Agenda item: 7

Ref: ET/05/11/05

BOARD MEETING – 14 SEPTEMBER 2011

QUARTER 1

CORPORATE PERFORMANCE REPORT

(INCLUDING JULY UPDATE)

ISSUE

1.To provide to the Board a reportonour corporate performance in Quarter 1 (April, May and June 2011).

RECOMMENDATION

2.The Board is asked to NOTE and COMMENT ON the performance issues outlined.

BACKGROUND

3.The Quarter 1 Corporate Performance report is intended to review CQC performance across the first quarter of the 2011-12 reporting year, considering both areas of successful delivery but also under performance. Given the timing of this Board meeting, the report also specifically includes an update on performance in July.

KEY ISSUES

4.The attached report (Annex A) shows the first quarter performance to the end of June 2011, updated to include July 2011. The scorecard shows that across most areas good performance is being achieved. In particular we have made good progress in the registration of Tranche 3 Dental providers, whilst working at the same time to improve our performance on BAU registrations. 85% of our NHS planned reviews have been completed. We completed the Dignity and Nutrition inspection programme; have started the Learning Disability Programme; and are planning our Domiciliary Care reviews. We have carried out increased enforcement activity and responded to greater volumes of contacts following the Panorama programme. A summary of the key issues arising, together with a commentary specifically on those areas where under performance is being reported is provided below :-

Overview

  • Registration Programme - Tranche 3: 79% of Dental and Private Ambulance new in scope providers have now been issued with NoDs and 53% have had certificates issued by the end of July. Operations will process the remaining T3 applications by 1 October 2011.
  • Registration Processing - BAU: The percentage of BAU applications completed within the 8 week target is 54% as at the end of July, against a target of 60% (80% target by the end of Q2). The aim is to move to a target of 90% within 8 weeks, but this is being done in stages, as the target is significantly shorter than that of the previous organisations. There is renewed focus on eliminating the registration backlog, due to better reporting enabling Operations to track the 8 week timescale.
  • Compliance monitoring: The total number of planned reviews undertaken in July was 690 and the total number of responsive reviews was 304. The majority of both types of reviews undertaken were for ASC/ IHC. 85% of the planned reviews for the NHS have been completed, with some months to go until the two years anniversary of initial registration of NHS providers in April 2010.
  • Enforcement: The number of warning notices served more than doubled in July (79 in July compared with 35 in June). This is likely to be due to better reporting on CRM and an increased enforcement focus across regions. Additional enforcement action was taken as a result of a programme of unannounced inspections following the Winterbourne View BBC Panorama Programme. In addition we have responded to increasing volumes of whistle blowing contacts.
  • Call Handling: All call handling targets were achieved in July. There have been a total of 601 whistle blowing enquiries received since the whistle blowing team was created. 370 of the enquiries were received in July (231 in June).
  • On 5 July we started publishing full registration details for independent health and adult social care providers on our care directory. This means the public will be able to find more detailed information about care homes, domiciliary care agencies and independent healthcare providers on our website.
  • The volume of vacancies carried by CQC is still contributing to the under spend. Recruitment of Compliance Inspectors from August will help reduce the monthly under spend.
  • MI Reporting – Phase 1 of the project to improve Operations MI was completed at the end of June. More reliable and timely reports across registration (BAU), Compliance and Enforcement are now being supplied weekly and monthly to ET. Putting this data into a more accessible electronic dashboard, enabling drill down to a detailed level of information is advanced and will be available on the desktops of the Operations Management Team over Q2.

Areas of under performance

Registration – Business as Usual

  • (2.4) Applications completed within 8 weeks:
    The new MI data is improving the quality of information received by Operations. A focus for the new Interim Head of Registration is to improve performance in this area. Recruitment to Registration Assessor vacancies will provide additional capacity to help the regions achieve the target, with improvements anticipated over the coming quarter.

Deliver Programme of Compliance Reviews

  • (2.5) Planned reviews completed vs. those scheduled:
    The new compliance methodology will result in all NHS trusts and 75% of all other sectors receiving a review on a risk based basis.
  • (2.7) The % of draft compliance reports issued to timescale:
    Work is underway on the Management Information for this indicator to provide a better in-depth analysis and an action plan will be drawn up from this.

The poor performance is largely due to data errors which are being addressed. Until the data is improved, it is difficult to ascertain when the Rag status will become Green.

  • (2.10) % of site visits that involve Experts by Experience/ Acting Together:
    There are a number of improvement measures in place -

Though a provider dropped out of the new contract, a replacement has now been found

Experts by Experience are undergoing training sessions

A number of requests for EbE September and October visits are increasing.

Mental Health

  • (4.2-4.4)% Second Opinions completed within set time. There is an agenda item at this Board meeting that will discuss a number of Mental Health issues including a range of options addressing performance improvement methods for SOADs.

LINK TO STRATEGIC OBJECTIVES & BUSINESS PLAN

5.The corporate performance report provides evidence to the Board on how well CQC is delivering its activities and its strategic priorities.

RESOURCE AND RISK IMPLICATIONS

6.None specific to the performance report itself. Resource issues are highlighted at various points in the report.

RECOMMENDATION

7.The Board is asked to NOTE the attached Q1Corporate Scorecard Performance Report, which includes an update on performance in July 2011.

NEXT STEPS

8.Monthly reporting to the Executive Team, via the Business Delivery Authority will continue, enabling scrutiny of performance and management of related risks and issues. The next quarterly report to the Board will represent the Quarter 2 (2011/12) position.

John Lappin

Director of Finance and Corporate Services

14 September 2011

Annex A –Quarter 1 Corporate Performance Report (including July update)

Annex B – Strategic Risk Register

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