Agenda item 7
Paper No: CM/04/12/05
Annex A
ANNEX A - CQC Performance, Quarter 2, 2012
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
Q2 & YTD scorecard summary
Operating performance - Compliance inspections
Operating performance - Registration, Enforcement and MHA
Target
Q1
Q2
Year to
Date
Trend
RAG
Measure
NHS
inspections
37%
(128)
20%
(71)
14%
(50)
35%
(121)

A
ASC
inspections
32%
(8,042)
14%
(3,556)
18%
(4,384)
32%
(7,940)

A
registrations within
8 weeks
variation
registration within
4 weeks
IHC
inspections
17%
(474)
7%
(196)
7%
(186)
14%
(382)

R
% warning notices
- 14 days
Dental
inspections
24%
(846)
14%
(499)
15%
(523)
G
MHA
Commissioner
visits
Private
Ambulance
inspections
13%
42
4%
(13)
7%
(21)
A
SOAD requests
allocated within 4
working days
Measure
29%
(1,022)
11%
(34)


Target
Q1
Q2
Year to
Date
Trend
RAG
90%
87.6%
87.5%
87.6%

G
90%
70.6%
75.8%
73.1%

R
90%
79.9%
78.1%
80.6%

A

G

G
95%
75%
Target
Q1
Q2
106%
112%
(321 of 301)
( 598 of 530 )
72%
84%
79%
Resources and audit actions
Customer Service
Measure
121%
(277 of 229)
Year to
Date
Trend
RAG
Measure
Target
Q1
Q2
Year to Date
Trend
RAG
<2%
12.5%
7.8%
7.8%

R
48%
42%
65%
65%

G
<5%
3.6%
3.2%
3.7%

G
CI Vacancy rate
Calls in 30
seconds
Safeguarding
90%
94%
94.4%
94.2%

G
Calls in 30
seconds
Mental Health
90%
95.9%
95.5%
95.7%

G
Front line staff
mandatory
training
programme
stage 1
complaints
10% <
2011/12
105
96
201

G
Sickness rate
Stage 1
complaints
proceeding
stage 2
<20%
20%
(21)

R
Revenue variance
vs. budget
5%
- 8%
- 8%
- 8%

R
A
% of outstanding
audit actions
completed
90%
94%
94%
94%

G
stage 2
completed in <
20 days
95%
67%
27%
(26)
100%
23%
(47)
84%

2
CQC Performance - Q2, 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 inspections
Ref
Indicator
C01

C02

C03

C05

C04

Scheduled
inspections
undertaken
compared to
plan:
Target
Q1
12-13
Q2
12-13
YTD
Trend
RAG
NHS - at least 1
service per trust
(291 Trusts - 350
locations)
37%
(128)
20%
(71)
14%
(50)
35%
(121)

A
25,008 ASC
provider locations
32%
(8,042)
14%
(3,556)
18%
(4,384)
32%
(7,940)

A
2,764 IHC provider
locations
17%
(474)
7%
(196)
7%
(186)
14%
(382)

R
3,545 dental
provider locations
24%
(846)
14%
(499)
15%
(523)
29%
(1,022)

G
317 private
ambulance
provider locations
13%
42
4%
(13)
7%
(21)
11%
(34)

R
Commentary: In Q2 Operations reviewed and rebaselined all of the
targets with regions to take account for performance in Q1 and planned
increases in capacity in Q3 and Q4. Based on this, as of Q2 delivery of
the programme was on track for dentist locations and broadly on track
for NHS and ASC. IHC was an outlier in performance achieving 14% of
plan against a Q2 target 17%. Private ambulance inspections are also
under plan and will require a significant uplift of activity in the second
half of the year to meet plan. There are over 100 new compliance
inspectors that will complete training and begin inspections in Q3 and
Q4, which has been included in planning for the remainder of the year.
Additional actions to increase activity include overtime and the
recruitment of temporary healthcare professional staff in support of the
programme. The trajectory on the left is based on 5 weeks performance
to mid October, it should be noted that this is considered worst possible
projection, and that based on full year performance inspection activity
has increased at an average of 15% per month.
Latest position of inspection activity
The table below demonstrates the most recent inspection performance
information as at 1 November. Overall there have been 12,292
inspections or just over 38% of the planned programme for the year. At
671 inspections in the week this was the highest weekly number of
inspections this year, it is also the fourth consecutive week were
inspection activity has been around the 600 mark, significantly above
the average weekly performance of 396. The increase is largely due to
the deployment of new compliance inspectors and the use of overtime
by the regions. Although October performance has been notable,
meeting the annual inspection programme plan will be challenging,
there is 40% of the financial year remaining in which time the remaining
60% of the target is to be achieved.
Sector
YTD Target
(to 2nd Nov)
12-13 target
achieved
RAG
NHS
170
48.6%
180
51.4%
G
ASC
10,719
42.9%
10,249
41%
A
IHC
800
28.9%
534
19.3%
R
1,307
36.9%
1,282
36.2%
G
Amb
83
26.2%
47
14.8%
R
CQC
13,079
41%
12,292
38.4%
A
Dentist
1
This is the profiled target to date the annual target is given
numerically in the cells to the left
3
CQC Performance - Q2, 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
Q1
12-13
Q2
12-13
YTD
Trend
RAG
C07
Responsive inspections undertaken
-
489
516
1,005

