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					                                                Agenda Item: 7
                                          CM/04/11/04 Annex A




 Corporate Scorecard
 Performance
 Report
 2010-11 end of year performance review
 including Quarter 4 data




Report to:   Board


                            1
                                                            Agenda Item: 7
Prepared by:   John Lappin, Director of Finance and   CM/04/11/04 Annex A
               Corporate Services

Date:          5/18/2011




                                      2
Introduction
This report details our performance in 2010-11, our second year of operation as the Care Quality
Commission (CQC), and considers how our work this year has supported the achievement of our
priorities, to focus on quality and act swiftly to eliminate poor quality care,
and to make sure care is centred on people’s needs and protects their rights, and how we have
managed our resources and delivered our corporate functions.

The report is arranged as follows:

• Part 1 – Commentary reviewing CQC’s performance in the full year 2010-11

• Part 2 – Corporate scorecard performance report for 2010-11 - dashboard and scorecard - (including
Quarter 4)

During 2010-11 our performance was tracked in a monthly reporting cycle, through which the
Executive Team has kept an overview of delivery, issues and risks, to provide quarterly assurance to
the Board about our performance. This report does not aim to provide a wider review of our year's
work, which will be reported in the Annual Report and Accounts, due to be published in July 2011.

Performance reporting in 2011-12

We have developed a corporate scorecard for reporting from Quarter 1, as part of our 2011-12 to
2014-15 Business Plan. This is attached as Annex A. This will refresh this year's scorecard, to ensure
we remain focused on measuring the delivery of our delivery priorities, and through this, deliver our
strategic priorities; and the promises we have set out: focusing on quality and acting swiftly, being
proportionate, being open, working in partnership and involving people, and .

As part of the ongoing development of our performance measures, we have developed additional
measures on aspects of our involvement and communications work which play an important part in the
successful delivery of our objectives:
 • Experts by Experience involvement in our compliance activity
 • Availability of, and user satisfaction with, provider profiles
 • Provider surveys and satisfaction with CQC information

Data quality improvement

Performance reporting during 2010-11 has seen some change and improvement, both in responding to
data gaps or quality issues and aligning with CQC's changing registration and compliance remit, and
plans are in place within the M.I. project for further development early in 2011-12 in this important area.
Each performance report in 2011-12 will continue to include a commentary on data quality
improvements alongside the messages on organisational performance.




                                                       3
4
Part 1: Performance review 2010-11
Our work in 2010-11

This year has seen CQC delivering the significant tasks of registering new tranches of providers under the Health and
Social Care Act, carrying out ‘business as usual’ registration, and compliance and enforcement activities under two
systems, as registration under the Care Standards Act was replaced by registration under the Health and Social Care
Act.

We have experienced particular challenges in delivering aspects of our work as a result of re-registration of ASC
providers - the time we have taken to register new services and managers, and to process variations to registration has
proved a particular challenge, and as a consequence of our moving resource to support the re-registration process we
have undertaken less compliance activity in the year than expected. We continue to actively address these issues as
described later.

We have contributed to the development of significant Government proposals for changes to the NHS and to Arms
Length Bodies, including CQC. We have delivered significant structural changes within CQC, met Government
requirements regarding restricting recruitment and procurement activities, and contributed to Government efficiency
initiatives.

We have delivered our statutory functions regarding people subject to the powers of the Mental Health Act, and other
inspection functions.

We have also refocused our work on two strategic priorities:

o We focus on quality and act swiftly to eliminate poor quality care
o We make sure care is centred on people’s needs and protects their rights

These priorities are not new, but represent a refocusing, following changes in CQC’s functions over the year.

This section describes our achievements and areas for improvement in 2010-11.

Regulatory Activities

Registration and monitoring activity - Care Standards Act, April - September 2010:

• We undertook 13,809 social care inspections to assess and report on quality of services to the end of September.
• We registered 1,002 providers and 2,360 managers across adult social care and independent healthcare provision.

