been almost
150,000 calls to the National Customer Service Centre in
the first 9 months of the year, and all call handling targets
are on track. The quality of service has been recognised by
the ‘UK top 50’ call centres programme. This is the first
year the Centre entered the programme and
have been ranked 36th. Feedback from has been used to
identify improvements to customer service with a view to
incorporating benchmarks into the work of the NCSC.
100%
92%
(12 of 13)
92%
(12 of 13)
100%
(13 of 13)
94.8%
(37 of 39)

A
-
1.3m
1.4m
1.5m
4.2m

MI
Green
Green
Green
Green
Green

G
-
No data
:survey to
be run in
Q2
95.6%
No data:
survey run six
monthly
95.6%
NA
MI
8
CQC Performance – Q3, 2012– section 3, Manage our organisation, people and resources
Priority 3 – Manage our organisation, people and resources
Commentary:
Human Resources
Ref
Indicator
HR1
Establishment Total
HR1a
Establishment and vacancy rate
( establishment less permanent staff )
HR2
HR3a
HR4a
Target
Q1
12-13
Q2
12-13
Q3
12-13
YTD
Trend
RAG
-
2,292
2,296
2,392
2,392

N/A
5% by
Dec.
2012
14.8%
9%
3.1%
3.1%

G
Compliance inspector vacancy rate
<2%
12.5%
7.8%
0.4%
0.4%

G
New compliance inspectors complete full
induction programme within 12 weeks of start
date
100%
100%
100%
100%
100%

G
72%
by Dec
2012
N/R
N/R
65%
65%

G
Staff Complete mandatory e-learning per
annum and refresh it annually
HR5a
Frontline staff complete role specific
mandatory learning per annum and refresh it
annually
HR6
72%
42%
31%
29%
29%

R
Number of permanent staff (FTE)
-
1,849
2,015
2,188
2,188

MI
HR7
No of Vacancies
-
339
339
73
73

MI
HR7a
New staff pipeline (Staff with an offer of
employment)
-
111
74
74
74
N/A
MI
HR8
Temporary staff in established posts
-
44
50
53
53

MI
<1.125
% per
month
2%
1.8%
0.3%
1.4%

G
<5%
3.6%
3.2%
4%
3.6%

G
-
4
11
11
26

MI
HR10
Turnover2
HR11
Sickness Rate (based on calendar days)
HR12
Health and Safety - no. of workplace accidents
2
Vacancies and establishment - establishment increased in Q3 to
2,392 compared to 2,292 in Q1 reflecting the significant programme
of recruitment of additional compliance inspectors.
The Compliance inspector vacancy rate has improved
significantly from 12.5% in Q1 to 0.4% in Q3 against a target of 2%.
There is now a pipeline of candidates in place to fill future
Compliance Inspector vacancies in all regions. The establishment
and vacancy rate reflects the increase in staff, having improved from
14.8% in Q1 to 3.1% in Q3. overall vacancies have reduced from
339 in Q1 to 73 in Q3 a reduction of 78%.
Compliance Inspector and Registration Assessor mandatory
learning remains below target. HR is investigating this and a
comprehensive skills audit will seek to understand the organisational
mandatory training requirements and make recommendations for
delivering improvements.
Turnover and sickness rate
Turnover improved significantly in Q3 to 0.3% compared to 1.8% in
Q2 and year to date it stands at 0.3%. The sickness rate has
increased marginally from 3.6% in Q1 to 4% in Q3, although
performance remains within the 5% target.
1
Actual performance is the most recent fortnight reported, therefore not an average
rolling year average ( Sept 2011- Sept 2012) for Turnover is 7.2% and 4% for the sickness rate
3 The annual target is 96%, the monthly target is cumulative and 8% per month
2 The
9
CQC Performance – Q3, 2012– section 3, Manage our organisation, people and resources
Priority 3 – Manage our organisation, people and resources and governance
Commentary:
Corporate governance (complaints and statutory requests for information) and Finance
Indicator
Target

Number of stage 1 corporate
complaints received across the
organisation
10% less
than
2011/12
GL02
Stage 1 Corporate complaints upheld
Ref
GL01

GL03

GL05

GL04
Of the initial stage 1 complaints
received the number proceeding stage
2
Of those closed , the number of stage 2
reviews completed in 20 working days
Q1
12-13
Trend
RAG
318

G
3
(3%)
18
(3%)
N/A
MI
27%
(26)
12%
(13)
19%
(60)