MI
C09
The % of our inspections where we used one
or more involvement methods or tools NEW
-
61%
81%
71%

MI
C11
The % of draft compliance reports issued
within 10 days (of site visit)
90%
61%
64%
64%

R
Commentary:
The regulatory Committee has agreed to 3 thematic reviews this year
covering: Dementia, Experiences of people waiting for NHS treatment
and physical health needs of people with a learning disability.
The review of dementia started in September and is due to report in
December, the remaining reviews are planned and are on track to report
in March 2013. The number of QRP items is 40,451this is an increase of
more than almost 20% or 7,000 since May of this year.
Although draft and final report timeliness has improved in comparison
to the same period last year (which in Q2 2011/12 was 47% and 54%
respectively) it remains below plan for this year. The graphs below
demonstrate that the plan was only met once and that performance for
final reports in particular has a negative trend. Release 19 of CRM will
provide details at a regional and team level for draft and final report
timeliness, this will be reported to compliance managers to drive
performance through management actions. This is being monitored
weekly.
Draft reports
100%
C12

Target 90%
90%
The % of final compliance reports issued within
25 days (of site visit)
90%
68%
65%
68%

R
80%
70%
60%
50%
C13
% of newly registered locations inspected
found to be non- compliant
-
-
N/R
N/R
N/A
MI
C15
Total user voice items on QRP
-
See
YTD
40,451
40,451

MI
40%
30%
20%
10%
0%
Apr
C16
The number of thematic reviews undertaken
3
0
1
1

May
Jun
Jul
Aug
Sep
G
Final reports
100%
Target 90%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr
May
Jun
Jul
Aug
Sep
4
CQC Performance - Q2, 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:
Enforcement
Ref
Indicator
E12
Locations where enforcement action taken as a
% of all locations
E07
Number of warning notices served

E02

Percentage of warning notices issued within 14
days of identifying one is required
Target
Q1
12-13
Q2
12-13
YTD
Trend
RAG
-
0
N/R
N/R
N/A
MI
-
184
189
373

MI
90%
79.9%
78.1%
80.6%

A
Of 840 locations that have de-registered since the beginning of the year,
21 have done so following CQC intervention.
MI
E05
Number of suspensions
-
0
0
0

E09
Number of notices of decision to cancel
registration
-
5
N/R
N/R

MI
E11A
Number of locations de-registered voluntarily
-
402
417
819

MI
E11B
Number of providers de-registered – following
CQC intervention
-
9
12
21

MI
GL13
Prosecutions concluded with a favourable result
-
1
0
1
N/A
MI
E13b
Section 31 HSCA 2008 – urgent suspension of
registration ,or urgent variation or imposition of
conditions
-
3
2
5
N/A
MI
E13a
Section 31 HSCA 2008 – urgent removal of
conditions
-
0
0
0
N/A
MI
E14
Non urgent variations or imposition of conditions
-
0
0
0
0
MI
E15
Removal of conditions on non urgent variations
or impositions
-
0
0
0
0
MI

