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Performance and Capability Review

CQC action plan April 2012

Performance and Capability Review: CQC action plan 1

Contents Foreword 2 Introduction 4 Our action plan 5 1. Develop a new strategy for CQC 6 2. Strengthen and improve the effectiveness and consistency 9 of the regulatory model 3. Strengthen the governance of CQC 15 4. Develop CQC to be a high performing and learning organisation 18 Annex 1: Key actions 23 Annex 2: Mapping of the actions to the recommendations from 25 the Performance and Capability Review


Foreword The Care Quality Commission (CQC) aims to be a strong, well-respected regulator. The public and providers want this too. The Board of CQC believes that the public need to have confidence in us – so that they trust our judgements and tell us when they see poor care being delivered, safe in the knowledge that we will act on it quickly. We want care providers to be confident that we will enforce standards strongly and consistently – so that each sector is supported in delivering the quality of care that people have a right to expect. Over the past year CQC has been scrutinised by a number of bodies – the Francis Public Inquiry, the Health Select Committee, the internal management review around Winterbourne View, the NAO report and the recently published Public Accounts Committee report. In addition, the Department of Health’s Performance and Capability Review of CQC, carried out between October 2011 and February 2012, focused on the future capability of the organisation. The external scrutiny raised questions about our performance and role as the health and social care regulator. The Board acknowledges many of the criticisms that have been made about the effectiveness of the organisation during its first three years of its life, and notes the growing appreciation of the scale of the challenge that CQC was set. We will respond assertively to the recommendations of the Capability Review. Over the next year we will reset the strategic direction of the organisation, measure CQC’s impact and effectiveness, and hold the Executive to account for delivery. Since April 2009, we have made progress in creating a single regulator of health and adult social care services, spanning more than 22,000 providers of 40,000 services. We have developed a new regulatory model that uses the same standards of quality and safety across every sector based on outcomes for service users and patients. We have carried out more than 17,000 reviews of services since April 2011 – an average of more than 1,400 a month – and served more than 600 warning notices to providers in that time. During 2011/12 we have met all targets for carrying out inspections, delivered a new website which provides extensive information for the public about providers, and reduced the time taken for registration, with 89% of applications being concluded within eight weeks. We have heard what people have said and we embrace the changes we need to make. We already have a significant programme of work underway which will increase our effectiveness; the points raised in the Department of Health review mean that more has to be done. We are focused on reinforcing our management processes, making sure we use our regulatory powers appropriately and proportionately, and being transparent about how we’ve done this and how this impacts on care services. It will be a significant challenge for the organisation but we are clear about what needs to be done to ensure strong and well-respected regulation.


We can’t do this alone. Effective regulation plays its part but providers and commissioners, as well as the public and other regulators, must work with us to achieve consistent, good quality care in services across the country. Our action plan in response to the Department’s review and our annual business plan sets out how we will do that.

Dame Jo Williams Chair - on behalf of the Commissioners


Introduction The external scrutiny of CQC over the last year has raised a number of questions about our performance as the health and social care regulator. We are committed to addressing these issues. We have made a start. We had already begun a significant programme of work to address the issues we face: some have already been completed; many are underway. The Capability Review confirmed that, over the last nine months, we have put renewed focus on our core purpose – particularly in strengthening our operational base and improving our external engagement. However we have a challenging programme ahead. We have important issues to address: to become more strategic and set out more clearly what success looks like; to ensure that accountabilities are clear, and to evaluate the effectiveness of the new regulatory model. The strategy that we devised at the outset of CQC failed to take into account the complexity of the changes in the regulatory regime – in particular the workload implicit in registering so many providers and merging three organisations into one, while reducing costs and changing the working patterns and skill requirements of many of our staff. This meant that the progress we had hoped to make in both registering and then inspecting care homes and hospitals was not possible. For these reasons it is essential that CQC reviews its strategy, setting new objectives and performance standards in the light of what is possible and expected by the public, by Government and by our stakeholders. We have also learnt through experience that some of the assumptions we made about how the regulatory regime would work have not been borne out by experience. Accordingly we started work, early in 2011, to fully review the regulatory model. This work needs to be completed and the results implemented into our policies and practices. To be as cost effective as possible, CQC made an early decision to have a home-based workforce, thus divesting itself of the need for area and regional offices. This has, however, been more challenging than we had expected. Combined with the need – already identified by an internal review in early 2011 – for improved levels of consistency in applying the regulations, we recognise that we need to invest more in supporting and developing our workforce, ensuring improved productivity and effectiveness. Finally, it is recognised that CQC’s Board itself needs to be strengthened, work more effectively and improve the leadership it gives to the organisation.


