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					                                                                   Agenda item: 8
                                                                   Ref: CM/02/10/05

                           BOARD MEETING – 19 MAY 2010



  1. To provide to the Board the Quarter 4 Corporate Performance Report, including
     2009-10 impact report.


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


  3. The corporate performance report for Quarter 3 was reported to the Board in
     February 2010. Since that time work has continued to support better reporting in the
     current year and over the life of the Five Year Strategy.


  4. It was reported to the Board in November 2009 that CQC‟s performance information
     remained stronger on inputs and activity volumes than on measures of the quality of
     our activity and outcomes. Some better outcome measures have been developed to
     inform this year end report, working with colleagues across all directorates. However,
     work is ongoing to develop CQC‟s performance reporting systems .

  5. The Operating Committee and Executive Team have reviewed the evidence that
     supports the attached report, providing a selection of activity highlights and
     commentary on the impact of our work.

  6. Elements of the performance information contained within the attached report will
     also be reflected in the Annual Report a nd Accounts, due to be published in July


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


  8. Quarterly reporting to the Board will continue, subject to improvements linked to the
     planned performance development work.

   9. The Board is asked to NOTE the attached Corporate Performance Report and the
      ongoing work to develop better reporting measures and manage identified risks and
      issues to resolution.

ANNEX – Corporate Performance Report to 31 March 2009 (Quarter 4), including 2009-10
impact report.

Jamie Rentoul
Director of Regulation and Strategy
7 May 2010
Quarterly report for Board overview covering
period 1 January – 31 March 2010, including
2009-10 impact report
Corporate Performance Report – Introduction and contents

This report details our impact, achievements and limitations in 2009 -10, our first year of operation as
the Care Quality Commission (CQC), and considers how our work to date has support ed the
achievement of our five priorities:

       Making sure that care is centred on people's needs and protects their rights: we want
        people to be able to shape their own care.
       Championing joined-up care: we will look at how well health care and social care services
        work together.
       Acting swiftly to eliminate poor quality care: people have a right to expect that, if a
        service falls below essential standards of quality and safety, this is identified and acted on
       Promoting high quality care: where we see that care is improving, we will tell other
        organisations that provide or buy care so they can learn from what is working well.
       Regulating effectively, in partnership: we will work with other organisations to improve the
        quality of life for communities and local people.

We also describe our corporate performance in Quart er 4 (1 January – 31 March 2010) and
summarise the key performanc e trends and issues across our first year.

The contents of this Corporate Performanc e Report are:

       Part 1 – Our impact in 2009-10 (page 3)

       Part 2 – Performance information, Quarter 4 (1 January – 31 March 2010) (page 8)

Part 1: Our Impact in 2009-10

Our five year strategy 2010-15 sets out an ambitious set of priorities and describes the shift
in the quality of care we want to see. Our activities in 2009-10 are described in Part 1 of
this report in the context of these priorities and what we have achieved to date as we enter
2010-11 the first year of the strategy. We also describe the issues we have managed, and
those which may impact on our work in 2010-11. Part 2 of the report focuses in more detail
on the performance of each activity area.

The task of creating a new organisation is a significant one. To support the new system of
registration we have been restructuring our field force and will review our headquarters
activity to ensure we are in the best shape to deliver our responsibilities next year. As well
as taking on and successfully delivering a substantial programme of „business as usual‟
work inherited from our predecessors through a lot of hard work, commitment, planning
and co-ordination from people across CQC we have put in place a system that has been
successful in registering NHS services, with a huge task ahead as we continue the
registration process, ongoing monitoring of compliance and embedding the structural
changes needed to support it.

Eliminating poor quality care and promoting high quality care

At the heart of the work we do is a focus on the quality of care that people receive. There
are two main elements to our work here; ensuring that essential standards are met by
service providers, and assessing the quality of care over and above those essential
standards. We have combined legacy work with implementing the new system of
registration – delivering on both fronts. A substantial body of work has been carried out
relating to assessment of quality – describing a broader view of the quality of care.


   Care Standards Act: we registered 2,240 providers; 4,754 managers; and dealt with
    993 major and 524 minor variations. We undertook 741 independent healthcare
    inspections and 11,477 social care inspections to assess and report on quality of
   There were 1504 mental health visits and 15,288 requests for a second opinion;
   The annual assessments for commissioners (PCTs and councils) and NHS providers
    were completed on time;
   250 inspections were carried out to assess trust compliance with the Healthcare
    Associated Infections (HCAI);
   We undertook 20 joint inspections of children‟s services with Ofsted, inspections with
    13 Youth Offending Teams; and 1075 pharmacy and controlled drugs inspections;
   IR(ME)R - 483 exposures “much greater than intended” were investigated;
   CQC has six special reviews underway 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. Special review findings will feed into registration
    processes for organisations that provide care. The results will be published in 2010-11.
   We developed, consulted on and delivered a new system of registration and registered
    378 NHS trusts under the 2008 Act, 22 conditional on improvements being made. We
    commence 2010-11 having already identified areas of care which do not meet the
    essential standards we wish to see. Our knowledge about the performance of NHS
    organisations will grow as our profiles of quality and risks expand and improve.

What impact has there been on services?

   As at 8 April 2010, there are 5059 excellent (2009: 4175), 15716 good (2009: 14555),
    2623 adequate (2009: 4075) and 321 poor (2009: 424) adult social care services.
   The annual assessments for commissioners (PCTs and councils) and NHS providers
    reported in 2009 showed an increase in good and excellent services, and a decrease in
    poor or weak services.
   9 out of 10 Trusts initiated improvements in preventing and controlling infection as a
    result of our inspection. The Trusts we inspected fed back that the process was useful
    and proportionate.
   CQC prosecuted 11 charges relating to breaches of regulation and issued 5 cautions in
    lieu of prosecution. We successfully prosecuted 10 charges relating to carrying on
    services while unregistered.
   HCAI powers - we issued 5 Statutory Warning Notices - our first enforcement actions in
    the NHS.
   Within the NHS, performance improvements included more people seen in A&E within
    four hours, more receiving treatment within 18 weeks of referral, more screened for
    Chlamydia and reductions in MRSA and clostridium difficile cases.