There was a marginal increase in the number of warning notices in Q2 to
189 compared with 184 in Q1. This is more than double the same period
last year when a total of 196 warning notices were served. The percentage
of warning notices that are issued within 14 days of identifying one is
required has remained fairly constant between Q1 and Q2 at 79.9% and
78.1% respectively, and 80.6% year to date.
5
CQC Performance - Q2, 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
Registration
Ref
R01
Indicator
Target
Q1
12-13
Q2
12-13
YTD
Trend
RAG
Percentage of new provider and manager
registration applications completed within eight
weeks
90%
87.6%
87.5%
87.6%

G
Percentage of applications to change a
registration completed within four weeks
90%
70.6%
75.8%
73.1%

R
R04
% of applications rejected (Shared services)
<25%
21.8%
22.9%
22.4%

G
R05
Applications validated within 5 days - Shared
services
90%
98.4%
98.8%
98.6%

G

R02


R07
Primary medical services providers served with
all Notices of Decision by 31 March 2013
Commentary:
New provider and manager applications completed within 8 weeks
remains within plan at 87.6% year to date and within the threshold to be
rated as green (i.e 5% within target). Meeting the 4 week target for
variation applications remains challenging. The graph below illustrates
the weekly performance over the last 16 weeks, although performance
has improved on average in the last 6 weeks it remains significantly below
target. To improve performance Operations have made additions to
release 19 of CRM; this will provide data on those cases which are
delayed at the request of, or due to, the provider. This information can
then be used to assess where management actions can be targeted to
improve performance and what is due to circumstances beyond the
control of the CQC. Regionally the North, Central and London are
performing broadly consistently at around 80%, however the South has a
high number of complex registrations and sales of locations, meaning that
some cases are registered but then delayed by the provider. This is being
monitored by Operations and the new data will drive actions to improve
performance.
95.0%
100%
Update from Q3/4 summary of T5 progress below
Tranche 5 update
Overall the Tranche 5 registration is on track and progressing well. A survey was carried out with
the provider reference group held in September and there was significant qualitative feedback. The
majority of respondents found the registration set up process easy (81%) and over half also found
the registration application form easy to use (58%), and only a minority of respondents didn't find it
easy to use (9.4%). However just 37% of providers think registration will be beneficial to the quality
of care delivered by General Practice, many respondents felt they were already regulated
enough, and had concerns that the process is a tick-box exercise. Less than half felt they had
enough information and guidance to support them in completing the registration application form
(44%) – however this was mainly driven by a demand for a list of policies and procedures that
would lead to compliance, not an evaluation of the guidance. The number of providers setting up
online application accounts has slowed significantly to just 2 this week while a further 101 codes
were retired. Year to date 7,661 providers have set up their on line account . There are 486
outstanding responses to letters requesting that the providers set up an online application. 1,670
codes have been retired. 1,469 providers have submitted their applications and of these 1,279 have
been validated. To date 184 providers have declared non compliance with one or more of the
essential standards, these are reviewed and action plans agreed with each provider.
90.0%
85.0%
80.0%
75.0%
70.0%
65.0%
60.0%
55.0%
50.0%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
The percentage of applications rejected increased slightly in Q2, this
was identified as being due to new guidance, which has since been
reissued with minor amendments. To date performance has been strong,
particularly compared to last year when the rejection rate was between
35% and 45%.
6
CQC Performance - Q2, 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
‘Other ‘ inspections (controlled drugs, ionising radiation and joint inspections)
Ref
Indicator
Target
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
-
OC3
Q1
12-13
Q2
12-13
YTD
Trend
RAG
156
75
231

G
Mental Health Act Operations improvement programme:
8
2
10

G
0
0
3
N/A
N/A
9
9
18

G
2
0
2
N/A
G
Q1
12-13
Q2
12-13
YTD
Trend
RAG
95%
121%
(277 of
229)
106%
(321 of
301)
112%
( 598 of
530 )

G
Mental Health Act complaints - Percentage
and number of complaints triaged within 3
working days
90%
96.4% (81
of 84)
98.6%
( 209 of
212)
98% (290
of 296)

G
Mental Health Act Complaints Percentage of complaints received which
are responded to within 25 days
90%
94%
(83 of 84 )
100%
(212 of
212)
99% (295
of 296)

G
Requests entered within 4 working days of
receipt to allocate to Second Opinion
Appointed Doctors
75%
72%
84%
79%

