ANNEX A - CQC Performance, Quarter 4 and Full Year 2012/13

1. ANNEX A - CQC Performance, Quarter 4 and Full Year 2012/13 Agenda item 5 Paper No: CM/03/13/04 Annex A Contents Section 1– Scorecard summary Slide 2 Section 2– delivery priority 1: Deliver and Improve our regulatory and other functions Slides 3 - 7 Section 3– delivery priority 3: Manage our organisation, people and resources Slides 8 - 9 Section 4–Levels of compliance and non-compliance - registered locations Slides 10 - 13 Section 5 –CQCequality objectives tracker Slide 14 Section 6 –Explanatory notes to the scorecard measures Slide 15  All measures with a tick are included in our monthly performance dashboard which is published on our website. 1

2. Q4 and Full Year YTDscorecard summary Operating performance - Compliance inspections Operating performance - Registration, Enforcement and MHA Customer Service Resources and audit actions 2

3. CQC Performance – Q4, and full year 2012/13– 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 • In 2012/13 we undertook a total of 35,371 inspections, this includes inspections where we responded to concerns raised by users or where we followed up progress in resolving non compliance identified in earlier inspections as well as those that were scheduled to be undertaken in the year. • In short our overall 2012/13 business plan inspections programme for the year was achieved, compared with active locations compliance inspectors completed the programme in all but 8 locations. A full reconciliation to the 2012/13 Business Plan targets is given on the second table on the left • Note that our inspection figure of 28,583 inspections, this includes 852 locations that became inactive and deregistered after inspection (with 5 outcomes or more) these were reconciled to the overall inspection data at year end but not included in the quarterly breakdowns. • By sector: • 100% of NHS active locations completed (318), • The ASC programme completed all but 5 active locations (22,250 completed) • The IHC programme completed all but 3 active locations (2,117 completed) • 104% of Dentist locations and; • 100% of the active ambulance locations completed. • Notable achievements by sector are detailed in the cover paper of this performance report annex. 3

4. CQC Performance – Q4, and full year 2012/13– 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: Almost 5% of all of our completed scheduled inspections included Experts by Experience - There were 1,408 site visits that involved an Expert by Experience a significant increase compared with 506 or 3% in 2011/12. There were 1,760 responsive inspections undertaken this year compared to 2,589 in 2011/12, although a decrease of 829 it was expected given the rise in the number of scheduled inspections that have taken place this year in comparison to last year (over double). 72.2% of final compliance reports were completed within 25 working days compared with a plan of 90%, draft reports were also significantly under plan and 69% for the year. The underperformance can mostly be attributed to prioritisation of inspections but also to this indicator not reflecting the complexity of some reports, particularly at NHS Trusts. There were 3 thematic reviews completed during 2012/13 covering: Dementia, Hospital discharge arrangements , Access to secondary care. CQC carried out a review of hospital data looking at outcomes for people with dementia in hospital. The key findings were that almost a third of hospital admissions involving people with dementia did not include a record of their dementia, despite the fact that it had been identified in the past. Home care - There were are 250 home care services that provided care to more than 26,000 people, during the review more than 4,600 people were contacted and 738 people were visited in their own homes. The review found that 74% of the services were meeting all five of the standards that our inspectors checked. The number of total user voice QRP items in 2012/13 is 52,815 of these there were 40,102 NHS data items, 11,215, ASC data items and 1,498, IHC data items. In 2012/13, a project was undertaken to increase the volume and coverage of information submitted to CQC. The volume of 'people's voice' data items increased by 38% in NHS QRPs, 209% in adult social care and 33% in IHC. In February we launched a redesign of the QRP for ASC and IHC, incorporating new pages that clearly set out the regulatory history, correspondence and data relating to 'people's voice'. Inspectors feed back has been very positive. This year 86% of all newapplications were processed in under 8 weeks against a target of 90%. Although below plan this year’s performance represents a significant improvement compared to the overall percentage processed within 8 weeks last year which was 73%.Variation BAU applications within 4 weeks also ended the year under plan at 74%. 4