Registration and compliance activity Health and Social Care Act, October 2010 - March 2011:

• We re-registered 11,866 adult social care and independent healthcare providers;
• We registered ‘new in scope’ providers – 1,107 dental and private ambulance service providers (we remain on track
to process the majority of these by the end of June);
o We have undertaken preparatory work to commence registrations of primary medical care providers from 1 April
2012.
• We undertook 1411 compliance reviews (956 planned and 455 responsive) of providers (all sectors);
• Of 22 NHS providers registered with conditions, by the year end only 5 remained with conditions and during April
2011 a further 3 had those conditions lifted, leaving 2 of those NHS providers with conditions.
• We have undertaken over 500 enforcement actions (not including compliance actions - of which there were 201 in
Q4), and we prosecuted 3 charges relating to breaches of regulation, with one ongoing at the end of the year.

Other operational activity

• There were 1,565 mental health visits and 13,763 requests for a second opinion;
• 42 inspections were carried out to assess trust compliance with the Healthcare Associated Infections (HCAI);

                                                           5
• We undertook 49 joint inspections of children’s services with Ofsted;
• We undertook 85 pharmacy and controlled drugs inspections;
• We undertook a programme of special reviews and studies, focused on gathering intelligence about the quality of
care in order that we can target not just individual providers, but themes of improvement activity required.
• In Quarter 1 of 2010-11, experts by experience were involved in 168 registered service inspections, after which our
work focused on registration activity, and expert involvement continued to inform other activities: 138 experts by
experience were involved in the development of CQC policies, methodologies, pilots, publications, surveys, a review
and in training our staff.
• Mental Health Act work remains a critical part of upholding people’s rights. As part of the 1,565 mental health visits in
the year, 4,756 patients were seen by a MHA commissioner; of these, 225 returned a feedback postcard - 193 said
they found it useful to talk to a Commissioner and 85% overall returned a positive response.

Areas for improvement

The registration of new tranches of providers has impacted on other operational services with 'business as usual'
registration activity, such as processing variations, on hold from December 2010 to February 2011 to enable a focus on
issuing Notices of Decision. New ‘business as usual’ registrations were impacted by re-registration certificate
generation and technical issues which resulted in a delayed start to processing applications received. A registration
recovery project is underway with senior Operations management, focusing on providing additional resources, with
regional action plans in place to resolve current, and prevent future, backlogs. We are pleased to be able to report that
by Easter we had eliminated the backlog of applications received by 1 February, we will eliminate any further backlog
by the end of June and from July will process applications to an 8 week target.

The Operations directorate has initiated a significant implementation and modernisation review to consider all
processes and ways of working for efficiency and effectiveness. During 2011-12 the aim will be improved performance
and reporting as part of the benefits realisation to all internal and external customers.

Supporting activities

A risk-based approach to regulation means accessing information streams from across the sectors so we can act on
the intelligence we gather from the user voice and harder to reach sources, so our Quality Risk Profiles enable us to
target our activities. Information upload quantities to the Quality and Risk Profiles remained consistent, with all sectors
refreshed in each month of the final quarter. In the final upload of the year (March), 3% of the information uploads
indicated a very high or high risk rating. Regions review the information in the QRP and ascertain the correct action to
take, which includes undertaking the responsive reviews reported across the year.

It is also important that we continue to publish a large amount of our information, in order to enable people to
understand the quality of care available and make informed choices. Our website has received over 5.2 million visitors
this year and over 1.8 million inspection reports have been downloaded.

Throughout the year we published a number of statutory and other reports, as well as guidance. In Quarter 4 we
published the 2009-10 State of Care Report. We also published the final 2011-12 fees scheme, guidance and
consultation feedback report. Feedback on our mental health reports has been particularly positive.

We received 345,218 calls at the National Contact Centre, including 4,799 safeguarding calls - call volumes have
shown over 10% increase in the full year.

Stakeholders

In January and February we ran a survey of our monthly e-newsletter, which now has 35,961 subscribers. Over 200
people responded to the survey and 81% of those said they 'always' open and read the e-newsletter each month.

                                                       6
As we continue to address the issues and recommendations following our 2010 staff survey, work on internal
As we continue to address the issues and recommendations following our 2010 staff survey, work on internal
communications has continued to promote involvement and dialogue with our staff.

Financial and other resources

Within our financial management, we ensured that CQC ended the year to March 2011 within budget and forecast
expenditure and cash limits agreed with the Department of Health.