G
Mental Health Operations
Ref
M1
M2
M3
M16
Indicator
MHA Commissioner visits - Hospital visits
(Actual vs. Scheduled )
Target
Mental Health Act Operations:
Planned MHA Commissioner visits remain ahead of the schedule for the
year to date - against a planned programme of 530 inspections in the
first 6 months of the year, 598 have been completed. All complaint
targets are also on track, of 296 complaints about providers in Q1 and
Q2, 290 were triaged within 3 working days and 295 were responded to
within 25 days.
Several key milestones aimed at improving delivery of the Mental Health
Act Operations have been achieved year to date. An induction
programme for 20 new Commissioners will be delivered in November
and a further induction programme is on track for 30 new SOADs
starting in December. The increase in our available ‘pool’ of
Commissioners and SOADs will allow the Commission to act more
responsively to peaks in demand. Requests for SOADs moved from a
paper based process to an online request form aimed at improving
timeliness and reducing errors, as of September manual requests were
not being accepted, the MHA team have been communicating with
individual locations and have reduced the number of manual responses
to less than 10% in under 2 months with weekly reductions. In line with
other directorates all initial call and post is now handled by the NCSC
and from November complaints call handling will also move to the
NCSC. MHA has been closely involved with the strategic review team to
ensure that the MHA strategy is integral to the CQC strategy and
operations are further aligned. Following the introduction of the online
form, SOAD measures covering medication, ECT, and CTO visits will be
available from Q3 onwards.
7
CQC Performance - Q2, 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
NCSC Call handling indicators
Ref
NC2

NC3

Indicator
Target
Q1
12-13
Q2
12-13
YTD
Trend
RAG
Calls answered within 30 seconds Safeguarding
90%
94%
94.4%
94.2%

G
Calls answered within 30 seconds Mental Health
90%
95.9%
95.5%
95.7%

G
NC4
Calls answered within 30 seconds Registration
80%
79.9%
85.7%
82.8%

G
NC11
‘Other’ calls answered within 30
seconds
80%
76.1%
83.9%
80%

G
NC6
Calls abandoned - Safeguarding
3%
1.3%
0.7%
1%

G
NC7
Calls abandoned - Mental Health
3%
2.7%
0.8%
1.8%

G
NC8
Calls abandoned – Registration
5%
3.9%
1.9%
2.9%

G
NC9
Calls abandoned - Other
5%
4.6%
2.2%
3.4%

G
C12
Number of Whistle blowing contacts
N/A
1,654
2,025
3,679
N/A
MI
Publications
Ref
Indicator
P1
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
Target
Q1
12-13
Q2
12-13
YTD
Trend
RAG
100%
92%
(12 of 13)
92%
(12 of 13)
92%
(24 of 26)

A
-
1.27m
1.4m
2.67m

MI
Green
Green
Green
Green

G
-
93.5%
95.6%
95.6%

MI
NCSC call handling and quality
There have been almost 97,000 calls to the NCSC in the first 6 months
of the year, and all handling targets have been met. In April the NCSC
signed up with a nationally recognised performance improvement
programme for call centres which benchmarks service and quality
standards against other organisation’s UK call centres. The NCSC came
36th with a customer service score of 86%. Most other first-time
entrants scored around 40%. This achievement is one year ahead of
plan and the position ahead of expectations. The detail from the final
report will be used to identify improvements to customer service with a
view to incorporating benchmarks into the work of the NCSC.
Whistleblowing
A two week sampling exercise of whistle blowing enquires to identify
trends, themes and outcomes was completed in October and a
summary is included in the covering paper to this scorecard.
Provider sentiment tracking
Our second six monthly provider sentiment survey was carried out in
September, this is part of wider sentiment tracking and the response
rate and results have been very positive. The online questionnaire was
sent to all registered providers and there were over 3,500 responses,
which is approximately 10% of all providers and from a good mix of
services and sectors. The survey focuses on our model of regulation and
approach to inspection. The response to this question ‘providers feel
informed about CQC and have the information they need to be
regulated by us’ (P3) shows a small improvement (93.5% positive in
March compared to 95.6% positive response in September). A full
breakdown of responses by sector will be presented to the December
meeting of the Board. Specific findings and areas of improvement will
be shared with Operations and other directorates as well as providers.
Publications, web and communication
Year to date there have been almost 2.7m visits to our website of which
almost 1.7m were unique visits. The ‘information for the public’ section
of our website has been the most visited area in the first 6 months of the
year. The most popular pages of the public section of the site are the
provider profiles; of which there have been almost 2m pages viewed
since April. Information and guidance for the organisations we regulate
is the next most visited area; guidance about compliance has been the
most downloaded item, at almost 50,000 to date. Our monthly enewsletter has almost 31,000 subscribers.
8
CQC Performance - Q2, 2012– section 3, Manage our organisation, people and resources
Priority 3 – Manage our organisation, people and resources
Vacancies and establishment:
Human Resources
Ref
Indicator
Target
HR1
Establishment Total
HR1
a
Establishment and vacancy rate ( establishment
less permanent staff )
HR2
Q1
12-13
Q2
12-13
YTD
Trend
RAG
-
2,292
2,296
2,296