5. CQC Performance – Q4, andfull year 2012/13– 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: The number of warning notices increased 42% (or 272)in 2012/13 compared with 2011/12. This year there have 910warning notices issued compared to638 for the same period last year. Year to date there have been 910 warning notices served and 6 section 31 urgent suspensions of registration or urgent variation or imposition of conditions. Compared with last year there has been a significant increase (42%) in the number of warning notices served - there were 638 last year. Our business plan target was to serve 90% of warning notices within 14 days of identifying one is required. For the year 83% have been within plan There were 1,508 providers that cancelled registration, of these 75 locations that have de-registered since April 2012 were due to CQC intervention. Notable legal action during the year 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. 5

6. CQC Performance – Q4, and full year 2012/13– 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: Mental Health Act Operations There were 1,090 MHA Commissioner visits undertaken in 2012/13, this compares with 1,502 in 2011/12. Although a reduction when compared with last year this is still over and above scheduled MHA Commissioner visits for this year. Overall SOAD performance was below plan, in 2012/13, 712 or 70% SOAD medicines visits have been attended within 10 working days of receipt of request. There have been 344 of 68% of SOAD Electroconvulsive Therapy (ECT) visits and, 68% Community Treatment Order visits were done within target. Recruitment is on going to increase the number of available doctors. The SOAD leadership has been strengthened to include a Principle SOAD. Notable working with partners included Mental Health Act Commissioners worked with HMI Constabulary and HMI Prisons on a joint review of the use of police custody in nine police areas. The findings will be published in a joint national report. There were 671 or 87% of MHA Complaints were triaged with 3 working days, which is marginally below plan. There were 796 or 71% MHA complaints responded to within 25 days, a significant decline when compared with Q1 and Q2 performance of 94% and 100% respectively. Information for ‘other’ inspections has been requested and will be included when received and reconciled. 7

7. CQC Performance – Q4, and full year 2012/13– 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: • The National Customer Service Centre (NCSC) achieved all service targets in 2012/13. There were over 201,000 calls handled in 2012/13 compared to 213,000 in 2011/12 a reduction of 5.6%. In the prioritised areas of calls relating to Safeguarding and Mental Health 94.3% and 95.3% respectively were answered within 30 seconds compared to a target of 90%. • There were 8,634 Whistle blowing contacts received across CQC during 2012/13; the number of contacts increased gradually from 1,725 in Q1 to 2,579 in Q4. The increase in Q4 is possibly linked to media attention of the Francis report. • In April 2012, a Safety Escalation Team was set up to make sure that all high-risk information received into the NCSC is triaged and processed efficiently, consistently and quickly. The NCSC was recognised for its customer service during 2012/13 by the ‘UK top 50’ call centres programme. This is the first year the Centre entered the programme and have been ranked 36th • . • Publications, web and communication • There were 6m visits to the website during 2012/13, a 25% increase compared with 4.8m in 2011/12 The most visited unique pages were: • Reports surveys and reviews , 240,116 views, • Contact us , 225,847 views • Jobs, 202,073 views. • Some of the most popular downloads were: • Guidance about compliance, 109,693 • Judgement framework, 20,417, • Applications to register, 13,724. • All key publications were published on target, notably, Deprivation of Liberty Safeguards annual report, Mental Health Act annual report, CQC Care update 2, Homecare themed inspection report and Dignity and Nutrition reviews on ASC and NHS. 8