G
100%
77%
81%

A
Q2
12-13
Q3
12-13
105
96
117
-
7
(7%)
8
(8%)
<20%
20%
(21)
95%
67%
YTD
No of stage 2 complaints upheld

-
5
2
0
7
N/A
MI
95%
95.9%
(304)
97.3%
(268)
92.6%
(263)
96.1%
(835)

G
GL07
Information access requests closed
within deadline
GL08
Parliamentary Ombudsman enquiries
-
12
3
11
26

MI
GL09
Of closed requests proportion closed
within deadline - Freedom of
Information
95%
95.8%
(236)
97.1%
(189)
97.5%
(175)
97%
(600)

G
GL10
Of closed requests proportion closed
within deadline - Data Protection
95%
92.9%
(28)
100%
(37)
84%
(34)
92%
(99)

G
GL11
Of closed requests proportion closed
within deadline - Info Sharing
95%
98%
(40)
94.7%
(42)
93.1%
(54)
95.3%
(136)

G
Urgent cancellations of registration
(under section 30 of the HSCA 2008)
-
0
0
1
1

MI
90%
97%
94% 1
95%
95%

G
5%
£36M v
£39.1M
(8%)
£81.3M v
£74.9M
(8%)
£123.8M
v
116.9M
(6%)
£123.8
Mv
116.9M
(6%)