N/A
15% by
June
2012
14.8%
14.8%
9%

G
Compliance inspector vacancy rate
<2%
12.5%
7.8%
7.8%

R
HR3
New compliance inspectors complete full induction
programme within 12 weeks of start date
100%
100%
100%
100%

G
HR5
All front line staff undertake mandatory
training on an annual basis.
48%3
42%
65%
65%

G
-
1,849
2,015
2,015

MI
-
339
339
207

MI
HR6
HR7
Number of permanent staff (FTE)
No of Vacancies
As of 26 October there were 833 compliance inspectors in post,
compared with the full year planned establishment of 955. The
vacancy rate has fallen from 25% in April to under 8% at the end of
September. In addition to the current 833 in post there are 82
confirmed new inspectors with induction dates in one of five remaining
induction programmes between 15th October and 7th January. There
are 7 regionally confirmed vacancies, (all in the South). Recruitment
of intelligence and policy managers as well as the Director of Health
Watch England is ongoing with all appointments at interview or offer
stage. CQC establishment currently stands at 2,296 compared with
1,971 for the same period last year.
Turnover and sickness rate
Turnover decreased marginally in Q2 from 2% in Q1 to 1.8% and
year to date stands at 3.7%. The sickness rate also declined to 3.2%
compared with 3.6% in Q1, however the overall illness rate has
marginally increased compared with the same period last year, the
illness rate in Q1 2011/12 was 2.6% in Q1 and 3.6% in Q2. The graph
below illustrates the quarterly sickness rate for each of the last 6
quarters.
4.00%
HR7
a
HR8
HR1
0
New staff pipeline (Staff with an offer of
employment)
-
111
74
74
N/A
MI
-
44
50
50

MI
3.50%
3.00%
Temporary staff in established posts
Turnover2
<1.125
% per
month
2.50%
2.00%
2%
1.8%
3.8%

G
1.50%
1.00%
HR1
1
Sickness Rate (based on calendar days)
2
<5%
3.6%
3.2%
3.7%

G
0.50%
0.00%
Q1
HR1
2
Health and Safety - no. of workplace accidents
-
4
11
15

MI
Q2
Q3
Q4
Q1
Q2
Illness rate
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 - Q2, 2012– section 3, Manage our organisation, people and resources
Priority 3 – Manage our organisation, people and resources (and Governance)
Complaint handling
Corporate governance (complaints and statutory requests for information) and Finance
Ref
GL01

GL02
Indicator
Target
Number of stage 1 corporate complaints
received across the organisation

GL05

GL03
Trend
RAG
Q2
12-13
10% less
than
2011/12
105
96
201

G
-
7 (7%)
8 (8%)
15 (7%)
N/A
MI
<20%
20%
(21)
27%
(26)
23%
(47)

R
Stage 1 Corporate complaints upheld

GL04
YTD
Q1
12-13
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
Statutory requests for information
95%
67%
100%
84%

A
-
5
2
7
N/A
MI
95%
95.9%
(304)
97.3%
(268)
96.5%
(572)

G
-
12
3
15

MI
No of stage 2 complaints upheld

GL07
Information access requests closed within
deadline
GL08
Parliamentary Ombudsman enquiries
GL09
Of closed requests proportion closed within
deadline - Freedom of Information
95%
95.8%
(236)
97.1%
(186)
96.5%
(422)

G
GL10
Of closed requests proportion closed within
deadline - Data Protection
95%
92.9%
(28)
100%
(37)
96.5%
(65)

G
Of closed requests proportion closed within
deadline - Info Sharing
95%
98%
(40)
94.7%
(42)
96.4%
(82)