Ensuring care is centred on people’s needs and protects their rights, championing
joined-up care (and involving people in our work)

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
sources, so our Quality Risk Profiles enable us to target our activities. It is also important
that we continue to publish a large amount of our information, we aim to enable people to
understand the quality of care available and make informed choices.

   People were involved in our work in a variety of ways particularly in consultation on
   Continued „expert by experience‟ involvement in inspections means we have a user
    focus on the assessment of the quality of care: in 2009-10, involvement in 543
    registered service inspections and 34 council service inspections.
   2009 outpatient surveys undertaken which show significant improvements in most
    aspects of patients‟ experiences of outpatient care and treatment since the last surveys
    in 2003 and 2004.
   Mental Health Act work remains a critical part of upholding people‟s rights. 1504 mental
    health visits in 09-10 covered every mental health service provider in England and
    4934 patients were seen, with a further 15,288 second opinion requests handled.
   We have had regular contact with 800 local organisations representing people who use
    services and their carers. Speak Out networks have expanded from 20 to 80 and will
    provide increased input, from harder to reach groups, to our reviews and studies;
   Call handling at the National Contact Centre improved from 67% in Quarter 1 to 98.6%
    in Quarter 4. 1100 safeguarding calls were received each quarter, and we operated a
    service above our targets for handling those calls. In the year, 1484 calls were taken by
    the out of hours service and 60 of those calls were escalated to the on call officers.
   The state of health care and adult social care in England identifies that there have been
    great improvements in aspects of health and social care, for example, waiting times
    and supporting more people to live at home. However there remains unacceptable
    variation with a small number of services not meeting acceptable standards of quality
    and safety. Progress in joining up care has been made but needs to accelerate in order
    to meet demands of demographic change, and a fundamental cultural shift is needed
    so care becomes more person-centred.
   We continue to publish a large amount of our information. Our website has received
    over 2 million unique visitors this year (of 4.8 million total visitors) and over 600,000
    inspection reports have been downloaded each quarter. We delivered 48 publications,
    of which 15 were legacy reports.
   Equality and Human Rights Scheme published in March 2010. New registration will
    enable us to focus on outcomes for people, and with this scheme underpinning our
    operating principles we have a real opportunity to monitor how the quality of care
    maintains and protects people's rights and promotes equality.
   We developed, consulted on and published our Strategy 2010-15 and also developed
    and published a number of strategies to ensure that CQC‟s work meets the needs of
    people in particular groups or with particular needs.

Regulating effectively, in partnership

We have defined our strategy against which we will be held to account for our own
effectiveness of regulation, but to reduce the burden of inspection we must ensure we are
aligning our work, and sharing information, with other bodies to reduce duplication. This
year there is evidence of us sharing information and working jointly, but the effectiveness
has been variable and our challenge now is to build on this and translate what we know
about providers into joint actions.

   Provider Advisory Group has been set up with over 500 active members and is now
    giving feedback on how well we are working with partners to reduce duplication and
    overlap of activity. There have been over 40 forums spanning various aspects of how
    registration will work in practice, allowing the opportunity to engage effectively with
    different provider communities.
   Risk summits were established to enable communication between organisations
    involved in early warning systems in the NHS.
   A single reporting system for safety related incidents in the NHS was developed with
    National Patient Safety Agency.
   Planned Collaborative Reviews took place in each region, bringing together a range of
    regulators and audit and risk bodies sharing information, reviewing plans and
    assessing safety, quality and effective use of resources in each NHS provider.
   Comprehensive Area Assessment (CAA) programme - working with five other
    inspectorates we have jointly assessed the quality of care in 152 local authority areas,
    providing for the public details of the combined assessment of their local authority.

What performance areas concerned us?

Our corporate performance in 2009-10 has been 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 effectiveness. In some areas
performance has fallen short of target or we have focused management attention to
address any risks or issues which may impact on the delivery of our business plan in 2010-

The regulatory activity areas which have been consistently flagged as managing significant
issues relate to registration processing times, the Second Opinion Appointed Doctor
Service and social care inspections; each of these areas being reported as performing
below target - although in part this is due to the maturity of the legacy systems and
processes which underpin their performance reporting.
   There were issues with social care inspection data availability across the year and as the
    update of the system with inspection data has not yet been finalised year end figures show
    that 11477 of 11687 planned inspections (98.2%) were completed. At the year end we
    have received assurance from the Director of Operations that the schedule of inspections
    had completed by 31 March.

   Within the Second Opinion service, the target time for completing an opinion following
    its request has been consistently below target, with processing against target times
    running below 45% across all opinion types. A management review has been
    commissioned to explore the issues here, which include the targets in use and factors
    impacting on the service such as staffing levels and support from providers, and
    projects have commenced to review the structure of the mental health service and the
    data systems in use.