8. CQC Performance – Q4, and full year 2012/13– section 3, Manage our organisation, people and resources Priority 3 – Manage our organisation, people and resources • Commentary: • Sickness rates and turnover remained low throughout the year and were well within tolerances for the full year targets to be achieved. There was a marginal increase in the overall illness rate to 3.65% of all working days lost to illness, compared with 3.2% last year while turnover reduced to 7.1% this year compared with 8.1% last year. • In February, the staff survey ‘pulse check’ results were published, notably there were some improvements since the staff survey in 2012: • There is an overall satisfaction rate of 58%, up 10% • Significant increase in CQC changing for the better 15% increase; • people committed to CQC’s future direction up 13%; • And 10% more would recommend CQC as a good place to work • Mandatory training completion remains low at the end of March 2013. The current mandatory compliance rate overall, and specifically for CIs and RAs requires further investigation to understand the organisational and operational constraints which may be impacting on completion of mandatory training or the effective recording of mandatory training having been completed. These investigations will be undertaken by the end of June 2013. What will also help us establish a contemporary and accurate picture is the skills audit that CIs and RAs will be undertaking in the next few weeks enabling CQC to audit its own records against those that staff hold. Our full training needs analysis work will result in a much more effective list of mandatory training that will be a key part of our new Academy. • At the beginning of the financial year there was a vacancy rate of almost 25% for compliance inspectors, following a successful recruitment campaign this has been reduced to zero and a full complement of 955 compliance inspectors are now in place with all training cohorts having been completed. • HR led in sourcing and training the inspectors and with other areas managed significant risks to quickly turnaround and deploy the Inspectors across the country. The HR team also managed a quick turnaround for the recruitment and training of over 150 Bank Inspectors that helped deliver our challenging inspection commitments. 9

9. CQC Performance – Q4, and full year 2012/13– section 3, Manage our organisation, people and resources Priority 3 – Manage our organisation, people and resources and governance Commentary: In 2012/13 we received 414 stage one complaints compared with 495 during 2011/12 a decrease of 16% compared with a planned reduction in complaints of 10%. Complaints progressing to stage 2 ended the year at 20% compared with our threshold of 20%. Overall 83 complaints progressed to stage 2. Stage 2 complaints handled in under 20 days ended the year at 83% overall within plan, which represents just 14 complaints not within plan, often due the complex nature of the complaint or the requirement of information from a range of sources. Statutory requests for information There have been 1,148 requests for statutory information this year,1,107 or 96.4% were completed within the statutory deadlines compared to 1,403 or 97.8% in 2011/12. The majority, 803, were freedom of information requests, although significantly down from last year when there were 1,103. Audit actions The percentage of outstanding audit actions in 2012/13 was95%which exceeded the 90% target. 10

10. CQC Performance –Q4, and full year 2012/13– 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 CQC Performance – April - June, Q1, 2012– compliance outcomes The graph to the left illustrates levels of compliance across all 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 Q4 there were23,479 or 47.4% compliant locations compared with13,218 or 32.5% in Q1, an increase of 10,261. There are 20,794 or 42% locations have not yet had an inspection (compared with 23,306 in Q1) and 5,281 or 10.7% were non compliant with at least one outcome. Adult Social Care has the highest percentage of compliant organisations at 67.3%, Independent Healthcare has 55.2% and Independent Ambulances has 44.4%, although across all the sectors there are locations that are yet to be reviewed. Year to date there have been 910 warning notices served to 578 providers, 75 locations have de-registered following intervention by the CQC and there have been 6 urgent suspensions of registration, or urgent variation or imposition of conditions using Section 31 powers. 11

11. CQC Performance – Q4, and full year 2012/13– section 4, compliance outcomes Levels of compliance and non-compliance - registered locations NHS locations non-compliant with one or more outcomes, by age The following graphs show , for the NHS, for Adult Social Care, and for other providers, the period of time that they have been non-compliant. 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. In Q4 2011/12 there were 128 NHS trust locations that were non complaint compared to 134 in Q4 2012/13. A general increase in the numbers of NHS locations non-compliant for less than one quarter from 34 in Q4 2011/12 to 39 in Q4 2012/13, whilst there has been a been an increase (from 13 to 30) in the number non-compliant for over one year (although this number has been broadly stable since Q2 and should be considered in the context of a significant increase in inspection activity). The following two slides are in the same layout as this slide and illustrate the levels of compliance at ASC (slide 12) and IHC, Ambulance and dentist locations (slide 13). 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