G
Urgent cancellations of registration (under
section 30 of the HSCA 2008)
-
0
0
0

MI
90%
94%
94% 1
94%

G
5%
£36M v
£39.1M
(8%)
£81.3M v
£74.9M
(8%)
£81.3M v
£74.9M
(8%)

R
GL11
GL14

GL12
Percentage of outstanding critical and
important audit actions completed
F01
Revenue expenditure plus depreciation
variance vs. Budget (excluding fee income)
Year to date there have been 201 stage one complaints, this is a
significant decrease compared to the same period last year, when
there were 291 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 increased in Q2
to 27%, the complaints team have reviewed this and are satisfied that
the increase is not related to complaint handling at stage 1 but instead
an increase in the number of complainants asking for a review.
Following improvements to the complaint handling process all
complaints in Q2 were closed within 20 working days compared with
67% in Q1, at the current average performance, 95% of all complaints
will be handled within target for the full year meeting the annual
business target.
There have been almost 600 requests for statutory information in the
first 6 months of the year. 572 or 96.5% were completed within the
statutory deadlines. The majority, 422, were freedom of information
requests. There were 65 data protection Act requests and 82
information sharing requests. All measures are on track to achieved
their 2012/13 business plan targets.
Audit actions
In the first 5 months of the year there were 308 audit actions raised,
of these 303 were due to be completed by the end of August. Of the
outstanding audit actions the majority relate to safeguarding and
whistle blowing (21 actions of 43 in progress) and knowledge and
information management (11 actions of 43 outstanding).
Revenue expenditure
Year to date revenue expenditure shows an under spend of £6.4m
(excluding fee income or 8%) consisting of staff costs of £5.0m, Non
Staff Costs of £0.1m, depreciation of £1.3m. The under spend has
remained at an average of 8% year to date.
This figure is correct as of the last reported update in
respect of year to date performance to August
1
10
CQC Performance –Q2, 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 Q2 there were 17,292 compliant
locations compared with 13,218 in Q1. 19,683 locations have not
yet had an inspection (compared with 23,306 in Q1) and 4,411
were non compliant with at least one outcome, (compared with
4,117 in Q1). Year to date there have been 373 warning notices
issued to non compliant locations, 21 locations have de-registered
following intervention by the CQC and there have been 5 urgent
suspension of registration ,or urgent variation or imposition of
conditions using Section 31 powers.
CQC Performance – April - June, Q1, 2012 – compliance outcomes
90%
31.0%
80%
57.2%
70%
67.0%
15.5%
77.9%
60%
84.3%
99.8%
50%
40%
5.8%
5.0%
30%
53.5%
2.0%
20%
36.9%
28.0%
4.1%
20.1%
10%
11.6%
0%
Independent
Ambulance
Independent
Healthcare Org
NHS Healthcare
Organisation
Compliant
Primary Dental Care
Non compliant
0.2%
0.0%
Primary Medical
Services
Social Care Org
Not yet reviewed
11
CQC Performance – Q2, 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.
The graph illustrates the total number of locations that were non compliant in each quarter. There has been a decrease in total non compliant locations in each of the last three quarters, there were
128 in Q4 2011/12, 116 in Q1 of this year and 112 in Q2. Importantly there has been a notable decrease in aged NHS non compliance, locations that were non compliant for any period over two
quarters represented 50% and 57% of the total non compliant locations in Q4 and Q1 respectively, at the end of Q2 this figure had fallen to 31%
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.
Location been non
compliant for:
Q4
2011/12
Q1
2012/13
Q2
2012/13
140
13
25
16
120
13
10%
22%
14%
100
26
26
19
5
20%
16%
4%
24
22
14
19%
19%
13%
31
29
28
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
80
24
60
25
16
19
5
14
22
28
31
40
20
24%
25%
25%
34
21
49
27%
18%
44%
128
116
112
29
49
34
21
0
Q4
Q1
Non compliant for < 1 quarter
Non compliant for < 2 quarters
Non compliant for < 4 quarters
Non compliant for > 1 yeat
Q2
Non compliant for < 3 quarters
12
CQC Performance – Q2, 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
Q2
2012/13
178
432
460
Over one year
5%
More than three
quarters but less
than one year
More than two
quarters but less
than three quarters
12%
12%
4500
4000
372
500
489
3000
11%
13%
13%
2500
656
783
663
2000
20%
21%
17%
1500
More than one
quarter but less
than two quarters
1,078
1,0701
1,039
1000
32%
29%
27%
500
Less than one
quarter
1,065
956
1,255
0
32%
26%
32%
3,349
3,741
3,911
Total non compliant
in period
432
3500
178
372
500
656
783
1078
1070
1065
956
Q4
Q1
460
489
663
1039
Non compliant for < 1 quarter
Non compliant for < 2 quarters
Non compliant for < 4 quarters
Non compliant for > 1 yeat
1255
Q2
Non compliant for < 3 quarters
On the table on the left, the number of locations non compliant for 2-3 quarters at the end of Q2 fell to 663 from 1,070 last quarter. There has been a small increase in the number of locations noncompliant overall, and those non-compliant for over a year.
1 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 – Q2, 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:
Q4
2011/12
Q1
2012/13
Q2
2012/13
450
1
8
20
400
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%
2%
5%
350
13
23
38
300
5%
6%
10%
250
31
53
114
200
12%
14%
30%
150
68
137
116
100
8
23
53
1
31
114
13
26%
35%
30%
145
166
98
0
56%
43%
25%
258
387
386
137
68
116
145
50
20
38
166
98
Q4
Q1
Non compliant for < 1 quarter
Non compliant for < 2 quarters
Non compliant for < 4 quarters
Non compliant for > 1 yeat
Q2
Non compliant for < 3 quarters
The number of non-compliant locations overall has stayed static, in comparison with previous quarters, and those in groups of non-compliant for more than two quarters, 3 quarters and four quarters
has increased. Again further analysis, including of the effectiveness of actions we take, is being taken forward.
14
CQC Performance - Q2, 2012,– section 5, equality outcomes
All priorities – corporate equality objectives
Commentary:
Equality actions
Indicator
Target
EQ1
Embed equality across all our regulatory
and corporate activities
Green
rating
Green
Green
Green