The cumulative expenditure (revenue, transition and capital) to the end of the year was £177.0m against a budget of
£198.3m. Subject to revaluation of assets, IAS19 pension adjustment, final audit and publication in the Annual Report
and Accounts.The Recurring budget for the year was under spent by £18.9m which is largely due to the initiatives
announced by the coalition government in May 2010. A freeze on recruitment meant CQC carried a high number of
vacancies and therefore under spent on staff costs by £8.2m. A similar freeze on consultancy ensured an under spend
of £3.4m. Both under spends are evidence that CQC achieved the government objective and delivered the required
savings. Capital charges is provisionally under spent by £6.6m (awaiting the revaluation of assets), a reduction in
anticipated capital expenditure and assets brought into life later in the year than expected have both reduced the
depreciation charge for the year.

The Transitions budget for the year was fully utilised as expected. The main expenditure related to redundancies
following internal restructures (£9.2m) and the registrations programme (£7.2m).

Capital Expenditure was under spent by £2.4m in the year, mainly due to efficiencies achieved in external labour and
project management costs.

Income for the year was over budget by £1.8m, this is due to a combination of lower than expected deregistered
services and a high volume of registration variations received.

Underpinning the operational activity we have delivered this year, we have effectively managed our corporate services
to ensure an efficient service has been provided. We have ‘retired’ one legacy IT system, ICAP, moving our operations
to the CRM system. We have seen ongoing improvement in our governance systems and information handling. We
have continued to deliver our Estates strategy, which in 2011 will see a smaller estate and continued efficiency in how
we use space.

Change

We have introduced significant changes to our field force roles and re-organised our headquarters structure and roles
within it, in order to align our frontline and supporting functions with our new regulatory model.

At the end of the year we continue to scope new projects and programmes which will further strengthen our delivery in
2011-12, with an Operations Implementation Review programme which will incorporate the ongoing work on mental
health modernisation and shared services transformation - work to re-align these programmes is reflected in our
reporting on them in the scorecard.

We have also made significant contributions to the wide-ranging proposals in the NHS White Paper and the arm’s
length bodies (ALB) review: these proposals will lead to the creation of Healthwatch England within CQC by 2012, and
the integration of certain functions of the Human Fertilisation and Embryology Authority, Human Tissue Authority, and
National Information Governance Board for Health and Social Care into CQC.

The MI and Performance Reporting project which is focused on reviewing future reporting requirements and the
development of associated MI. This project remains focused on the priority operational reporting areas, and is actively
managing resourcing issues across the MI development workstreams. New and improved data sources identified for
delivery through this project will inform the operational measures reported in this scorecard as we move into 2011-12;
at the end of the year we have not been able to establish an accurate position across a number of operational activities,
and the MI&PR project remains focused on trying to bring about rapid improvements.
                                                              7
and the MI&PR project remains focused on trying to bring about rapid improvements.




                                                         8
            Part 2: Corporate Scorecard Performance Report 2010-11 -
                                including Quarter 4
                                                             Performance Dashboard:
                                                                      Specific highlights from Quarter 4
Part 1 of the report gave an overview of the year's performance. Specific highlights from the final quarter, 1 January to 31 March, are:
● Overall, Quarter 4 performance has been consistent with that reported at Quarter 3. The challenge of delivering a large number of new and re-registrations of
providers has had an impact on processing of 'business as usual' registrations, and work has been undertaken to address delays and backlogs. Some ongoing
data availability issues affect the details in this report, clearly indicated throughout in relation to enforcement, compliance and mental health.
● We have been working to finalise the registration of the ASC and IHC providers; by the end of March, 12,007 providers had applied to re-register, 11,866 had
been issued with all Notices of Decision, and 11,573 had certificates issued. Some providers had not applied to register and these cases are being investigated.



● After commencing for social care and independent healthcare providers in October, compliance activity continued across Quarters 3 and 4, with 838 planned
reviews undertaken (30% of those scheduled).
● We published the final 2011/12 fees scheme, guidance and consultation feedback report and the State of Care 2009-10.
● Key areas which have experienced performance issues this quarter are the Contact Centre, with call handling affected by peaks in registration queries, and
ongoing performance issues across MH Second Opinions due to resource issues.
● Resource issues also affected the reviews and studies projects, and are impacting on the Future of Care programme which will be a key area of delivery to
monitor in 2011-12.