   Registrations under the Care Standards Act show average processing times varying
    between the different registration types. Across the year, social care provider
    registrations have been processed within 4 months in 89.2% of cases, and independent
    healthcare provider registrations 68%. Social care managers have been registered
    within 2 months in 68.8% of cases, and 52.2% of independent healthcare provider
    registrations. All of these have been measured against a target of 90%, so social care
    provider registrations are close to achieving target, with the others registration types
    requiring careful management to drive improvement. The National Processing Centre
    consistently managed within 10 days all registration types received after 19th October.
    For applications prior to this date it is not known the extent of impact through the end to
    end process relating to handover points between the NPC and regional operations; a
    review is ongoing to explore the process, and this is due to report early in 2010-11
    which will inform our existing work as well as the new registration types we are moving
    towards as our remit extends to include the registration of additional service types in

    Issues continuing to be actively managed

    The performance information included in Part 3 relates to Quarter 4 activities, and
    highlights issues and risks still being managed at the end of 2009-10; these are ongoing
    issues and any activities not completed by the end of the year may impact work planned
    for 2010-11. Key amongst these issues are:

   Processing times for new registrations may be impacted by backlogs of social care and
    independent healthcare registrations; this is being dealt with as part of the end-to-end
    review of the registration service. Increasing numbers of registration applications are also
    being sent to the National Processing Centre by providers in order to meet deadlines of the
    cut off points for receiving applications, which is expected to have an effect on the re-
    registration of providers. Resource modelling is being completed within Operations to allow
    for resources to be channelled to re-registration.
   Implementation of the new Field Force model in 2010-11 will result in structural changes
    within Operations and new methods for monitoring compliance. There may be an impact
    on the monitoring of unregistered services as the work of the Regional Enforcement Teams
    transfers to the Compliance Teams - management reviews of all services are being
    undertaken to reduce this risk. The Special Reviews and Studies team is also liaising
    closely with the Operations Programme team to determine operations requirements and
    delivery in view of the planned restructure.

   Mental Health Act activity - issues from increased CTO second opinions and requests
    continue and are being addressed by writing to all mental health providers to clarify our
    expectations on them for patients on CTO with effect from 1 April. Further work is being
    undertaken to review this service as part of the mental health improvement project. There
    is also a plan to reduce the mental health activity data dependence on paper based
    systems with a business case in place for improving business practices.
   In relation to Inspections, remaining data issues continue to be addressed by a data
    cleansing exercise in the regions, in readiness for the decommissioning of the ICAP
    system and transfer of its functions into CRM, so a single system can support our cross-
    sector compliance monitoring.
   A number of our other systems and processes are being reviewed with a view to making
    changes and improvements in 2010-11. A query management project to identify more
    accurate ways of recording regional data about health care complaints shared with the
    commission is underway. The new system is to be piloted and evaluated ahead of a
    general rollout across the organisation. IT and the Programme Delivery team are working
    on a solution (to be in place by October 2010) to simplify the process of scanning into
    CRM, reducing the labour required under the current process.
   Another issue, as we move into a period of change as our Field Force model is
    implemented, is ensuring the activities which support Operations remain fit for purpose.
    Shared Services are putting in place a new structure and instituting improvements, for
    example to support front line Operations more efficiently. To reduce the risk posed by
    current systems in the National Contact Centre (NCC) new software has been

Future reporting

   Performance reports have evolved in 2009-10 into combining key performance
    indicators; narrative; and risks, issues and mitigating actions, enabling the Executive
    Team and the Board to hold the organisation to account.
   With consultant support, we have just completed a review of our performance reporting
    systems and measures to refine the way in which we report on our activities; focus on
    areas of high regulatory risk, and identify where reporting processes are sound and
    where they require attention.
   We still have work to do to improve measures relating to the quality of our work and
    move towards a balanced scorecard approach. Current measures focus on tracking
    delivery. Measures assessing the quality of our work are important to move to
    assessing the outcomes we are achieving.

Part 2: Performance Information, Quarter 4

                                                  Quarter   Quarter   Page
Activity                                            3         4

Registration and monitoring compliance

- Registration under the Care Standards Act         R         R        11

- Registration programme                            A         A        12

- Enforcement and Investigations                    A         A        13

Mental Health Act activity                          R         R       14-15

Assessments of Quality

- Inspections                                       A         G       16-17

- Commissioner Reviews / CAAs                       G         G        18

- Special Reviews and Studies                       A         G        19

Specialist statutory regimes and joint working      A         G        20

How we work – enabling activities

- Finance                                           A         G        21

- Shared services and complaints                    G         G       22-23
- Organisational Development & Human Resources,     A         G        24
Equality & Diversity

- IT and information governance                     A         A       25-26

- Engagement Activity                               G         A       27-28

Our Performance in Quarter 4 – Overview (regulatory activities)

Between Quarter 3 and Quarter 4, performance levels have been maintained on the main programmes of
      In Quarter 4, the data shows that we completed 2007 social care inspections and 205 independent
       healthcare inspections, lower numbers than in the previous quarter (2630 and 540, respectively,
       during Quarter 3), representing the front loading of inspection schedules in previous periods. All three
       batches of independent healthcare inspections have been completed. The Director of Operations
       reports that all adult social care key inspection site visits were completed by year end; the data has
       not yet refreshed to reflect this due to the impact of the ongoing data issues reported throughout the
      Fewer draft key inspection reports were completed within the target time of 4 weeks, 61.1% to 71.3%
       in Quarter 3. As previously reported, the social care inspection schedules were brought forward so
       this has impacted on the preparation times for reports, resulting in the backlog.
      The registration programme continues into 2010-11 and remained at Amber throughout Quarter 4 as
       successful delivery is feasible but issues require management attention. Most issues appear
       resolvable at this point. The NHS register was published on line and tools and guidance for on-going
       compliance were also published.
      A full set of data is included for enforcement; demonstrating the improvement of reporting systems
       following the partial data collection at Quarter 3. Within the enforcement teams, delays in processing
       Statutory Requirement Notices were experienced in Quarter 4 as a result of increased activity for
       some regions which were simultaneously suffering staff shortages. Representations and appeals
       have declined in respect of 'technical failures' and due to smarter evidence, indicating the robustness
       of the service. Low activity levels for independent healthcare providers make performance difficult to
       assess, but as we continue to track performance over a longer period we should be able to identify
      Visits under the Mental Health Act significantly exceeded targets in Quarter 4, and at the end of the
       year 1504 visits had been completed. The increased number of visits meant that there was also a
       higher than average number of patient meetings (1611) and document checks (1852) between
       January and March.
      Social care quality ratings have continued to improve across the year, with an overall increase of 11%
       between April 2009 and March 2010. Since April 2009, 3607 services have improved their ratings (ie.
       increased by one or more levels) although 1176 have decreased by one or more levels, mainly
       relating to services moving to poor from adequate. The number of services in enforcement has
       decreased from 7 in Quarter 3, to 4 in the last quarter.
      Four of the six special reviews are reported as green. „Physical health needs of people with mental
       health needs and learning disabilities‟ is amber due to challenges of covering both issues in one
       review. „Meeting healthcare needs of people li ving in care homes‟ is Amber due to data issues,
       resourcing and tight timeframes. National report publication dates for all reviews have been agreed
       with Engagement, scheduled between September 2010 and January 2011.
Particular issue s being addressed are
      The processing of Registrations under the Care Standards Act remains an area of concern, but work
       is still ongoing on the end-to-end review of registration, which is due to report in May and will take into
       account the issues in 2009-10 and future registrations under the Health and Social Care Act.
      The mental health Second Opinion service remains on Red as it was in Dec ember (Quarter 3).
       Wider work to review this service will be undertaken as part of the mental health improvement project,
       which will consider the structure of the service as well as data handling improvements .