G
EQ2
Ensure that, we identify and respond
appropriately when providers do not meet
the equality aspects of the essential
standards of quality and safety
Green
rating
Green
N/A
N/A
N/A
No
update
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
Green
Green

G
EQ4
Involve a diverse range of people who use
services in our work
Green
rating
Green
Green
Green

G
EQ5
Increase the uptake of accessible
information for easy to read. Large print and
6 community language downloads.
Green
rating
17,644
67,614
85,278

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
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
Amber
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
N/A
A
Green
rating
Green
Amber
Amber
N/A
A
Ref
EQ9
Improve the percentage of staff who have
the knowledge, skills and tools to embed
equality and human rights in their work.
Q1
12-13
Q2
12-13
YTD
Trend
RAG
This is the second update against the equality objectives. Notable
progress compared to the objectives has been included below as well
as risks and issues to delivery.
Objective 3: A report on availability of equality intelligence and actions
for the next stage of developing equality intelligence has been
completed.
Objective 4: The Regulatory Development directorate has been holding
conversations with equality groups such as, Speak Out, Acting Together
and eQuality Voices on our strategic review to ensure diverse groups
contribute to the consultation as it develops. Planning is underway to
carry out equality monitoring of experts by experience involved in the
Acting Together programme. Work has also started on a project to
support local CQC engagement with voluntary sector organisations
which will build relationships with, for example, organisations for people
with a learning disability.
Objective 5 is measured by an increase in the number of downloads
from the CQC website for accessible publications for example easy-toread, large print or one of 6 languages. The website accessibility section
has also been updated with a link on the home page to guide users with
accessibility issues on how the site and contents can be made
accessible. In addition to the downloads in accessible formats there has
also been an increase in the number of hard copy requests from
members of the public for publications or reports in easy-to-read, Braille,
large print or one of 6 languages, there were 24 in Q1 compared with
212 in Q2.
Objectives 7 to 9, overall these objectives are rated as amber following
the results of the staff survey. Further analysis of the results are being
carried out and a meeting led by HR in October will plan actions based
on the analysis. 50% of staff said that they felt CQC is committed to an
environment which is free from bullying and harassment. This result,
and other survey results, will drive improvement action around bullying
and harassment and staff experience of equal treatment at work. Work
aimed at improving the diversity of the workforce included LGBT
targeted advertising in London during recent compliance inspector
recruitment.
15
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.
16