                                                               1. Regulatory Activity
Objective                                                                                              Q1          Q2           Q3           Q4         Trend*
1.1.1 Registration of providers                                                                         A           A           A/G         A/G           D
1.1.2 Manage the re-registering of providers                                                            A           A            A           A            D
1.1.3 Manage the registering of dental and private ambulance providers                                                                       A
1.2 Deliver programme to monitor compliance                                                            A            G            A          A/R           
1.3 Assessing the quality of health and social care provision and commissioning                        A            A            R           R            D
1.4 Deliver Mental Health Act / SOAD visiting effectively                                              R            R            R           R            D
1.5 Deliver other statutory inspection responsibilities                                                G            G            A           A            D
1.6 Publish information on quality of health and social care services                                  A            A            G           G            D


                                                              2. Supporting Activities
Objective                                                                                              Q1          Q2           Q3           Q4         Trend
2.1 Shared Services Centre - call handling times                                                       G            G           A/R           R           
2.2 EDHR compliance                                                                                    G            G            A            G           
2.3 Communications                                                                                     G            G            G            G           D


                                                                    3. Stakeholders
Objective                                                                                              Q1          Q2           Q3           Q4         Trend
3.1 Effective and well supported workforce                                                              A           A            A            G           

                                                       4. Financial and other resources
Objective                                                                                              Q1          Q2           Q3           Q4         Trend
4.1 Income/ expenditure is controlled and planned                                                      G            G            A            A           D
4.2 Develop IS and ICT                                                                                 G            G            G            G           D
4.3 Deliver high standard of corporate governance                                                      A            A            A            A           D


                                                                         5.Change
Objective                                                                                              Q1          Q2           Q3           Q4         Trend
5.1 Deliver Registration Programme                                                                    A/R           A            A           A            D
5.3.2 Deliver HQ Review Programme                                                                      G            A            A         Closed
5.4 Deliver Shared Service Transformation Programme                                                    A            G            G         Closed
5.5 Deliver Modernising Mental Health Act Programme                                                    A            A            A          A/R           


* Trend compares current quarter to previous quarter
                                                                               9
10
                                           Performance Scorecard: Quarter 4 (1 January - 31 March 2011)
                                             **DRAFT**   CQC Balanced Scorecard - May 2010   **DRAFT**


                                                                                     1. Regulatory Activity
Objective                                                   Target   Q1        Q2       Q3       Q4      Trend Supporting detail

1.1.1 Registration of providers (business as usual)

                                                                                                                Due to the impact of ASC re-registration and technical issues combined with high
% of registrations completed in set time period (adult                                                          volumes of applications, rejections and resubmissions, a backlog built up from Q3 and
                                                             90%     90%      92%
social care)                                                                                                    processing times increased. A registration recovery project has been addressing these
                                                                                                                issues and by Easter a backlog of applications prior to February was cleared. By the
                                                                                                                end of June any subsequent backlog of applications will be cleared. From 1 July, CQC
                                                                                                                will introduce an 8 week target for busienss as usual registration processing, and will
% of registrations completed in set time period
                                                             90%     45%       53%                              monitor and report progress through its Operations managemeent, Executive and
(independent healthcare)
                                                                                                                Board.


1.1.2 Manage the re-registering of providers (adult social care and independent healthcare)
Total number of providers served with all Notices of
                                                            12,007      0     9,922    11,451   11,866     
Decision                                                                                                        The 12,007 target represents applications received, with the Q4 figures showing a
                                                                                                                cumulative position; the cessation date for incoming transition applications was 18
                                                                        0     40,043   44,865   49,326     
Total number of Notices of Decision issued                                                                      March. Applications are outstanding for a few providers which are being followed up and
                                                                                                                if necessary appropriate enforcement action will be taken.
Total number of certificates issued                                     0       0      5,240    11,573     




1.1.3 Manage the registering of dental and private ambulance providers

                                                            8,203       n/a    n/a      n/a     1,107          This tranche of new registration activity has been impacted by the availability of CRB
Total number of providers served with Notices of Decision
Total number of Notices of Decision issued                              n/a    n/a      n/a     4,461      
                                                                                                                checks for dental practitioners. Close working with PCTs and DH has enabled this to be
                                                                                                                progressed and lessons learnt are being considered to inform GP practice registrations
Total number of certificates issued                                     n/a    n/a      n/a      NR             in 2011-12.