A
GL14

GL12
Percentage of outstanding critical and
important audit actions completed
F01
Revenue expenditure plus depreciation
variance vs. Budget (excluding fee
income)
Complaint handling - Year to date there have been 318
stage one complaints, this is a decrease of 15% or 55
compared to the same period last year, when there were 373
stage one complaints received. The majority of complaints
were from members of the public and service users. The
number of stage 1 complaints proceeding to stage 2
decreased in Q3 to 13.
77% of stage 2 complaints in Q3 were closed within 20
working days compared with 100% in Q2. Year to date 81%
of these complaints were closed against a target of 95%.
There have been a number of complex stage 2 complaints
considered by the Corporate Complaints team. Due to a small
number of complaints received the percentage fall in Q3
only equates to 1 complaint.
Statutory requests for information
There have been almost 869 requests for statutory
information in the first 9 months of the year. 835 or 96.1%
were completed within the statutory deadlines. The majority,
619, were freedom of information requests. There were 143
information sharing request and 108 data protection Act
requests. All measures are on track to achieve their 2012/13
business plan targets.
Audit actions
In the first 9 months of the year 95% of audit actions raised,
were due to be completed by the end of December against a
target of 90%.
Revenue expenditure
Year to date revenue expenditure shows an under spend of
£6.9m (excluding fee income or 6%) consisting of staff costs
of £5.4m, depreciation of £1.9m and an overspend on Non
staff costs of £0.4M .
This figure is correct as of the last reported update in
respect of year to date performance to August
1
10
CQC Performance –Q3, 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
100%
CQC Performance – April - June, Q1, 2012
compliance
The –
graph
to the left illustratesoutcomes
levels of compliance across all
90%
23.2%
80%
50.6%
70%
60%
64.0%
73.9%
50%
16.6%
69.1%
98.6%
5.9%
40%
6.0%
30%
20%
10%
6.3%
sectors. This graph should be viewed as a ‘snapshot’ at a given
point across a range of variables, for example, which outcomes
are reviewed and when, therefore it is not possible to make a
perfect and direct comparison quarter on quarter. However by
means of an overview, a comparison with other quarterly
snapshots demonstrates that - at the end of Q3 there were
20,133 compliant locations compared with 17,292 in Q2. 16,156
locations have not yet had an inspection (compared with 23,306
in Q1) and 4,795 were non compliant with at least one outcome.
Year to date there have been 651 warning notices served to 422
providers, 41 locations have de-registered following intervention
by the CQC (compared to 21 in Q2) and there have been 3
urgent suspensions of registration, or urgent variation or
imposition of conditions using Section 31 powers.
60.3%
2.7%
43.5%
30.0%
19.8%
28.2%
0.7%
0%
Independent Independent
NHS
Primary
Primary Social Care
Ambulance Healthcare Healthcare Dental Care Medical
Org
Org
Organisation
Services
Compliant
Non compliant
Not yet reviewed
11
CQC Performance – Q3, 2012 – section 4, compliance outcomes
Levels of compliance and non-compliance - registered locations
NHS locations non-compliant with one or more outcomes, by age
Non compliance is broken down by sector and period. On the table on the left, the column ‘Q4 2011/12’ demonstrates the number that were non compliant by age at the end of that quarter. The row ‘less
than one quarter’ shows that there were 34 non compliant NHS locations at the end of Q4, tracking this group by following the arrow shows that the number of these that were non compliant fell in Q1
2012/13 to 29 and then again to 14 in Q2 2012/13 and 11 in Q3 2012/13. The graph illustrates the total number of locations that were non compliant in each quarter. There was a decrease in total non
compliant locations in Q1 and Q2 and then an increase in Q3, this may or may not be related to the increase in inspections in Q3. This data includes locations consistently non-compliant with a single
outcome and locations that were non-compliant at the beginning of several quarters but with different outcomes. Some of the latter group may have returned to compliance during a quarter, only to
become non-compliant again by the time the data is captured at the beginning of the next quarter. Further analysis is being undertaken to review the movements in compliance, evaluate the effectiveness
of actions, non compliance across outcomes and the variation across sectors.
The following two slides are in the same layout as this slide and illustrate the levels of compliance at ASC (slide 13) and IHC, Ambulance and dentist locations (slide 14)
Location been non
compliant for:
Over one year
More than three
quarters but less than
one year
More than two quarters
but less than three
quarters
More than one quarter
but less than two
quarters
Q4
Q1
Q2
Q3
2011/12
2012/13
2012/13
2012/13
13
25
16
29
80%
10%
22%
14%
22%
70%
26
19
5
11
60%
20%
16%
5%
8%
24
22
14
11
100%
13
90%
25
19
19%
13%
8%
22
29
28
26
10%
24%
25%
25%
20%
0%
34
21
49
54
27%
18%
44%
41%
Total non compliant in
period
128
116
112
131
28
26
29
34
Q4
Less than one quarter
11
31
20%
31
14
11
24
30%
19%
29
5
26
50%
40%
16
49
54
Q2
Q3
21
Q1
Non compliant <1 qtr
Non compliant <2 qtrs
Non compliant <4 qtr
Non compliant >4 qtr1
Non compliant <3 qtrs
Note that these slides must be viewed in the context of time lags between inspection and final
publication of the report and also the lag to re-inspection following identification of non-compliance
12
CQC Performance – Q3, 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:
Q4
Q1
Q2
Q3
2011/12
2012/13
2012/13
2012/14
90%
178
432
460
953
5%
12%
12%
23%
372
500
489
501
11%
13%
13%
11%
Over one year
More than three
quarters but less
than one year
More than two
quarters but less
than three quarters
More than one
quarter but less than
two quarters
Less than one
quarter
Total non compliant
in period
1
656
783
100%
663
501
178
80%
70%
460
500
489
659
452
656
783
60%
50%
432
372
1078
40%
663
674
1039
880
1255
1529
Q2
Q3
1070
30%
20%
21%
17%
12%
1,078
1,0701
1,039
710
32%
29%
27%
17%
1,065
956
1,255
1529
32%
26%
32%
37%
3,349
3,741
3,906
4,194
20%
1065
10%
956
0%
Q4
Q1
Non compliant <1 qtr
Non compliant <2 qtrs
Non compliant <4 qtr
Non compliant >4 qtr1
Non compliant <3 qtrs
Note that these slides must be viewed in the context of time lags between inspection and final
publication of the report and also the lag to re-inspection following identification of non-compliance
The increase in ASC Q4 to Q1 is due to a small difference in the time range between the two sets of data used for the report.
13
CQC Performance – Q3, 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
Q4
Location been non
compliant for:
Q1
Q2
Q3
2012/13
2012/13
2011/12
2012/13
1
8
20
45
Over one year
<1%
2%
5%
10%
More than three
quarters but less
than one year
13
23
38
73
5%
6%
10%
16%
31
53
114
83
12%
14%
30%
18%
68
137
116
63
26%
35%
30%
14%
145
166
98
205
56%
43%
25%
44%
More than two
quarters but less
than three quarters
More than one
quarter but less
than two quarters
Less than one
quarter
Total non compliant
in period
258
387
100%
90%
386
469
1
13
31
8
23
53
20
38
34
68
80%
70%
114
68
137
60%
70
50%
116
40%
30%
92
145
205
166
20%
98
10%
0%
Q4
Q1
Q2
Non compliant <1 qtr
Non compliant <2 qtrs
Non compliant <4 qtr
Non compliant >4 qtr1
Q3
Non compliant <3 qtrs
Note that these slides must be viewed in the context of time lags between inspection and final
publication of the report and also the lag to re-inspection following identification of non-compliance
14
CQC Performance – Q3, 2012,– section 4, equality outcomes
All priorities – corporate equality objectives
Trend
RAG
Green