Our Performance in Quarter 4 – Overview (enabling activities)

       The financial position was stable at the end of the year. The Annual Report and Accounts is due for
        publication by 15 July 2010 and will include details of the revenue, capital and transition expenditure
        in 2009-10. Ahead of that, CQC was wit hin the budget and forecast expenditure and cash limits
        agreed with the Department of Health for the financial year ended 31 March 2010.
       Our shared services continued to perform well in Quarter 4, improving further upon the processing
        times reported at Quarter 3. Call handling at the National Contact Centre shows continual quarter-
        on-quarter improvement, with nearly all calls (98.6%) answered, and the overall status of the
        National Processing Centre reported as Green. There was a slight increase in safeguarding calls,
        and the proportion of calls answered within 20 seconds continued to rise well above the target 90%
        (94.5% in Quarter 4, up from 92% in Quarter 3).
       There remained no investigations in Quarter 4 resulting from a complaint unresolved, indicating
        the robustness of our complaint handling.
       Staff turnover decreased over the last two quarters from 5.9 % to 2.0 % due mainly to Q3 containing
        a large number of redundancies. Average sickness days remained at a low level and showed a
        slight drop over the same period.
       CQC‟s equality and diversity profile has remained consistent across all previous reporting periods,
        and on a par with other public sector organisations generally. Following a period of consultation, new
        staff diversity networks have been established throughout the organisation, and the Equality and
        Human Rights Scheme was published in March, setting out a number of actions we will take as an
       In line with the continuing rise of the Commission's public profile, over 25% more information access
        requests were received in Quarter 4 than in Quarter 3 and response times improved to 93.8% on
        target with a comprehensive plan developed for ongoing work to ensure an effective and efficient
        information governance function.
       IT service delivery was consistent between the last two quarters, based on helpdesk response times
        and customer ratings.
       At the end of Quarter 4, Experts by Experience inspections had completed 56.7% of the annual
        target. Other areas of Engagement activity showed stable trends.
       Most website usage statistics between Quarters 3 and 4, including the number of visits, inspection
        reports downloaded and number of newsletter subscribers, show an increase. However, the number
        of unique visitors declined (by 7.6%) over the same period.
       On 1 April 2009, CQC inherited 23 offices in 13 locations and by implementing our estates
        strategy, introducing home working and changing our business services arrangements, we had
        reduced the estate to 8 offices by the end of October.

Contextual information

CQC‟s regulatory remit applies within the following context for 2009-10:

       380 NHS Trusts and 148 Local authorities
       150 Primary Care Trusts
       Risk-based inspections of approximately 27,000 registered health and social care providers
       c.12,000 second opinion requests per annum
       c. 13,000 social care key inspections
       c. 1200 independent healthcare inspections
       c. 1000 enforcement actions
       c. 260,000 calls 24.000 emails 2,600 letters
       1,932 permanent staff at CQC

Key Performance Information for each activity area

Registration under the Care Standards Act                                           Quarter          Quarter
                                                                                      3                4

There are ongoing performance issues in this area wit h all categories of registration remaining below
target, and some furt her decreases in performance since Quarter 3. An end to end review of the function
is underway and is due to report at the start of May.

Key Performance Indicators                              Target      Quarter 3       Change       Quarter 4

Registration completed in 4 months (social care)         90%
                                                                     347 / 387
                                                                      (89.7% )                   431 / 483
                                                                                                   (89.2% )
Registration completed in 4 months
(independent healthcare)
                                                         90%           71.2%                     139 / 185
                                                                                                   (75.1% )
Manger registrations completed in 2 months
(social care)
                                                                    821 / 1079
                                                                     (76.1% )                   824 / 1239
                                                                                                  (66.5% )
Manger registrations completed in 2 months
(independent healthcare)
                                                         90%           62.8%                      82 / 142
                                                                                                   (57.7% )
Major variations completed in 3 months
(social care)
                                                                     192 / 218
                                                                      (88.1% )                   187 / 256
                                                                                                   (73.0% )
Major variations completed in 3 months
(independent healthcare)
                                                         90%           68.8%                       27 / 51
                                                                                                   (52.3% )
Minor variations completed in 1 month
(social care)
                                                                       34 / 48
                                                                      (70.8% )                     40 / 56
                                                                                                   (71.4% )
Minor variations completed in 1 month
(independent healthcare)
                                                         90%           12.2%                       21 / 34
                                                                                                   (61.8% )
Registrations/ variations outstanding 6 m onths+
(Social care only)
                                                                         96                         114

Since April, 565 social care services received their first inspection following registration, rated as:
Poor             20 (3. 5%)                                  Adequate         161 (28.5% )
Good             360 (63.7% )                                Excellent        24 (4. 2%)

1) There are still registration processing backlogs which need to be cleared
which may affect performance in the first months of 2010/11.                                No significant
2) There are also an increased number of applications being sent to the                     risks reported.
NPC by providers in order to meet deadlines of the cut off point for
receiving applications. This will have an affect on the re-registration of
Mitigating actions against Issues
1) The end to end review will aim to clear backlogs.
2) Resource modelling is being completed by Ops to allow for resources to be c hannelled to re-registration.