Our action plan Our action plan is grouped under the four headings highlighted above and incorporates all the recommendations of the six key lines of enquiry in the Capability Review. The action plan has also taken account of the findings of the Public Accounts Committee published on 30 March 2012 and feedback from other scrutiny processes during 2011/12. Over the next few pages, we have set out what we are doing under each of these headings and the outcomes we are striving for. Annex 1 has a summary of the key actions, and in annex 2 we have mapped them to the recommendations from the Capability Review.

Performance and Capability Review: CQC action plan 6 1

1. Develop a new strategy for CQC The landscape of care provision is changing as a result of the Health and Social Care Act 2012, against a backdrop of increasing demand from people who use services and a challenging economic environment. We need to develop a new strategy, setting out our role as a regulator. This will set out our vision and priorities for the next five years, and how we measure our own success. The Board made provision in 2011 to review its strategy and organised a series of specific Board strategy meetings. The first of these meetings was in October 2011.The process of developing the strategy will be as inclusive as possible, drawing contributions from as wide a set of stakeholders as we can and subjecting the outputs to a three-month public consultation. Our ‘stakeholders’ in this respect include the users of the services we regulate, the general public, service providers, third sector organisations and advocate groups, other regulators in the health and social care sectors, the Department of Health and the Government. We aim to publish the final strategy by December 2012. We will take action in the following areas:

1.1 Clarifying our role in a complex environment with commissioners and other regulators

The definition of the CQC’s role as a regulator within the health and social care landscape will be a key part of the development of our revised strategy. This definition will need to take account of how CQC makes best use of its limited resources in a period when financial pressures may impact on the quality of care provision. Extensive engagement with our stakeholders will help us determine where CQC fits within the new health and social care landscape. The engagement will take place as part of the initial development of the draft strategy and then through a three month public consultation. In order to complete the view of the landscape, the Government will need to decide whether CQC should take on the additional responsibilities of the HFEA, HTA and NIGB. CQC’s Board discussed and considered these proposals in November 2011 and concluded that there would be little benefit and significant risks in CQC taking on these additional responsibilities. The Board believes that there are few potential savings associated with this proposal and that this would expand and complicate the Accounting Officer role, distracting CQC from the challenge of refining and delivering it’s regulatory activities. An impact assessment was commissioned after the Board meeting and is due to report by June 2012. We will begin a public consultation on the strategy during the summer of 2012, and will publish it by December 2012. We will use it to inform the 2013/14 business planning process that will begin at the end of 2012.


1.2 Set out the expected outcomes over time, and measures of success for CQC It has been observed in both the report of the National Audit Office and in the Department of Health (DH) performance and capability review that CQC has not been clear in setting out the measures of success which it aims to achieve. We accept this criticism and plan to include clear measures in the new strategy currently being developed. These will be tested with the public and our stakeholders through the consultation process taking place this summer. In the interim we will publish in April 2012 a scorecard based on the success measures which can be found in our business plan, for example progress towards our inspection target and achievement of target time limits for registering new applications. We accept however, that some of these are proxy measures and whilst they may reflect improved efficiency they may not address the issue of impact. We are also undertaking a review of the processes and supporting IT systems used to define, collect and confirm organisational performance data. The output from this review will set out the system and processes required to support future operational and organisational needs. Additionally, as part of the changes we are making to our regulatory model, we are making significant changes to our compliance regime. These will be completed by September 2012, with the first measures of the effectiveness of the changes available by December 2012.

Conclusion The development and confirmation of the strategy, taking into account the wide range of stakeholder views, will clarify our role as regulator in the changing health and social care landscape. It will also set out our measures of success and the outcomes we will aim to achieve over the next five years. To achieve this, the following table sets out the key actions and when we will complete them:


Actions

2012/13 Sub Theme

Q1 Q2 Q3 Q4

2013/14

1.1 • Engagement with stakeholders to develop new strategy

• Baseline of stakeholder awareness of CQC and its role completed

• Decision taken on additional responsibilities for CQC

• Public consultation of CQC strategy completed

• CQC strategy completed and published

• Initial communication of CQC strategy to stakeholders completed

• Continuing communications with stakeholders on published strategy

Q1 Evaluation of success of external communication of strategy completed

1.2 • New measures defined in 2012/13 business plan reported

• Public scorecard of existing success measures first published

• Review of existing arrangements for defining, collecting and confirming data completed

