ANNEX A - CQC Performance,
April – June, Quarter 1, 2012
Public Agenda item: 9
Paper no: CM/03/12/06
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 – Levels of compliance and non-compliance - registered
locations
Slides 12 - 15
Section 5 – CQC 2012/13 equality objectives tracker
Slide 16
Section 6 – Explanatory notes to the scorecard measures
Slide 17
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)
100%
22%
NHS
78%
90%
80%
19%
ASC
IHC
Dentists
Graph 1
demonstrates
the percentage
of inspections
completed by
sector in Q1
and the
relevant Q1
profiled target
is given by the
line:
81%
9%
91%
12%
88%
44%
70%
60%
63%
73%
84%
50%
91%
14%
40%
6%
30%
5%
20%
41%
31%
10%
2%
22%
14%
2%
7%
PDC
Ind Amb
0%
NHS
Ambulance 4%
ASC
IHC
96%
Compliant
Non compliant - enforcement
Non compliant w ith at least one outcome (no enforcement)
Not yet subject to a completed review of compliance
2. Public facing and governance
Indicator
Provider information on the CQC
website updated weekly
Target
100%
YTD
92%
4. Resources
RAG and
trend
G
Finance
Target
YTD Actual
RAG and trend
£39.1M
£36M
Ap
Establishment and Vacancy rate
15% by June
14.8%
G p
Turnover
1.125% per
month
1.97%
G p
<5%
3.57%
G p
p
Number of calls to the NCSC
N/A
44,901
Safeguarding calls answered within
30 seconds
90%
94.0%
G
q
Stage 2 complaints completed
within 20 working days
95%
67%
R
p
FOI handled within deadlines
95%
95.8%
G
p
% of outstanding critical and
important audit actions completed
90%
94%
G
p
N/A
Year to date (Quarter1 )
Revenue expenditure plus
depreciation variance vs. Budget
Human Resources
Sickness rate
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
C01
NHS - at least 1
service per trust
(291 Trusts of which
there are 350
locations)
C02
C03
C05
C04
Scheduled
inspections
undertaken compared
to plan:
Target
23%
(811)
Q4
11-12
N/A
Q1
12-13
YTD
Trend
RAG
22%
(76)
22%
(76)

A
18.8%
(4700)
18.8%
(4700)

A
8.86%
(245)
8.9%
(245)

R
25,008 ASC
provider locations
20%
(49941)
2,764 IHC provider
locations
14%
(3881)
N/A
reported
together
in
2011/12
3,545 dental
provider locations
15%
(5401)
16.1%
(1433)
12.2%
(449)
12.2%
(449)

A
317 private
ambulance provider
locations
9%
(291)
N/A New
4%
(13)
4%
(13)

R
-
342
469
469

MI
100%
N/A New
N/A
N/R
N/A
N/A
-
N/A New
73.8%2
73.8%2
N/A
MI
N/A
N/A
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)
ASC Scheduled Inspections
2500
2000
C07
Responsive inspections undertaken
C08
Percentage of our inspections where we talked
to people about their experience of care
C09
The % of our inspections where we used one
or more involvement methods or tools NEW
C10
Percentage of compliance actions followed up
in under twelve weeks
100%
N/A New
N/R
First due
Q3
C11
The % of draft compliance reports issued
within 10 days (of site visit)
90%
65.1%
14 days
61%
61%

R
C12
The % of final compliance reports issued within
25 days (of site visit)
90%
77.0%
(28days)
67.7%
67.7%

A
C13
% of newly registered locations inspected
found to be non- compliant
-
-
-
First due
Q2
N/A
MI
C15
% of user voice items added to QRP NEW
-
N/A New
(18%)
29601
(18%)
29601
N/A
N/A
1
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.
1500
1000
500
0
April
This is the
profiled
target
to date the
annual
target is given numerically
in the
cells to theSee
leftcommentary
C16
The
number
of thematic
reviews
undertaken
N/A
N/A
2 This is the latest figure in respect of June, no Q1 figure has been reported but will be available for the next report
A
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
Indicator
E01
The % locations where enforcement action has
been taken
C10
Target
Q4
11-12
Q1
12-13
YTD
Trend
-
Report being developed due Q3
Percentage of compliance actions followed up in
under twelve weeks
100%
Report being developed due Q3
E02
Percentage of warning notices issued within 14
days of identifying one is required
90%
E03
Number of Notices of Proposal to cancel
registration issued
E05
Number of suspensions
-
-
E06
E07
N/A
79.9%
79.9%
A
Report being developed due Q2
0
0
0
Number of penalty notices served
Number of warning notices served