Key Performance Information for each activity area

Registration Programme                                                                Quarter           Quarter
                                                                                        3                 4

The programme still remains at Amber as successful delivery is feasible but issues require management
attention. Most issues appear resolvable at this point. The NHS register has been published on line and
tools and guidance for on-going compliance have also been published.

     1) Successful delivery of batches of ASC and IHC providers into registration is dependent on a complex
     data management exercise that involves using data held within our current register. Furthermore, this
     needs to take into account the overlap and links between the Care Standards Act 2000 and the Health
     and Social Care Act 2008.
     2) There are significant challenges around delays to the production of the ASC1.0 Quality and Risk
     3) Specialised resource limitations within Data Management to accommodate the change and
     expansion required within the programme.

 Mitigating actions against Issues
     1) The data validation exercise that commenced in January 2010 has now been concluded and the
     work has been handed over to Operations. There is an ongoing dialogue and coordination between
     data management systems, Engagement and Operations who are working together to develop detailed
     plans. Resource planning continues and further resources are being identified.
     2) Intelligence and IS are reviewing all aspects of the Quality and Risk Profile project including technical
     issues and delivery plan.
     3) Data Management are reviewing their capacity and deployment of resources. IS are reviewing the
     delivery schedule and agreeing a revised prioritisation and timeline. IS are also reviewing their capacity
     and deployment of resources.

     Risk that organisational restructuring may impact on the registration of services and monitoring of

 Mitigating actions against Risks
     The Head of Programme Delivery and the Registration Programme Manager are holding cross
     programme meetings and are integrating their management of risks and issues across both
     programmes to ensure the delivery of the new regulatory model.

Key Performance Information for each activity area

Enforcement and Investigations                                                     Quarter            Quarter
                                                                                     3                  4

A full set of data is included representing reporting system improvements across Quarter 4. Adult social care
and Independent healthcare enforcement activity has been undertaken by Regional Enforcement Teams
since January 2010. Delays in processing Statutory Requirement Notices (SRNs) were experienced as a
result of increased activity for certain regions simultaneously suffering staff shortages. The service remains
rated as Amber: transition of enforcement work to Compliance Teams carries risks which are mitigated, but
require close monitoring. Representations and appeals have declined in respect of 'technical failures' and due
to smarter evidence.

 Key Performance Indicators                                       Quarter 3                 Quarter 4
 Statutory Requirement Notices are issued swiftly                    87%               SC 50 / 116 (43. 1%)
 (target 10 days from referral)                                                        IHC 15 / 24 (62. 5%)

 % of Statutory Requirement Notices (SRNs) that                      80%                 SC 44 / 53 (83%)
 have resulted in compliance                                                             IHC 5 / 5 (100%)

 Social care services that have returned to                          18%                   15 / 68 (22%)
 enforcement action within 24 months

 Notices of Proposal to Cancel are sufficiently robust             SC 61%               SC 20 / 24 (83.3%)
 to proceed past the representations stage (internal              IHC 100%              IHC 17 / 20 (85% )

 SRNs are sufficiently robust to proceed past the                    85%               SC 50 / 116 (43. 1%)
 representations stage (internal appeals)                                               IHC 9 / 24 (37.5%)

 Number of referrals received about unregistered                     168                        219
 independent healthcare or social care services*

 Investigations of unregistered services in progress                 154                        206

* each service will have a management review which will consider all of the factors relating to th e case
and assess the risks involved.

Unregistered services pose risk in light of Field Force proposal to delete Regional Enforcement Teams.
Unregistered Referrals: One region experienced exceptional increase.

Mitigating actions against Issues
Risk reduction process in progress: Management Reviews of all services. Separate report to Deputy
Director of Operations.

Risk to the effective management of Operational Regulatory risks in the organisations that CQC regulates due
to errors in managing concerns and information.

Mitigating actions against Risks
New Head of Regulatory Risk to be appointed to oversee CQC‟s systems for managing regulatory risk within
Operations with reporting to ET and Audit and Risk Committee.

Key Performance Information for each activity area

Mental Health Act activity – 1/2                                                       Quarter           Quarter
                                                                                         3                 4

As reported at Quarter 3, the Second Opinion function remains under pressure. Four new appointments were
made to the panel over the Quarter 4 period, recruitment is ongoing and we have three days of interviews and
an induction day arranged for April. We are also in the process of recruiting to the staff posts on the second
opinion support team which have been filled with long term agency staff for 2009-10. Visiting activity as
previously reported may be lower than in previous years due to the reduced opportunities for additional and
themed activity whilst maintaining honorarium levels of activity through the recruitment of MHA

Key Performance Indicators                              Target        Quarter 3       Change        Quarter 4

Mental Health visits over the period                     100%
                                                                       344 / 375
                                                                        (91.7% )                    654 / 375

Total number of individual patients seen Y TD               -            3265                         4934

A verage number of documents checked per
                                                            -             3.23                         2.8

Outcomes of section 134 adjudications                       -           1 NFA*             -          2 NFA*

Second opinion requests (year to date figure)               -            10138                       13601**

SOAD visits within target time overall
                                                                      695 / 1968
                                                                       (35.3% )                     654/1573
                                                                                                      (41.6% )

SOAD visits within target time overall (ECT)             100%
                                                                       115 / 330
                                                                        (34.9% )                      79/227
                                                                                                      (34.8% )

SOAD visits within target time overall (CTO)             100%
                                                                        83 / 726
                                                                        (11.4% )                      89/409
                                                                                                      (21.8% )
Of those where visit was completed outside of
                                                                       256 / 640                      160/319
28 days, how many SOs were requested 28                     -                                         (50.2% )
                                                                        (40% )
days or more after the start of CTO

* NFA = no further action; where the organisation is asked to make a decision but before the decision process was
either started or completed the situation changed and we were no longer required to make a judgement e.g.
the Consultant revis ed their decision to withhold the patient's mail.