• First measurements of performance of new compliance regime available


2. Strengthen and improve the effectiveness and consistency of the regulatory model CQC’s regulatory model is built on four complementary strands: we register, we inspect, we enforce and we publish what we find. Registration confirms CQC’s judgement that a provider has credibly and legally declared that they will meet essential standards, and are fit to provide services. Once they are registered, our inspectors have a continual oversight of the information we have about them, and physically inspect their services on a regular basis (mostly once a year; once every two years for dentists). Inspections are risk-based: if there are concerns about a provider, we inspect more frequently. If we find that standards aren’t being met, we take timely and effective enforcement action. And we publish inspection reports and web-based profiles of providers so that the public and commissioners can make choices about care services. Early in 2011, feedback from our own inspection staff, providers and external stakeholders helped us recognise that the detailed processes within the model were unwieldy and cumbersome. We therefore started a major programme to simplify these processes, with the aim of freeing up our inspectors to carry out more inspections and enforce the standards more quickly, making it clearer to providers what it means to be inspected, improving the clarity and consistency of our judgements, and getting information about inspections to the general public more quickly. The simpler, stronger model came into effect on 1 April 2012 and the enhancements will be fully in place by September 2012. We will then begin a cycle of monitoring the model’s performance and appropriateness for each sector we regulate, making changes and refinements based on the evidence we collect. We will take action in the following areas:

2.1 Ensure the right expertise is drawn on at the right time in the right environment to deliver effective regulation CQC uses a generic model of regulation across all sectors. This model can be adapted and focused depending on the degree of risk, with teams drawing on experts for specific targeted inspections as necessary. CQC is committed to ensuring that the right level of specialist expertise is available when needed and clinical and professional associates can already be accessed from a ‘bank’ of resource if required. It is our intention to create a stronger pool of expertise in this ‘bank’, and to continue to recruit specialist expertise. To improve consistency in the use of this resource we will be introducing clearer information for inspectors from June 2012, including guidelines on what triggers the need for specialist involvement. We will evaluate the use of clinical and professional associates and experts by experience, once the new guidelines are in place. This evaluation will be complete by December 2012 and will inform a decision on whether the right balance has been struck on use of specialist expertise.


In addition to specialists supporting the generic model of regulation, there are also examples where specialist expertise is used, for example, for activity relating to Ionising Radiation (Medical Exposure) Regulations, controlled drugs responsibilities and joint inspections, with Ofsted, of children’s safeguarding arrangements.

2.2 Complete the refinements to the regulatory model As part of the changes we are making to our regulatory model, significant enhancements are being made to our compliance regime. These will be complete by September 2012 and include a new framework for risk which will enable inspectors to assess risk in timely and systematic way. These developments will also enable us to make further improvements to our website by September 2012 so that information about providers can be provided in a timely and searchable way. Alongside the changes to the compliance regime, we are continuing to raise the professional standards of our inspectors. We have reflected these standards in our recruitment process for new inspectors, and will use the midyear and annual performance reviews to identify any gaps and development needs for existing inspectors. We will continue to use thematic reviews and in depth inspections where appropriate, and are developing a consistent approach for their planning and activation.

2.3 Effectively gather and synthesise information (e.g. from service users, staff, regulators and other bodies) to take account of in assessing regulatory risk Our intelligence directorate gathers information from a wide range of sources and uses it to assess regulatory risk across all providers. However, we recognise the need to increase the range of information available to assess risk in sectors other than the NHS. By June 2012 we will have appointed a Director of Knowledge and Information Management to lead this function and continue its development. We are also conducting a pilot to trial new ways of using ‘soft’ information (such as feedback from third sector organisations) in our risk analyses, so that we can take account of patient and user insight. We expect this pilot to complete and deliver results by December 2012. We are improving the wider availability of information by developing a consistent approach to information sharing with professional regulators and other bodies. We are also making changes to simplify access to the results of risk analyses for inspectors, enabling better use to be made of it in their judgements. Finally, we will be developing processes to ensure relevant information from local HealthWatch organisations is made available to inspectors from October 2013.


2.4 Ensure CQC is consistent and transparent in its compliance activity and regulatory decision making We are setting up a dedicated team of Quality, Risk and Assurance managers, supported by enhancements to our IT systems, whose role will be to ensure consistent and accurate sign off of reports. We will also be creating a quality framework and will report internally on the quality checks being undertaken and the potential improvements they point to. These arrangements will be embedded within a revised corporate governance framework aimed at strengthening decision making and the way in which risks are escalated to Board level (see also section 3.2).

2.5 Evaluate CQC’s effectiveness in regulation We have been challenged by the PAC and others to monitor the impact of regulation. This is a complex matter because improvement in performance and compliance with the standards may be the result of a number of factors unrelated to CQC’s activities, rather than the regulator acting as a deterrent. We are committed to understanding how effective we are across the sectors we regulate, and demonstrating whether we provide value for money. We will test how well we conduct our role through an internal quality framework and through evaluation. This will include independent research and a programme of targeted internal evaluations, the first of which will be completed in September 2012. We are currently tendering for independent experts to design and deliver and independent evaluation of our impact, effectiveness and value for money. They will also help us to revise our internal approach to evaluation, and to refine and embed this in our business as processes. We expect interim results for this work around January 2013, with final result in the summer of 2013. We are also implementing information system improvements that will allow us, at individual inspector level, to capture and analyse decisions that led to inspection activity and resulting judgements about compliance. This and other information, such as the amount of time taken to deliver an inspection and feedback from providers, will allow us to monitor and review our effectiveness as a regulator. These changes will be complete by September 2012, which will allow us to gather the first set of data on effectiveness by December 2012 with three months of data, and undertake a more complete review by April 2013.