1.2 Deliver programme to monitor compliance

                                                                                                                In 2010-11, 13,809 CSA inspections were carried out. Cessation of the CSA means
CSA inspections vs plan                                      90%     82%      100%      na       na
                                                                                                                inspection activity at October, superseded by compliance reviews under the H+SC Act.

                                                                                                                Compliance activity in Q1 and 2 was applicable to the NHS only. From October ASC
Planned compliance reviews completed vs. plan               4,385       0       0       118      838       
                                                                                                                and IHC sectors as well as NHS were subject to this activity. Numbers of compliance
                                                                                                                reviews increased in Q4 following the previous quarter's focus on ASC re-registration
                                                                                                                and training for monitoring compliance under the H+SC Act. 838 of 2,826 planned
Responsive reviews completed vs. plan (plan/target figure
                                                            1,447       1       8       116                
                                                                                                                compliance reviews (30%) and 330 responsive reviews were completed in Q4 for all
refers to available capacity to carry out responsive                                             330
                                                                                                                sectors.
reviews)

                                                                                                                Of the 22 NHS providers registered with conditions all except 2 have had all conditions
NHS provider conditions reduce over time                     <22        18     10        9        5        
                                                                                                                removed as at April 2011- at 31 March there were 5.

                                                                                                                201 compliance actions were also carried out in Q4. Not previously reported under this
No. enforcement actions in period                                    171       74       13       252       
                                                                                                                KPI, compliance actions are relevant to enforcement.


1.3 Assessing the quality of health and social care provision and commissioning

                                                                                                                Resources for the two remaining reviews have been redirected to develop the new
                                                                                                                themed approach which includes the reprioritisation of topics previously identified as
Reviews and Studies - project status                        100%        G      A/R       R        R        D    subjects for review. This has resulted in a loss of knowledge and expertise on the two
                                                                                                                remaining reviews, but these risks to timescale and content continue to be managed
                                                                                                                and mitigated under senior leadership. These are the last two remaining outputs from
                                                                                                                the legacy approach and are scheduled to publish in June & July.


1.4 Deliver Mental Health Act/SOAD visiting effectively
                                                                                                                Visits: In Q4 the quarterly target was exceeded resulting in overall yearly performance
Mental health visits completed vs target                    100%     83%      100%      66%     100%           of 90% against target. 1,567 Mental Health Act Commissioner visits were completed of
                                                                                                                the scheduled 1744. The performance issues in year were caused by a number of
                                                                                                                Commissioner vacancies and sickness absences. Second opinions: across the full year,
% Second Opinions completed within set time                 100%     31%      36%       42%     36%            13,763 second opinions were completed, of which 4,953 were within the target
                                                                                                                processing time.


1.5 Deliver other statutory inspection responsibilities

                                                                                                                During Q4 36 IR(ME)R inspections and 181 Pharmacist inspections were completed.
% inspections completed vs plan                             100%        G       G        A        A        D    Due to resource issues, a number of inspections had to be postponed to enable the
                                                                                                                team to concentrate on handling the statutory notifications.


1.6 Publish information on quality of health and social care services
                                                                                                                Mental health publications were a key focus in the quarter. We continued to roll-out
% key publications on target                                100%        A       A        G        G        D    registration documents. We also published the final 2011-12 fees scheme, guidance
                                                                                                                and consultation feedback report and the State of Care 2009-10.

                                                                                    2. Supporting Activities
Objective                                                   Target   Q1        Q2       Q3       Q4      Trend Supporting Detail
2.1 Shared Services Centre - call handling times



                                                                                                   11
                                          Performance Scorecard: Quarter 4 (1 January - 31 March 2011)
                                            **DRAFT**   CQC Balanced Scorecard - May 2010   **DRAFT**
                                                                                                                  Of 345,218 calls received, 250,177 have been answered within the 20 second target,
                                                                     92.1%     96.4%     57.3%     60%            3,876 of these were Safeguarding calls.The queries received at the Contact Centre
Call handling within target 20 seconds                        80%                                            
                                                                     74,072    82,471    49,755   43,879          when registration application windows opened or provider correspondence was issued
                                                                                                                  significantly impacted call length and response times in Q4. Steps are being taken to
                                                                                                                  work more closely with the communications team to manage the responses to provider
                                                                                                                  communications. In Q4 technical systems issues outside our control and a building
                                                                     96.4%     95.9%      72%      69%            move contributed to the lower performance levels, however were resolved and
Safeguarding call handling within target 20 seconds           90%                                            
                                                                      1045      1117      951      763            performance by the middle of April was above target levels.