** The total figures reported do not include requests received and subsequently marked as cancelled. It should be
noted that CQC received a total of 15,288 second opinion requests in the period 1 April 2009 – 31 March 2010 and
those subsequently marked as cancelled would have required administrative time and on occasion SOAD time to
process and conclude even though they are excluded from the figures reported.

Key Performance Information for each activity area

Mental Health Act activity – 2/2                                                  Quarter          Quarter
                                                                                    3                4

1) Number of and arrangements for CTO second opinions impacting on SOAD service overall
2) CTO requests impacted by „no shows‟
3) Data remains dependent on paper based system
4) Second Opinion performance is below current performance targets

Mitigating actions against Issues
1), 2) The Care Quality Commission wrote to all mental health providers to clarify our expectations on them
for patients on CTO with effect from 1 April. Day sessions for CTO requests continue to be arranged
wherever possible and practicable. Further work to review this service will be considered as part of the
mental health improvement project.
3), 4) A Business case for improving business practices and reducing paper based actions was
approved by Operating Committee on 1 March.

Risk to the delivery of the mental health Second Opinion Appointed Doctor (SOAD) service due to major
increases in demand for the service.

Mitigating actions against Risks
Additional SOAD doctors have been recruited to meet demand for the service. In April the MH
Organisational Development Programme will start changing the structure and delivery of mental health

Key Performance Information for each activity area

Inspections – 1/2                                                                  Quarter            Quarter
                                                                                     3                  4

The Director of Operations has confirmed that all adult social care key inspection site visits and associated
activities were completed by year end; the data has not yet refreshed to reflect this due to the impact of the
ongoing data issues on ICAP. Official figures from ICAP show that we completed 98.2% of the programme
by year end, due to duplicate records; our scheduling tool, CAiRE, shows that we completed 100% of the
social care inspections.

 Key Performance Indicators                                     Quarter 3                   Quarter 4
 Independent healthcare inspections completed
                                                             536/542 (98.9% )            741/741 (100%)
 following risk-based review (year to date)*

 Social care inspections completed to date**               9470 / 11687 (81%)        11477 / 11687 (98.2% )
 Poor rated services visited within the last 12
                                                           135 / 154 (87.7%)          73 / 78 (93.6%)
 Adequate rated services visited within the last 12
                                                           504 / 682 (73.9%)         335 / 407 (82.3%)
 Quality Ratings Review Service (QRRS): Provider
                                                                   N/A                      6 / 16
 requests accepted for review
 Recommendations from QRRS:
                                                                   24                          3
                           No change
                                                                    4                          0
                           Rating up
                                                                    0                          1
                           Rating down
                                                                   16                        24
                           No decision to date
 *The 741 inspections were undertaken on a risk basis following 2075 reviews of providers
 ** As part of the data cleansing the figure reported at Quarter 3 has been adjusted

 Number of services in each rating currently and at
                                                            As at 8 Apr 2009            As at 8 Apr 2010
 the start of the year
 Excellent                                                         4175                       5059

 Good                                                             14555                       15716

 Adequate                                                          4075                       2623
 Poor                                                               424                        321
 New/Unk nown                                                      1147                       1202

 In Enforcement                                                     19                           4

 For 2009-10, provider quality ratings have increased overall by 11%, a figure that balances 3,607
 increases, 1,176 dec reases and 17,269 unchanged ratings.

Key Performance Information for each activity area

Inspections – 2/2                                                                Quarter         Quarter
                                                                                   3               4

Data issues still remain on ICAP.

Mitigating actions against Issues
Regions will continue to data cleanse ICAP ready for its decommissioning.

Risk that the Commission applies its processes for making regulatory judgements of services

Mitigating actions against Risks
This risk is being mitigated by the delivery of Quality and Risk Profiles (QRPs) as part of the new model
of regulation. The QRP project reports to the Registration Programme.

Key Performance Information for each activity area

Commissioner Reviews / CAA                                                   Quarter        Quarter
                                                                               3              4

Commissioner ratings were published in December 2009 and are included below for information. The
CAA programme als o published its reports in Dec ember, and in Quarter 4 evaluation work has been
carried out to assess the process and identify actions for future development.

 NHS Performance Ratings:                           NHS Performance Ratings:
                               2009     2008                                         2009    2008
 QUALITY                                            FINA NCIA L MANAGEME NT

  Excellent                    15%      26%          Excellent                       26%     24%

 Good                          47%      35%         Good                             45%     37%

 Fair                          33%      34%         Fair                             26%     34%

 Weak                           5%       6%         Weak                              3%      5%

Local Authority social care commissioning
                                                                               2009         2008

Excellent                                                                       32           27

Well                                                                            108         104

Adequate                                                                         8           19

Poor                                                                             0           0

TOTAL                                                                           148         150

Key Performance Information for each activity area

Special Reviews and Studies                                                        Quarter          Quarter
                                                                                     3                4

The State of Care report was published in February 2010. The financial downturn study has been placed
on hold until aut umn 2010 at the Chief Executive‟s request, but the six special reviews are underway and
continue into 2010-11, with one reported as amber at the end of Quarter 4. All other reviews are on track
for delivery. National report publication dates for all reviews have been agreed with Engagement, with
reports to be published bet ween September and January 2011.

Project Status                                                              Quarter 3         Quarter 4

State of care report                                                          Amber             Green

Stroke pathways review                                                        Green             Green

Meeting healt hcare needs of people living in care homes                      Amber             Amber*

Meeting the physical health needs of those with mental health                 Green            Amber**
needs and learning disabilities
Social services‟ res pons e to people‟s first contact with them               Amber             Green

Commissioning for healt hy weight                                             Green             Green

Support for families with dis abled children                                  Green             Green

Impact of financial downturn on quality of care                               Green       Green
    *Due to data issues and tight timeframes. No review lead in post since Jan 2010.
    **Changes to scope to go to the Special Reviews and Studies Programme B oard in April due to
    challenges of covering ment al healt h needs and learning disabilities in one review.