2.6 Deliver an effective and timely response to serious concerns and information, including from whistleblowers We have completed a significant amount of work to improve our response to serious concerns and information. We are improving our relationships with local safeguarding teams across England through regular meetings, to ensure that responsibilities are clear. We have revised our internal safeguarding training, with all staff required to receive it during induction and annually as a refresher.


CQC’s national customer service centre received in excess of 200,000 calls during 2011/12. On average, calls are answered within 14 seconds and there is a process to ensure that whistleblowers are immediately transferred to a dedicated team of four people. This team is responsible for tracking calls through to a satisfactory conclusion with CQC inspectors. In its report published on 30 March 2012, the public accounts committee noted that CQC had recently closed its dedicated whistleblowing hotline. This is incorrect, and we have in fact strengthened our whistleblowing procedures since June 2011. Our dedicated team has dealt with over 4,200 contacts since it was set up and we are assessing the impact of this arrangement on the actions we take. We are working with all professional regulators across the sectors to develop a common whistleblowing protocol for the staff they represent. We believe that changes are needed to our legal powers in order help us act quickly when serious concerns are raised, and we will pursue these changes with the Department of Health.

Conclusion A major programme of work is underway to enhance the way we put the regulatory model into practice, and to allow us to better monitor its performance and identify further improvements. Our own monitoring and assessment of the regulatory model will be supplemented by an independent external evaluation of our impact and effectiveness. The following table sets out the key actions for enhancing and monitoring the performance of the regulatory model, and when we will complete them:


Actions

2012/13 Sub Theme

Q1 Q2 Q3 Q4

2013/14

2.1 • Implementation of an enhanced ‘bank’ of clinical and professional associates and consistent guidelines for their use completed

• Evaluation of use of clinical and processional associates completed

2.2 • Implementation of new compliance regime completed

• Inspectors midyear review - development needs identified

• Further improvements to the way Provider information can be searched on our website

• Inspectors end of year review - development needs identified

2.3 • Appoint director of knowledge and information management

• Simplified inspector access to regulatory risk information

• Information flows between HWE & CQC defined and agreed

• Pilot of ‘soft’ information in risk analysis completed and findings reported


2.4 • Dedicated team of Quality, Risk and Assurance managers created

• Corporate Governance Framework and underlying risk management processes agreed by Board and executive team

• Update of IT systems and processes to allow better audit trails completed

• Start internal reporting of quality check outcomes and lessons learned

• Quality and assurance framework and reporting in place

2.5 • First phase of targeted internal evaluation of CQC impact and effectiveness completed

• Interim internal evaluation of regulatory model changes completed

• Internal review of regulatory model changes completed & recommendations made

• Interim results for work with independent experts

Q2 Results from work with independent experts published

2.6 • Common whistleblowing protocol agreed with other professional regulators

• Whistleblowing information included within the market report

• Review of how enforcement powers have been used completed and recommendations made

• Pursue further regulatory and enforcement powers


3. Strengthen the governance of CQC A strong governance structure is an important foundation for the development of CQC as a high performing organisation. CQC is developing and strengthening its governance structures in partnership with the Department of Health. We will take action in the following areas:

3.1 Develop and clarify our relationship with the Department of Health The Department of Health has acknowledged that the relationship with the Commission has generally been open. But it recognises, as do we, that there has been uncertainty over the responsibility for owning and mitigating the strategic risks facing the Commission. The Department also recognises that while its relationship with the Commission’s Accounting Officer has been clear, there is less clarity about what the relationship should be between the Commission’s Board and the Department. We welcome the Department’s highlighting of this issue, and look forward to discussing the situation with them in the near future, with a view to coming to an agreed a statement defining this important relationship. The Commission’s Chair is in regular contact with the Permanent Secretary and will be seeking an initial meeting to begin this process. We also welcome the Department’s commitment to increase the size of the Commission’s Board and to authorise the recruitment of new members. We have already begun to discuss new proposals with the Department of Health around what the agenda should be at formal accountability meetings. Additionally, the improvements we are making to our workforce planning capability will allow us to better inform the Department for Health of the impacts of changing priorities and adding responsibilities.