RAG

MI
-
0
0
0

MI
-
252
219
219

MI
-
N/A
New
108
108
N/A
MI
E07a
Number of locations with a warning notice
served
E09
Number of notices of decision to cancel
registration
-
E11A
Number of locations de-registered voluntarily
-
E11B
Number of providers de-registered – following
CQC intervention
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
252
E12
Locations where enforcement action taken as a
% of all locations
Enforcement is continued overleaf
9
N/A
New
5
5
250

MI

MI
219
200
200
411
411
147
150
-
-
N/A
New
9
0
0
9
N/A
MI
100
0
N/A
MI
51
50
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
Target
Q4
11-12
Q1
12-13
YTD
Trend
RAG
Section 31 HSCA 2008 – urgent suspension of
registration ,or urgent variation or imposition of
conditions
-
N/A
New
2
2

MI
E13a
Section 31 HSCA 2008 – urgent removal of
conditions
-
N/A
New
0
0

MI
E14
Non urgent variations or imposition of
conditions
-
N/A
New
0
0

MI
E15
Removal of conditions on non urgent
variations or impositions
-
N/A
New
0
0

MI
-
N/A
New
N/R
Target
Q4
11-12
Q1
12-13
YTD
Ref
Indicator
E13b
E16
Non urgent cancellation of registration
N/R
N/A
MI
Trend
RAG
Registration
Ref
Indicator
R01
Percentage of new provider and manager
registration applications completed within eight
weeks
90%
88.7%
87.6%
87.6%

G
R02
Percentage of applications to change a
registration completed within four weeks
90%
N/A
New
70.6%
70.6%

R
R04
% of applications rejected (Shared services)
R05
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
June
71%
May
<25%
30.7%
21.8%
21.8%

G
Applications validated within 5 days - Shared
services
90%
99%
98.4%
98.4%

G
R07
Primary medical services providers served with
all Notices of Decision by 31 March 2013
100%
R08
MI
Primary medical services providers served with
all Notices of Decision after 31 March 2013
Tranche not yet open
19%
74%
April
16%
68%
0%
10%
20%
30%
22%
40%
50%
Within target
N/A
60%
70%
80%
90%
100%
Missed target
Tranche not yet open
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
Indicator
NC2
NC3
NC4
Target
Q4
11-12
Calls answered within 30 seconds Safeguarding
90%
98%
94%
Calls answered within 30 seconds - Mental
Health
90%
98%
Calls answered within 30 seconds Registration
80%
89.0%
NC11
‘Other’ calls answered within 30 seconds
NC6
Q1
12-13
YTD
Trend
RAG
94%

G
95.9%
95.9%

G
79.9%
79.9%

G
80%
92.0%
76.1%
76.1%

G
Calls abandoned - Safeguarding
3%
0%
1.3%
1.3%

G
NC7
Calls abandoned - Mental Health
3%
0%
2.7%
2.7%

G
NC8
Calls abandoned – Registration
5%
1%
3.9%
3.9%

G
NC9
Calls abandoned - Other
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%
Number of Whistle blowing contacts
N/A
1%
N/A
4.6%
1,654
4.6%
1,654

N/A
G
MI
100%
Performance
C12
5%
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
1/6/12
8/6/12
15/6/12 22/6/12 29/6/12
Week ending
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
Trend
RAG
Publications
P1
Weekly provider information on the website
refreshed timely
P4
Total visits to the website
P2
Key publications are on target – State of
Care; Mental Health Act Monitoring report;
Annual report; reports of thematic
inspections
P3
Providers feel informed about CQC
regulatory system and have the information
they need in order to be regulated by us
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.
100%
79%
92%
92%

G
-
1,148,043
1,270,862
1,270,862

MI
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.
100%
100%
100%
100%

G
Graph – most visited areas of the CQC website
93.5%
Provider
survey to be
run every
six months
N/A
N/A
MI
-
Hits'
Homepage
20233
‘Other ‘ inspections (controlled drugs, ionising radiation and joint inspections)
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
-
1 Status
N/R
5
20862
156
8
156
8

G

G
0
N/A
N/A
6
9
9

G
2
N/A
165957
38641
0
2
34499
Public
N/R
N/R
Orgs we regulate
G
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.
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
Target
Q4
11-12
Q1
12-13
YTD
Trend
RAG
MHA Commissioner visits - Hospital
visits (Actual vs. Scheduled )
95%
106%
(428)
121%
(277)
121%
(277)