12. CQC Performance – Q4, and full year 2012/13– section 4, compliance outcomes Levels of compliance and non-compliance - registered locations ASC locations non-compliant with one or more outcomes, by age The following graph shows Adult Social Care for the period of time that they have been non-compliant. In Q4 2011/12 there were 3,349 providers non compliant compared to 4,465 in Q4, 2012/13. There was an increase from those providers that are non compliant for less than one quarter; 1,065, Q4 , 2011/12 to 1,437 in Q4 2012/13, however the percentage remains constant at 32%. The proportion of providers that are non compliant over one year has increased from 178 or 5% in Q4 2011/12 to 933 or 21% in Q4 2012/13. It is important to note that during the same period the number of compliance inspections ( with 5 or more outcomes) has increased from 9,818 (although this combines both ASC and IHC) to 22,250 , an increase of 127%. 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 13

13. CQC Performance – Q4, and full year 2012/13– 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 The following graphs show IHC, Primary Dental Care and Independent Ambulance providers, for the period of time that they have been non-compliant. There were 258 providers non compliant in Q4 2011/12 compared to 678 in Q4 2012/13. There was an increase from those providers that are non compliant for less than one quarter 145, Q4 , 2011/12 to 352 in Q4 2012/13, or from 56% to 52%. The proportion of providers that are non compliant over one year has increased from 1 or 0.4% in Q4 2011/12 to 77 or 11% in Q4 2012/13. It is important to note that during the same period the number of compliance inspections (with 5 or more outcomes) has increased significantly. 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

14. CQC Performance – Q4, and full year 2012/13,– section 4, equality outcomes All priorities – corporate equality objectives Commentary: Below is an update of the equality objectives performance. Objective 1: The ET and Board received quarterly updates covering our equality objectives as part of the overall performance governance of CQC. Objective 2: The work to evaluate the regulatory response and make recommendations for future practice has been completed and the findings reported to the Executive Team. Actions have been identified for 13/14 to address gaps and improve the overall response. Amber because although the issues are identified, improvement actions have not been completed yet and many need to be integrated into the Strategy programme work projects. Objective 3:Information is currently available relating to protected characteristics has been reviewed, a strategy for ongoing monitoring and development of new data sources is currently being drafted. Information on cases of unlawful discrimination have been sourced and communicated to compliance inspectors. The Intelligence directorate has developed a clear project plan, with appropriate resources, to improve the information and intelligence that we hold to better identify risks to equality for organisations that we regulate. This work is well developed though not completed. Objective 4:Speak-Out Network members made up of a diverse range of local community groups and were significantly involved in the Strategy Review consultation, along with members of the Equality Voices Group and Experts by Experience. There has been a similar level of engagement with the developing Statement of User Involvement. Objective 5: The number of web downloads for the CQC for Easy reads, Large print and alternative languages totalled 68,577 in 2012/13. , this is due to the number of Corporate publications published since January 2013 including CQC response to the Francis report, the Strategic Review and Dignity and Nutrition review into both Care homes and Hospitals. Objective 6: MHA Commissioners from two regions are currently piloting the equality monitoring formal methodology during their visits to patients who are detained under the Mental Health Act. This work will be evaluated and then used more widely during 2013/14. Objective 7: Analysis of equality monitoring suggest that there is little movement in the staff profile. However, some action has been taken to improve the data that CQC hold and to look at positive action measures to improve the number of black and minority ethnic staff in senior grades. 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:A revised Bullying & Harassment Policy has been published which includes reference to accessing the 25 Dignity at Work Advisors. This is additional to the work of an external expert. This is rated amber to reflect that monitoring of this work will be reflected in the staff survey later in 2013. Objective 9: Work on methods for domiciliary care agencies and community based services has included developing feedback methods to meet a range of communication needs - giving inspectors better tools to ensure a diverse range of people who use services can give us their views. In developing judgement framework impact examples, we have included specific case studies around equality aspects of our standards, for example in relation to GP services. These are available to both inspectors and providers. 15

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. Experts by Experience Experts by Experience are people who have experience of using or caring for people who use health, social care and mental health services. FinanceOur 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. 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. The Quality and Risk Profiles (QRP) gather key information about care providers that helps inspectors to see where risks lie and prompt them to take a closer look. It is also an essential tool for providers and commissioners to monitor performance in their own services. 16