3.2 Strengthen the CQC corporate governance structures and framework It is imperative to strengthen the Board and the process to appoint additional commissioners is underway. A unitary board structure may better enable the board to understand the performance of the organisation and improve oversight and the CQC Board are currently evaluating the advantages and disadvantages of this option. From May 2012 we will implement a revised corporate governance framework. This will strengthen the current processes of escalating regulatory and business delivery risks to Board level through a committee structure, and ensure that the Board and Executive can make fully informed decisions. This will aid transparency around decision making in relation to the deployment of CQC’s resources and will also ensure that regulatory risks are captured and considered in a coherent way. We will keep under review the effectiveness of the corporate governance framework, and in particular risk management processes.


We will be developing a catalogue of case studies, where CQC could have been more effective at identifying poor care and taking action, and use this information to continually improve how we deliver the regulatory model. We are reviewing the Board development programme, and will restart it following the recruitment of the additional commissioners. We will also strengthen the resources available to Board members when this would support specific duties within their portfolios.

Conclusion CQC is developing and strengthening its governance structures, and developing its relationship with the Department of Health. This will ensure that it can operate consistently and independently when making regulatory judgements, whilst ensuring that it can appropriately be held to account for its responsibilities. The table below sets out the key actions we will take to enhance our governance, and when we will complete them:


Actions

2012/13 Sub Theme

Q1 Q2 Q3 Q4

2013/14

3.1 • Draft CQC strategy completed for public consultation (including role in regulatory landscape)

• Improvements to formal accountability relationship agreed between CQC Board and DH

• First DH quarterly accountability meeting with revised agenda

• Resource planning tool completed and implemented (to better inform impacts of changing priorities)


3.2 • Review of existing Board development programme completed

• Corporate Governance Framework and underlying risk management processes agreed by Board and executive team

• Appointment of additional commissioners

• Decision taken on whether to create a unitary board structure

• Proposals for the assessment of strategic regulatory risk complete

• Lessons learned catalogue created

• Implement Board development programme following additional appointments


4. Develop CQC to be a high performing and learning organisation To improve the effectiveness and productivity of CQC, we need to invest more in supporting and developing our workforce. Our aim is to be a high performing and learning organisation, but we still have work to do to fully realise this. Merging three different organisational cultures has been more challenging and has taken longer than we expected, and our early decision to have an inspection workforce that is predominantly home-based presented significant challenges. We also recognise there is a significant amount to do in order to provide meaningful management information. We will take action in the following areas:

4.1 Ensure that resources are deployed effectively and that we can respond quickly to a rapidly changing environment In March 2012 we began to develop a workforce planning tool to help us determine, at a strategic level, the resources required to respond to a range of regulatory scenarios. This will help us to be transparent in the resources we need to reallocate to meet rapid changes in requirements and the cost of these, and to quantify the resource impacts of new organisational responsibilities.

4.2 Complete the integration of mental health act functions into the rest of CQC The internal management review of events at Winterbourne View found that there was little sharing of intelligence between agencies and internally between Mental Health Act Commissioners and local inspection staff. Whilst we have made progress in integrating mental health act functions into the rest of the organisation, though there is still much to do. The strategic review will consider how CQC reconciles and delivers against its full range of responsibilities and this will include responsibilities under the Mental Health Act (MHA). Integration of MHA business processes is continuing, while the associated development of IT systems is underway and will be complete during 2013/14. The integration of the related corporate services for MHA functions (finance, HR, procurement etc) is complete.

4.3 Build HealthWatch England as an effective organisation and develop strong relationships with local HealthWatch We regard the creation of HealthWatch as an excellent opportunity to further develop our understanding about the experiences of service users. We are continuing with the development of HealthWatch England (HWE), and are creating the processes necessary to work effectively with local HealthWatch


(LHW) organisations and use the relevant information that we gather from them. The HWE Chair will be appointed by June 2012 and we will have completed branding and website development in September 2012. HWE will be formally constituted in October 2012 so that it is ready to engage with local HealthWatch bodies as they are created. We will agree regulations for HWE that fit within our governance arrangements with the Department of Health, who are responsible for their enactment.

4.4 Learn from past experience and successfully deliver online registration for primary care services and other providers CQC has already begun an extensive programme of engagement with primary care services, for example by meeting with every Local Medical Committee (LMC) Chair. Work to register these services by April 2013 is currently underway, and progressing on schedule. Registration will begin in July 2012 using a new online registration system that we are developing. Once registration of primary care services is complete we will look to adapt the system and approach to provide an online experience for use by all providers registering with CQC.

4.5 Strengthen strategic planning, analytical capability and strategic risk management A dedicated team will be recruited to lead, coordinate and support strategic planning and analytical capability. However, in order to undertake the strategic review and define the new strategy, an internal team have been brought together and strengthened with external resource. We will continue to review the strategic capability within the organisation in response to specific needs such as the strategy review, and we will also review how our analytical capability can be used to inform strategic decisions.