G
Mental Health Act complaints Percentage and number of complaints
triaged within 3 working days
90%
N/A
New
96%
(68 of
71)
96%
(68 of
71)

G
Mental Health Act Complaints Percentage of complaints received
which are responded to within 25 days
90%
N/A
New
94%
(187 of
198)
94%
(187 of
198)

G
Requests allocated to Second Opinion
Appointed Doctors within 4 working
days
75% in Q1
& Q2
increasing
to 95% in
Q3 and Q4
N/A
New
61%
61%

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
HR1
HR1a
HR2
HR3
HR4
HR5
HR6
HR7
HR7a
HR8
1
Indicator
Establishment Total
Target
Q4
11-12
Q1
12-13
YTD
Trend
RAG
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.
-
2259
2292
(12/13)
N/A

N/A
15% by
June
2012
17.9%
14.8%
14.8%

G
<2%
N/A
New
12.5%
12.5%
N/A
R
Post period update: Following additional recruitment in July the
number of outstanding compliance inspectors has fallen to 80.
Green
N/A
New
Green
Green
N/A
G
Graph – vacancies in the last 5 Quarters
All staff who are new to frontline roles successfully
complete induction programme within 10 weeks of
new role starting
95%
N/A
New
All front line staff undertake mandatory training on
an annual basis.
96%
Establishment and vacancy rate ( establishment less
permanent staff )
Compliance inspector vacancy rate
Induction and other frontline staff training on target
Number of permanent staff (FTE)
No of Vacancies
New staff pipeline (Staff with an offer of
employment)
Temporary staff in established posts
Vacancies
98%
98%
N/A
G
500
450
400
N/A
New
Green
-
-
1849
1849

MI
-
404
339
339

MI
N/A
MI
Green
N/A
G
350
300
FTE
Ref
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%.
250
200
150
-
-
111
111
100
50
0
Q1 -11/12
Q2 -11/12
Q3 -11/12
Q4 -11/12
Q1 - 12/13
Time
-
28
44
44

MI
Actual performance is the most recent fortnight reported, therefore not an average
9
CQC Performance – April - June, Q1, 2012 – section 3, Manage our organisation, people and resources
Priority 3 – Manage our organisation, people and resources
Resources
Human Resources (continued)
Q4
11-12
Q1
12-13
Ref
Indicator
Target
HR10
Turnover2
1.125%
per
month
1.7%
1.97%
1.97%

G
<5%
3.2%
3.57%
3.57%

G
-
4
4
4

MI

A

A
HR11
Sickness Rate (based on calendar days)
2
YTD
Trend
HR12
Health and Safety - no. of workplace
accidents
AR1
Frequent usage of Activity Recording Tool
(ART) by Compliance Inspectors
85%
N/A
N/A
68.4%1
AR2
Frequent usage of Activity Recording Tool
(ART) by Registration Assessors
85%
N/A
N/A
71.6%
RAG
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
Region
1
Finance
North
South
Ref
F01
Indicator
Revenue expenditure plus depreciation
variance vs. Budget (excluding fee income)
Target
Full year
11-12
Q1
12-13
YTD
Trend
RAG
London
0%
10%
20%
30%
40%
50%
60%
70%
80%
Performance
5%
£149.4M
v 157.7M
(5%)
£36M v
£39.1M
(8%)3
£36M v
£39.1M
(8%)

A
Registration Assessor ART usage by region - latest
CQC
Region
North
Central
South
London
1
Actual performance is the most recent fortnight reported, therefore not an average
rolling year average ( July 2011- June 2012) for Turnover is 7.42% and 4.11% for the sickness rate
3 Excludes fee income
2 The
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Performance
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
GL01
GL02
Indicator
Target
Number of stage 1 corporate complaints
received across the organisation
10% less
than
2011/12
122
105
-
N/A
New
<20%
Stage 1 Corporate complaints upheld
GL04
Of the initial stage 1 complaints received
the number proceeding stage 2
GL05
Of those closed , the number of stage 2
reviews completed in 20 working days
GL03
No of stage 2 complaints upheld
Trend
RAG
105

MI
7
7
N/A
MI
N/A
New
20%
(21)
20%
(21)
N/A
G
95%
67%
67%
67%

R
-
N/A
New
5
5
N/A
MI
-
0
0
0

MI
95%
98.4%
95.9%
(304)
95.9%
(304)

G
8
12
12

MI
Q4
11-12
Q1
12-13
YTD
GL06
No of stage 2 complaints referred for
independent investigation
GL07
Information access requests closed within
deadline
GL08
No. of Parliamentary Ombudsman enquiries
made of CQC
-
No. of Parliamentary Ombudsman
investigations made of CQC
-
0
0
0