G
N/A
N/A
N/A
N/A
Green
Green
Green

G
Green
Green
Green
Green

G
Green
rating
17,644
16,143
15,759
49,566

G
EQ6
Monitor whether people detained
under the Mental Health Act have
their rights to equality under the Act
and Code of Practice protected
through our monitoring functions,
and actively seek improvements
where we uncover shortcomings
Green
rating
Green
Green
Green
Green
N/A
G
EQ7
Improve the diversity profile of
CQC's workforce so it is
representative of the communities
we serve
Green
rating
1st
report
Q2
Amber
Green
Green
N/A
A
EQ8
Improve the percentage of staff
who say that they feel safe from
harassment and are treated equally
at work
Green
rating
1st
report
Q2
Amber
Amber
Amber
N/A
A
Improve the percentage of staff
who have the knowledge, skills and
tools to embed equality and human
rights in their work.
Green
rating
Green
Amber
Amber
Amber
N/A
A
Indicator
Target
Q1
12-13
Q2
12-13
EQ1
Embed equality across all our
regulatory and corporate activities
Green
rating
Green
Green
Green
EQ2
Ensure that, we identify and
respond appropriately when
providers do not meet the equality
aspects of the essential standards
of quality and safety
Green
rating
N/A
N/A
EQ3
Improve information and
intelligence that we hold about
health and social care providers in
order to better identify risks to
equality
Green
rating
Green
EQ4
Involve a diverse range of people
who use services in our work
Green
rating
EQ5
Increase the uptake of accessible
information for easy to read. Large
print and 6 community language
downloads.
Ref
EQ9
Q3
12-13
YTD
This is the third update against the equality objectives. Notable progress
compared to the objectives has been included below as well as risks and issues
to delivery.
Objective 1: The ET and Board received quarterly updates covering our
equality objectives as part of the overall performance governance of CQC.
Objective 2: A plan from the evaluation of equality and human rights in
compliance reviews was carried out in Q3 and will be implemented from Q4.
Objective 3: A project plan, governance group and monitoring have been
established to deliver this priority - identified work streams are currently on
course. A reference group was set up and analytical resources allocated to
deliver pilot of quantative indicators for the NHS. The report on availability of
equality information on priorities and actions for next stage of work has been
completed. Work is ongoing on the new mental health minimum dataset and
on the multi-agency design of learning disability data collection set.
Objective 4: Work is underway to monitor diversity of CQC involvement
mechanisms and address gaps including: monitoring Speak Out network areas
of interest in line with protected characteristics (Speak Out includes many of the
seldom heard equality groups such as refugees, transgender people and gypsies
and travellers) eQuality Voices recent recruitment of 10 new members to fill
identified gaps including transgender people, carers of older people and
refugees, Acting Together - Support organisations carry out equality monitoring
and we are investigating best ways to bring this together and identify gaps for
future expert by experience recruitment
Objective 7: An analysis of staff profile has recently been completed for our
annual equality information report (including for the first time analysis by pay
grade). Work is underway with staff equality networks on the equality action
plan arising from the staff survey may identify action we need to take in relation
to making the profile more representative. Learning and development and the
Race Equality Network are working together to develop opportunities for career
development for Black and Minority ethnic staff.
Objective 8: This objective is rated as amber overall to reflect the significant
work required in this area following the 2012 staff survey. To assess work to
date a proposed ‘pulse check’ for 500 staff of 20 questions is being prepared
and will be presented to ET in late February. Work is underway to identify
specific action required to take around bullying and harassment for particular
staff groups, such as disabled staff, through the Staff Survey Equality Action
Plan development. In Q3 HR appointed named officers for staff to talk to, during
bullying and harassment week and they are planning other actions to improve
support to staff who feel that they have been bullied or harassed.
Objectives 9: Staff undertake equality training at the induction, this takes the
form of an interactive session called equally yours, which includes updates to
focus upon inclusion and using external networks. There is further work to
improve the guidance that was identified following feedback, this means that
some of the work will be delivered slightly later than planned.
15
CQC Performance – section 6, understanding the scorecard
A document with public to technical definitions of our
corporate measures has been completed and is available
on the intranet. This section is intended as an accessible
guide to the overall performance areas in this report.
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.
16