4.6 Review inspector workloads, ensure that appropriate support is provided and that there is a positive organisational culture As part of the work to enhance the regulatory model, we have undertaken a large programme of staff engagement which has allowed us to reiterate our priorities and objectives and support staff. Values and behaviours have been developed by staff and these are being embedded through recruitment processes, objective setting, personal development plans and appraisal processes. Leadership principles have also been developed as a means of setting the tone for management behaviours and values. Further staff engagement will be undertaken as part of the strategic review, both to gather staff input during the process and to communicate the results. We will continue to track staff sentiment and will conduct a staff survey during the Summer of 2012. At an operational level we are upgrading the tools that we use to manage the deployment of resource. We are rolling out a new IT system (the ‘Activity Management System’) that allows more detailed recording of staff activity, which


in turn allows CQC to gain a better understanding of where efficiency gains can be made We will have developed a new quality and assurance framework by April 2013 and this will support the management of workforce effectiveness as well as the application of learning where most needed. We have recently delivered a large and extensive recruitment programme, and expect to have a full complement of inspectors in place by October 2012.

Conclusion We are improving how we access our own information, and how we then use it to plan and deploy our resources and measure our performance. We have learned lessons from previous registration efforts and are applying them to the registration of primary care services. We will take the opportunity provided by the creation of HealthWatch to capture more feedback from service users. We continue to work on the integration of Mental Health Act functions but realise there is more still to do.


The table below sets out the actions that we are taking to develop the organisation and when we will complete them:

Actions for this theme

2012/13 Sub Theme

Q1 Q2 Q3 Q4

2013/14

4.1 • Rollout of Activity Management System completed

• Strengthened internal governance arrangements for taking on new organisational responsibilities in place

• Staff communication improvements completed

4.2 • Joint working protocol between compliance teams and MHA commissioners reviewed and implemented

• Re-engagement of MHA Commissioners on CQC T&Cs completed

• MHA commissioners have increased use of CQC intelligence capability

• Confirmation of new role and management of SOADs, including expectations of professional revalidation and accreditation

Q4 IT system development completed

4.3 • Appoint HWE Chair

• HWE website, identity & branding completed

• Support & guidance package for LHW completed

• Systems and support for information sharing with LHW completed

• HWE formally constituted

• Pilot of information sharing completed

Q1 LHW organisations go live


4.4 • Continuing programme of engagement with primary care services

• Begin registration of primary care services

Q1 Primary Care service registration completed Plan developed for adapting primary care registration tool and processes for wider use

4.5 • Dedicated strategic planning and analysis team created

4.6 • Staff have better visibility of Board and executive team members

• Rollout of Activity Management System completed

• Resource planning tool completed and implemented

• Communication capability with front line staff strengthened

• 3-year resource plan completed

• Full complement of operations staff in place

• Conduct a staff survey

• Quality & assurance framework and reporting in place


Annex 1: Key actions Below is a summary of the key actions that will be delivered over time. Those in bold are primarily the responsibility of the Department of Health:

2012/13

Q1 Q2 Q3 Q4

2013/14

1 -

Stra

tegy

• Engagement with stakeholders to develop new strategy

• Public scorecard of existing success measures first published

• Decision taken on additional responsibilities for CQC

• Public consultation of CQC strategy completed


• Continuing communications with stakeholders on published strategy

Q1 Evaluation of success of external communication of strategy completed

2 –

Reg

ulat

ory

Mod

el

• Implementation of an enhanced ‘bank’ of clinical and professional associates and consistent guidelines for their use completed

• Dedicated team of Quality, Risk and Assurance managers created

• Implementation of new compliance regime completed

• Review of how enforcement powers have been used completed and recommendations made

• - First phase of targeted internal evaluation of CQC impact and effectiveness completed

• Interim internal evaluation of regulatory model changes completed

• Evaluation of use of clinical and professional associates completed

• Internal review of regulatory model changes completed & recommendations made

• Interim results for work with independent experts

Q2 Results from work with independent experts published


3 -

Gov

erna

nce

• Review of existing Board development programme completed

• Corporate Governance Framework agreed by Board and executive team

• Decision taken on whether to create a unitary board structure

• First DH quarterly accountability meeting with revised agenda

• Implement Board development programme following additional appointments

4 –

Org

anis

atio

nal C

apab

ility

• Appoint HWE Chair

• Continuing programme of engagement with primary care services

• Dedicated strategic planning and analysis team created

• Resource planning tool completed and implemented

• Full complement of operations staff in place

• Strengthened internal governance arrangements for taking on new organisational responsibilities in place

• Staff communication improvements completed

• Start registration of primary care services

• HealthWatch England formally constituted

• - Mental Health Act commissioners have increased use of CQC intelligence capability

• Quality and assurance framework and reporting in place

Q1 Local HealthWatch organisations go live Registration of primary care services completed


Annex 2: Mapping of the actions to the recommendations from the Performance and Capability Review

Recommendation Theme(s) Overview and Key Actions

1) The Department of Health, through the National Quality Board, needs to build on work already underway with CQC and others to develop explicit statements as to the distinctive roles of national bodies in assuring quality and providing incentives for quality improvement

1.1 Overview: In developing its new strategy, CQC will take account of the changing health and social care landscape.

2012/13

Q2: Public consultation of CQC strategy completed

Q3: CQC strategy completed and published

2) CQC’s strategy needs to be revised, explaining what role and impact its regulatory action is intended to have in specific sectors over time.