MI
Of closed requests proportion closed within
deadline - Freedom of Information
95%
98%
95.8%
(236)
95.8%
(236)

G
GL10
Of closed requests proportion closed within
deadline - Data Protection
95%
100%
92.9%
(28)
92.9%
(28)

G
GL11
Of closed requests proportion closed within
deadline - Info Sharing
95%
100%
98%
(40)
98%
(40)

G
GL14
Urgent cancellations of registration (under
section 30 of the HSCA 2008)
-
0
0
0

MI
GL12
Percentage of outstanding critical and
important audit actions completed
90%
N/A
New
94%
94%

G
GL08a
GL09
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
Freedom of Information
Information Sharing
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
100%
The graph to the left illustrates levels of compliance across all
sectors. As at the end of Q1 there were 13,218 compliant locations
and 23,306 had not yet been subject to a review. There were 4,117
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.
CQC Performance – April - June, Q1, 2012 – compliance outcomes
90%
80%
44%
70%
60%
63%
73%
84%
50%
91%
14%
Non compliant – enforcement
40%
6%
30%
5%
20%
41%
31%
10%
2%
22%
14%
2%
7%
PDC
Ind Amb
0%
NHS
ASC
IHC
Compliant
Non compliant - enforcement
Non compliant w ith at least one outcome (no enforcement)
Not yet subject to a completed review of compliance
NHS
2
ASC
87
IHC
4
PDC
0
Ind Amb
0
Total
93
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 noncompliance 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
Q4
2011/12
Q1
2012/13
35
35
21
30
28%
18%
30
29
24%
25%
30
22
15
24%
19%
10
20
19
5
16%
16%
12
25
9%
22%
There were 35 non
compliant locations
in Q4 2011/12
29 of them were
still non compliant
at the end of Q1
2012/13
25
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
20
0
<1 quarter
>1 but <2 quarters
Position at the end of Q4 11/12
>2 but <3 quarters
>3 but <4 quarters
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:
Q4
2011/12
Q1
2012/13
1168
969
36%
26%
More than one quarter
but less than two
quarters
1010
1057
800
31%
28%
600
More than two quarters
but less than three
quarters
607
793
19%
21%
Less than one quarter
More than three
quarters but less than
one year
355
500
11%
13%
Over one year
149
422
5%
11%
1200
1000
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
14
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
Q1
2012/13
160
145
171
140
56%
44%
120
62
132
25%
34%
29
53
60
12%
14%
40
12
23
20
5%
6%
0
8
0%
2%
100
80
0
<1 quarter
>1 but <2 quarters
Position at the end of Q4 11/12
>2 but <3 quarters
>3 but <4 quarters
Position at the end of Q1 12/13
15
CQC Performance – April - June, Q1, 2012 – section 5, deliver our equality objectives
All priorities – corporate equality objectives
Commentary:
Equality actions are included in Directorate Business plans, and successful delivery is achieved
Ref
Indicator
Target
Q4
11-12
Q1
12-13
YTD
Trend
RAG
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.
EQ1
Embed equality across all our regulatory
and corporate activities
Green
rating
N/A
new
Green
Green
N/A
G
EQ2
Ensure that, we identify and respond
appropriately when providers do not meet
the equality aspects of the essential
standards of quality and safety
Green
rating
N/A
new
Green
Green
N/A
G
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.
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
N/A
G
Further information will be included in the mid year performance report.
EQ4
Involve a diverse range of people who use
services in our work
Green
rating
N/A
new
Green
Green
N/A
G
EQ5
Increase the uptake of accessible
information for easy to read. Large print and
6 community language downloads.
Green
rating
N/A
new
17644
17644
N/A
G
Increase the uptake of accessible
information for easy to read. Large print and
6 community language hard copy requests .
Green
rating
N/A
new
24
24
N/A
G
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
N/A
new
Green
Green
N/A
G
Improve the diversity profile of CQC's
workforce so it is representative of the
communities we serve
Green
rating
N/A
new
To be
reported
in Q2
N/A
N/A
N/A
Improve the percentage of staff who say
that they feel safe from harassment and are
treated equally at work
Green
rating
N/A
new
To be
reported
in Q2
N/A
N/A
N/A
Green
rating
N/A
new
Green
Green
N/A
G
EQ3
EQ5
EQ6
EQ7
EQ8
EQ9
Improve the percentage of staff who have
the knowledge, skills and tools to embed
equality and human rights in their work.
16
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.
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.
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.
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.
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.
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.
17