1) Operations restructure is impacting on the directorate‟s ability to agree to the delivery an d support of
inspections and follow-up work required for reviews.
2) Team resourcing issues - two review manager positions will become vacant.
3) Web form capacity issues and development delays due to registration and demand on resourcing.
Mitigating actions against Issues
1) Liaising with the Operations Programme Team to negotiate reviews delivery in light of the restructure.
2) A recruitment process is underway to fill the vacant manager positions.
3) Working with the relevant teams to improve the current process and agree delivery timeframes.
The Healthcare in care homes review timetable maybe delay ed due to lack of operations resource

Key Performance Information for each activity area

Specialist statutory regimes and joint working                                    Quarter          Quarter
                                                                                    3                4

All teams have completed their planned work and achieved or exceeded annual targets in quart er.

HCAI: Inspection programme completed in advance of forec ast; escalations, enforcement and follow ups
successfully completed or in progress.
Childrens service s: All inspections have been completed as scheduled and joint inspection reports and
PCT letters sent.
IRMER: There is no unusual notification activity this quarter, 7 inspections have been completed and
await publication.
Service Inspection: Successfully met targets, completing 100% of scheduled service inspections.
Pharmacy and Controlled Drugs: All referrals responded to and by the final quarter we had
consolidated our risk based approach.
Planned Collaborative Reviews: A full evaluation has been carried out of our 2009-10 method. Key
changes for 2010-11 have been discussed with our partners, but with no agreement reached to date.

In Quart er 4, 52 HCA I inspections took place (104% compared to target), with 24 follow up visits.

14 trusts were in breach of the regulation, including Statutory Warning Notices, and a further 25 had
areas of conc ern or measures for improvement.

The remaining 4 Planned Collaborative Reviews were completed in Quarter 4, so one for each of the nine
regions had been undertaken in the year. Each review involved a range of regulators and audit and risk
bodies working with Strategic Health Authorities and NHS organisations to review plans and activity to
assess safety, quality and effective use of resources and jointly agree p rospective risk-based regulatory
plans. A detailed evaluation is scheduled for early in 2010 -11.

Issues – Planned Collaborative Reviews
Current negotiations with external partners on method for 10/11 are ongoing and at times challenging. The
introduction of registration for the NHS requires changes to the system which impact on our partners.

Mitigating actions against Issues
Alternative methods are under discussion.

No significant risks reported.

Key Performance Information for each activity area

Finance                                                                          Quarter          Quarter
                                                                                   3                4

CQC was wit hin the budget and forecast expenditure and cash limits agreed with the Department of
Healt h for the financial year ended 31 Marc h 2010.

Recurring Revenue expenditure for 2009-10 was £158.6m against a December forecast of £159.7m and
budget of £166.8m.
Transition Revenue expenditure for 2009-10 was £29. 7m against a December forec ast of £31.0 and
budget of £38.3m.

Our capit al expenditure in the year was £15.6m against a budget of £22.4m.

All financial figures included in this report are subject to external audit review and clearance.
The target date for CQC to lay the Annual Report and Accounts before Parliament is Thursday 15 July

The net position (cost less income) shows an underspend against budget and a net £3. 2m underspend
against the forecast provided to DH in December 2009.

This comprises an underspend on total costs of £1.1m and an over recovery on fee income of £2.1m.

The cumulative year to dat e favourable variance of £3.2m to the end of March 2010 consists of:
       -       a favourable varianc e on fee inc ome, £2.1m (3.2% of budget)
       -       a favourable varianc e on staff costs, £4.2m (4.1% of budget)
       -       an adverse variance on non staff costs, £3.0m (5.2% of budget)
       -       an adverse variance on capital charges, £0.075m (0.4% of budget)

Within the adverse variance on „capital charges‟, a write off of fixed assets is included, amounting to
£2.7m. This includes the write off of ICAP (£0.4m), software in connection with the Annual Health
Check (£1.4m) and other fixtures and fittings totalling £0.8m.

The original budget of £38.3m agreed by the Transition Team was underspent by £8.6m, due mainly to
redundancy provisions not being utilised, lower ICT and temporary staff costs.

The actual spend for the year was £29.7m compared to the December forecast of £31. 0m.

The December forecast of capit al spend was £17.0m for 2009-10. The reported spend for the year is
£15.6m of which £14.8m related to IT& C projects, in particular IT infrastructure and the Registration
programme and £0.8m related to the Estates programme.

1. The valuation of the net liability position (as calculated by the scheme actuaries) of the 17 local
   government pension schemes that CQC inherited from predecessor organis ations, has increased
   significantly from £7.3m as at 31 March 2009 to £54.6m as at 31 March 2010.

    Although this increase does not have a significant impact our Income and Expenditure Account for the
    year ended 31 March 2010, there is a significant impact on the „net liability‟ position on the Balance

    Further future funding costs, by way of increased employ er contributions are likely to increase from the
    financial year 2011/12 onwards.
    Discussions are in hand with the Department of Health regarding all pension issues.

2. The capit al budget for the financial year 2010/11 has not yet been finalised by the Department of Health.
   There is a risk that, should funding be restricted, some projects may have to be delayed or cance lled.

Key Performance Information for each activity area

Shared services and complaints – 1/2                                                  Quarter        Quarter
                                                                                        3              4

The performanc e of our National Contact Centre and National Processing Centre has improved further in
the final quarter. New soft ware has helped to improve reporting on safeguarding calls. They are
prioritised over general enquiries to ensure that they are always at the front of the call queue (if there is a
queue). Incoming calls increased by 17% from Feb to March, but across the quarter 98.6% of those calls
were ans wered.
There are variations every month bet ween the number of people who contact us either to share
information about services with us or to complain about CQC. We have not been able to identify any
trend since recording began.