1.1

Overview: CQC’s revised strategy will explain the intended role and impact of its regulatory actions.

2012/13



3) Within CQC, action is needed to improve strategic planning and analytical capacity.

4.5 Overview: Strategic and analytical capacity will be boosted by the creation of dedicated team

2012/13

Q1: Dedicated strategic planning and analysis team created

4) Clearer measures of success and simple strategic performance metrics should be developed by CQC, working with the Department and other stakeholders, and then used rigorously to track performance.

1.2

2.5

Overview: CQC will commission an independent, external evaluation of its impact and effectiveness. This will be underpinned by improvements in the way management information is gathered and reported on.


2012/13

Q2: First phase of targeted internal evaluation of CQC impact and effectiveness completed


Q4: Internal review of regulatory model changes completed and recommendations made

Q4: Interim results for work with independent experts

2013/14

Q2: Results from work with independent experts


5) Priority should be given to work now underway to improve risk management and to assess how different regulatory options, including thematic reviews, frequency of inspections and possible focus on selected standards, can help to reduce risk.

2.1

2.2

2.3

2.5

3.2

Overview: A number of strands of work are aimed at improving the delivery of the regulatory model. Evaluation of these will be aided by CCQ’s revised corporate governance framework which will provide the basis for the consistent assessment of risk and regulatory decision making.

2012/13

Q1: Implementation of an enhanced bank of clinical and professional associates and consistent guidelines for their use completed

Q1: Corporate governance framework and underlying risk management processes agreed by the Board and Executive Team

Q1: Appoint director of knowledge and information management


Q2: Implementation of new compliance regime completed

Q: Evaluation of use of clinical and professional associates completed

Q3: Pilot of ‘soft’ information in risk analysis completed and findings reported


6) CQC needs to improve the quality and transparency of management information that is used to make resource allocation decisions.

4.1

4.6

Overview: A number of key initiatives will improve the quality and transparency of management information by the end of Q2

2012/13

Q2: Rollout of activity management system completed

Q2: Resource planning tool completed and implemented

Q2: 3 year resource plan completed

7) CQC to act to ensure that robust and costed plans are in place for taking on responsibilities; that these plans are the subject of independent test and assurance; and that they are agreed with the Department.

1.1

4.1

4.6

Overview: CQC will make improvements to the management information that it can draw on in order to better inform decision making

2012/13

Q1: Decision taken on additional responsibilities

Q2: Strengthened governance arrangements for taking on new organisational responsibilities in place




8) The Department should take steps to strengthen the Board and Board structures, including changing the Board so that instead of comprising only non-executives, it becomes a unitary board of majority non-executives with senior executives on the Board where they can be held to account.

3.2 Overview: CQC will evaluate the option of creating a unitary board and strengthen governance arrangements

2012/13

Q1: Decision taken on whether to create a unitary board structure

Q1: Agreement by the Board and executive team of the Corporate Governance Framework

Q1: Appointment of additional commissioners to the Board

9) CQC needs to review and reinstate the Board support and development programme.

3.2 Overview: The Board support and development programme will be evaluated and reinstated

2012/13

Q1: Completed review of existing Board development programme

Q1: Decision taken on whether to create a unitary board structure

Q2: Board development programme restarted following additional appointments

10) Capability at executive team level needs to be strengthened with greater strategic capability, and more and wider sector-specific expertise.

4.5 Overview: Organisational capability will be extended

Q2: Dedicated strategic planning and analysis team created

11) The Department should strengthen the arrangements for ongoing assurance and accountability of CQC in a way that

2.5

3.1

Overview: CQC will discuss and work with DH to improve arrangements for ongoing assurance and accountability


is consistent with CQC’s status as an independent regulator. 2012/13

Q1: Improvements to formal accountability relationship agreed between CQC Board and DH

Q2: First phase of targeted internal evaluation of CQC impact

Q4: - Interim results for work with independent experts

2013/14

Q2: Results from work with independent experts published


12) CQC needs to be more proactive and systematic in understanding the expectations of stakeholders and demonstrate it is a learning organisation.