                                                                                                                  No longer reported separately as service included in overall registration lifecycle
Registration processing vs target                              G       G         G         NR      NR       D
                                                                                                                  reported at 1.1 above.

2.2 EDHR compliance


                                                                                                                  The current status of the actions being delivered in the strategy break down as: 55
                                                                                                                  green, 19 amber, 3 red, 6 removed due to a change in CQC's remit; an overall move
Delivery of EDHR strategy on/ off target                     100%      G         G         A        G        
                                                                                                                  from Amber to Green in Q4. We have refreshed the action plan for 2011-2012 which will
                                                                                                                  form part of our Equality and Human Rights scheme annual report to the Board in May.

                                                                                        2. SUPPORTING ACTIVITIES
2.3 Communications

Visits to website                                              -     1.4m       1.2m      1.3m    1.4m      D     Consistent across the year, with a total of 5,227,873 visits in 2010-11.



                                                                                          3. Stakeholders

Objective                                                   Target    Q1        Q2        Q3       Q4      Trend Supporting Detail

3.1 Effective and well supported workforce
                                                                                                                  Permanent staff 1757 against target establishment of 1915. Vacancy figures shown are
Permanent staff (as at end of quarter)                      1,915    1,929     1,888     1,791    1,757           vacancies that were advertised in the quarter. Can include posts filled by the end of the
                                                                                                                  quarter, re-advertisements and project roles not part of the target figure of 1915, hence
                                                                                                                  permanent staff + vacancies does not sum to 1915. Q4 vacancy rise due to HQ review
No. vacancies (as at end of quarter)                                   61        25        15      263            closing and delegation to CQC of recruitment controls. Turnover shows two peaks at Q2
                                                                                                                  and Q4 owing to restructuring - Field Force and HQ Review. Sickness absence is
                                                                                                                  consistent across the whole year - reflects number of sickness absences recorded on
                                                                                                                  CQC's systems by managers. We continue to work to ensure full compliance with these
Turnover rate (leavers divided by total staff x 100)         1.13%   0.88%     2.33%     0.77%    2.27%
                                                                                                                  reporting systems.

                                                                                                                  The overall RAG status in the dashboard has moved to green, reflecting a number of
Sickness absence (quarterly average)                                 2.61%     2.94%     2.44%    2.59%
                                                                                                                  achievements in the HR area, including the roll out of a new PDR process, and a set of
                                                                                                                  Values and Behaviours, as well as the conclusion of the HQ review process, and
Staff grievances upheld                                               NR         0         1        0             continued work to take forward actions arising from our last staff survey.



                                                                              4. Financial and other resources
Objective                                                   Target    Q1        Q2        Q3       Q4      Trend Supporting Detail
4.1 Income/ expenditure is controlled and planned

                                                                                                                  Figures show the favourable variance reported across the year was maintained through
On/ off target within capital, revenue, transition          Variance £10.4m £14.6m £19.5m £21.2m            D
                                                                                                                  to the end of the year, with a year end final position of £21.3m favourable variance.

                                                                                                                  Staff costs of all Directorates except Intelligence and Operations, as a % of all staff
Cost of staff in supporting functions as a % of all staff            25.1%     24.3%     24.3%    20.7%      
                                                                                                                  costs.

4.2 Develop IS and ICT
% ICT service incidents closed within target                  99%    99.6%     99.7%     99.7%    98.9%     D



4.3 Deliver high standard of corporate governance
                                                                                                                  In Quarter 4, 98.7% of FOI requests were closed in target time, and 100% of all other
Information requests closed within target time               100%    94.4%     96.8%     94.3%    99.5%      
                                                                                                                  requests
Requests for internal review (complaints against FOI and
                                                               0       7         6         0        6        
DPA decisions)
Serious Untoward Incidents reported to Information
                                                               0       2         2         0        1            Single complaint in Q4 was subsequently withdrawn
Commissioner's Office (information handling)

Health and Safety - no. of workplace accidents                        NR       8 YTD       9        6            6 incidents were reported in Q4: 4 office based and 2 involving homeworkers

Stage 1 complaints received                                            27        25       142       30           In Q3 Stage 1 complaints data was all CQC, other quarters it was the number dealt with
                                                                                                                  by the central team - this wider picture of Stage 1 complaints will be reported again in
Stage 2 complaints received                                            14        9         17       11           the future but only when accuracy can be fully assured.

Parliamentary Ombudsman referrals                                      1         0         5        5       D     No complaints taken to independent external investigation



                                                                                                5.Change
                                                                                  4. FINANCE & OTHER RESOURCE
Objective                                                   Target    Q1        Q2       Q3     Q4   Trend Supporting Detail
5.1 Deliver Registration Programme
Programme progress - % milestones achieved                   100%     A/R        A         A        A       D

Tranche 1 - NHS                                                                                                   The NHS registration tranche closed in this quarter.
                                                                      NR        A/G        A      Closed    D

                                                                                                                  There are significant business as usual issues and transitional processing has been
                                                                                                     12
                                                                                                                  backlogged at shared services with a recovery plan in place. Processing delays have
                                                                                                                  been experienced as a result of the CRB checks required for dental and private
                                                                                                                  ambulance providers; up to the end of the year, 1,107 of these providers had received
                                                                                                                  Notices of Decision, of the 8,203 received applications.
                                                   CQC Balanced Scorecard - The NHS registration March 2011)
                                     Performance Scorecard: Quarter 4 (1 January - 31tranche closed in this quarter.
                                       **DRAFT**                            May 2010              **DRAFT**
Tranche 2 - ASC/ IHC                                                                        There are significant business as usual issues and transitional processing has been
                                                              NR   A     A/G    A/G     D
                                                                                            backlogged at shared services with a recovery plan in place. Processing delays have
Tranche 3 - Dental practitioners                                                            been experienced as a result of the CRB checks required for dental and private
                                                              NR   A     A/R     A      
and private ambulances                                                                      ambulance providers; up to the end of the year, 1,107 of these providers had received
                                                                                            Notices of Decision, of the 8,203 received applications.
Tranche 4 - GP Practices
                                                              NR   A/G   A      A/G     


5.3.2 Deliver HQ Review Programme
                                                                                            The programme was formally closed in March following committee consideration of the
Programme progress - % milestones achieved vs target   100%   G    A     A     Closed   D   closure and handover materials.

5.4 Deliver Shared Service Transformation Programme

                                                                                            Programme closed in Quarter 4, pending realignment with the wider programme of the
Programme progress - % milestones achieved vs target   100%   A    G     G     Closed   D
                                                                                            Operations Implementation Review

5.5 Deliver Modernising Mental Health Act Programme
                                                                                            The Mental Health Modernisation programme is current at Amber/Red status due to
Programme progress - % milestones achieved vs target   100%   A    A     A      A/R     
                                                                                            rescoping and re-visioning activity currently underway, linked to the Operations
                                                                                            Implementation review. The programme governance structure is under review and
                                                                                            a change of programme management responsibilities is taking place.




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Annex A
The attached Annex shows the Performance Reporting Scorecard for the year 2011-12
(subject to final agreement with the DH).

This refreshes this year's scorecard, to ensure we focus on the achievement of our delivery
priorities, and through doing so, the delivery of our strategic priorities and promises.

Enhancements to the scorecard next year include:

Reporting on the more stretching target of 8 weeks to complete business as usual
registrations - from 1 July;

Reporting on the number of site visits we undertake, and whether we publish reviews to
target time;

Number of experts by experience we involve in site visits;

Accuracy and timeliness of provider profiles - from the mid year point

Number of Stage 2 complaints upheld - with a target of less than 10%

Together with reporting on new areas of work for CQC, such as the registration of general
medical practices.

In addition, we are continuing to work to develop new measures that reflect further the
impact of user voice in our work, and we will regularly report to the Board on our progress in
doing this.




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