1.1

4.3

Overview: CQC has initiated a number of pieces of work to engage with stakeholders and demonstrate it is a learning organisation

2012/13



Q3: Systems and support for information sharing with LHW completed

Q4: Pilot of information sharing completed

13) CQC should raise its game and take a lead in working more closely with other regulators within the health and care sector to increase joint effectiveness and reduce burden on providers.

1.1

2.3

Overview: CQC’s role within the health and care landscape and how it works with other regulators will be a key point of focus during the development of a new strategy.


2012/13


Q2: Information flows between HWE and CQC defined and agreed


14) Greater coherence and consistency is needed between the centre of CQC and its operational frontline, specifically, with the locally-based inspection teams.

4.1

4.6

Overview: CQC has improved communication in a number of ways and is ensuring that it understands workloads and challenges in front line inspection

2012/13

Q1: Staff have better visibility of Board members

Q1: Conduct a staff survey

Q2: Communication capability with front line staff strengthened

Q2: Rollout of activity management system completed

15) Links between the Mental Health Act functions and the rest of CQC need to be strengthened, including clearer metrics, information management and communications.

4.2 Overview: CQC continues to work towards the integration of MHA functions as appropriate

2012/13

Q1: Joint working protocol between compliance teams and MHA commissioners reviewed and implemented

Q3: MHA commissioners have increased use of CQC intelligence capability

2013/14

IT system development complete



16) CQC should set out clear plans for ongoing evaluation of the regulatory model and the effectiveness of individual interventions, including working with the Department to consider opportunities for joint evaluation under the Policy Research Programme.

2.5 Overview: CQC has clear plans in place outlining how it will evaluate its regulatory model

2012/13

Q2: First phase of targeted internal evaluation of CQC impact and effectiveness completed



Q4: Interim results for work with independent experts

2013/14

Q2: Results from work with independent experts

17) The regulatory model should make use of qualitative information in a systematic way, including drawing on patient and user insights gathered through HealthWatch England.

2.3

4.3

Overview: CQC continues to develop its capacity and capability in relation to the analysis and use of qualitative information. This includes consideration of the opportunities afforded by the creation of HealthWatch

2012/13

Q1: Appoint director of knowledge & information management

Q2: Simplified inspector access to regulatory risk information

Q2: Information flows between HWE and CQC defined and agreed

Q3: Pilot of ‘soft’ information in risk analysis completed and findings reported


18) CQC should be explicit about how far the compliance regime should be tailored to reflect the different risks and needs of different sectors and locations

1.1

2.2

Overview: During the review of its strategy, CQC will consider the principle of how the compliance regime should be tailored

2012/13


Q2: Implementation of new compliance regime completed


19) The Department should develop its capability and capacity on the regulation of safety and quality so as to provide ongoing challenge and support to CQC in developing its regulatory model.

3.1 Overview: CQC will work with DH to improve the formal accountability relationship

2012/13

Q1: Improvements to formal accountability relationship agreed between CQC Board and DH

20) CQC to review and implement improved access to sector-specific expertise for inspectors, specifically, inspectors should be able to call on patient, user or clinical expertise when they need it.

2.1

2.5

Overview: The use of and access to sector-specific expertise is at the heart of a number of initiatives underway within CQC

2012/13

Q1: Implementation of an enhanced bank of clinical and professional associates an consistent guidelines for their use completed

Q3: Evaluation of use of clinical and professional associates completed


Q4 - Internal review of regulatory model changes completed and recommendations made

21) Clear actions are needed by CQC to assure consistency and transparency in compliance activity and regulatory decision-making.

2.4 Overview: Consistency and transparency in decision-making will be aided by process and system developments as well as the introduction of specific roles focused on quality

2012/13

Q1 - Dedicated team of quality, risk and assurance managers created

Q2 - Update of IT systems and processes to allow better audit trails completed

Q3 - Start internal reporting of quality check outcomes and lessons learned

Q4 – Quality & assurance framework and reporting in place


22) CQC should develop and share with the Department plans for sustaining sufficient numbers of inspectors with the right skills and capacity to meet future priorities.

4.1

4.6

Overview: CQC will strengthen its resource and capacity plans through bespoke and ongoing analysis of management information

2012/13

Q2: Activity management system completed

Q2: Strengthened internal governance arrangements for taking on new organisational responsibilities in place


Q2: 3 year resource plan completed


23) On adult safeguarding, CQC should continue to work with local government and roll out staff training to improve local engagement and clarify roles, responsibilities and protocols.

2.6 Overview: CQC has made and will continue to make a number of changes to ensure that adult safeguarding arrangements are effective

2012/13

Q1: Common whistleblowing protocol agreed with BMA, RCN, GMC and NMC

Q1: Whistleblowing information included within the market report

Q2: Review of how enforcement powers have been used competed and recommendations made

Q3: Pursue further regulatory and enforcement powers

performance and capability review · performance and capability review of cqc, carried out between...

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