 Key Performance Indicators                                                  Quarter 3           Quarter 4

 Calls answered at National Contact Centre                                     93.6%              98.6%

 Safeguarding calls received at NCC                                             1118               1365

 The Grade of Service for Safeguarding calls was 94. 5% of calls ans wered within 20 seconds or less
 (target 90%). The Grade of Service for other calls was 90.2% of calls answered wit hin 20 seconds or
 less (target 80%).

                                                                               1 day            On Target &
 NPC sort and print times
                                                                            turnaround           within SLA
 NPC registration processing times:         SC (10 day target)               9.5 days            6.5 days
                                            HC (5 day target)                 1 day               4 days

 NPC allocation of urgent notifications to regions                           2.5 days            1.5 days

 Number of stage 1 complaints received in the Regions                            30                 40

 Number of complaints which have proceeded to stage 2 review                     28                 12

 Number of investigations resulti ng from a complaint unresolved                 0                   0

Key Performance Information for each activity area

Shared services and complaints – 2/2                                                Quarter           Quarter
                                                                                      3                 4

Conc erning experiences of people using services reported to the Complaints Review Service at a
regional level (total 30 healt hcare, 96 social care). The figures below relate to social care only as the
healthcare data was not recorded per region for this period.

Eastern                   4 SC                               South East                13 SC
East Midlands             34 SC                              South West                17 SC
London                    3 SC                               West Midlands             12 SC
Nort h East               5 SC                               Yorks + Humber             5 SC
Nort h West               3 SC

This is a new dat a field whic h was not reported in Quarter 3 as regional reporting systems were being
developed. Social care complaints remain higher than healthc are complaints, representing people
having traditionally been more familiar with contacting the regulator to share c oncerns about services.
The CQC website will be updat ed in the near future to reflect that although we cannot investigate the
complaint we do encourage people to share their experiences wit h us.

1) Updat es to NCC systems are not yet introduced. We are awaiting the installation of Hipath agent
desktop and CRM to be rolled out for social care (already in use for healthcare). Current systems are
not reliable and may have an impact on the level of service to our customers.
2) Compliance under new registration. Not all processes for compliance have been agreed and
therefore we are unable to confirm that staffing levels are sufficient.
3) Shared servic es are particularly concerned with regard to scanning into CRM as the process is
currently very labour intensive and requires amendments.
4) Regions are reporting nil ret urns for information about health care complaints shared with us.
Mitigating actions against Issues
1) Hipath agent desktop has been purchased and installation should be 19th April. Current systems are
being reviewed to reduce the amount of data they contain to try to stabilize them.
2) Shared Services are involved wit h the Registration Programme and will assess the impact when
processes are known. To meet the requirements of Operations with particular regard to new
registrations and the Field Force Model, Shared Services will put in place a new structure to enable
efficient support to Front line Operations - this means that teams have to be realigned and undertake
the new processes and at the same time continue with work under CSA Act.
3) This issue has been flagged to IT and the Programme Delivery team and we are working on a
solution to be in place by October 2010, to avoid the need for extra equipment and staffing.
4) A query management project has been undertaken to identify ways of recording the data needed. The
new system of recording the appropriate information on CRM is due to be piloted within the Private
Offices, the Complaints Review Service and shared services. Once the piloted has been evaluated it is
hope to roll it out across the organisation within a short timescale. This will ensure that all information is
recorded on one system and this will make accurate and frequent recording of statistics and information
No significant risks reported.

Key Performance Information for each activity area

Organisational Development,                                                    Quarter         Quarter
Human Resources, Equality and Diversity                                          3               4

We reported previously about benchmarking activity being undert aken, and work is ongoing to monitor
progress. 59% of ODHR Projects are showing a green RAG status. This figure is based on current
projects and does not take account of the large number of completed projects. The majority of the
projects marked as amber have been re-scheduled or are subject to re-design within new planning
The EDHR P osition remains relatively unchanged. The E DHR Strategy was published in March and sets
out a number of actions we need to take as an organis ation; we will monitor its implement ation through
future reports.

 Key Performance Indicators                                               Quarter 3        Quarter 4
 BME staff overall representation                                           11.4%            11.2%

 Disabled staff representation                                               5.6%            5.5%

 Number of permanent staff                                                   1,936           1,932

 Staff turnover rate                                                         5.9%            2.0%

 A verage sickness days per employ ee                                         0.5             0.4

 Percentage of sickness days that are long-term                             92.9%            68.4%

 HR Helpdesk calls handled to standard                                      98.6%            100%

Issues and Risks
No significant issues or risks reported.

Mitigating actions against Issues and Risks

Key Performance Information for each activity area

IT and information governance – 1/2                                                   Quarter           Quarter
                                                                                        3                 4

The Commission received over 25% more information access requests in Quarter 4 than in Quart er 3.
With the Commission's public profile continuing to rise, it is expected that numbers of requests will remain
at high levels. There was improvement in the handling of these requests, with 93.8% of responses issued
within the deadline.
Quarter 4 saw the quality of IT service delivery improve towards the standard to be expected over the
long term.

 Key Performance Indicators                                                 Quarter 3             Quarter 4
 Total number of FOI and Data Protection requests received                      201                   258
                                                                        143 / 198 (72.2%)      197/210 (93.8% )
 Responses issued within deadline
                                                                              (3 live)             (48 live)

                                                                          20,255 / 20,597      24,605 / 24,827
 IT helpdesk incidents resolved within 5 working days
                                                                              (98.3% )             (99.1% )
                                                                             147 / 275             110 / 197
 IT customers rating the service as excellent                                 (53.5% )              (55.8% )


The public facing CQC websites continue to deliver high performance and availabili ty with no periods of
downtime reported. The Registration systems that will become available to service providers for
Registration in April are undergoing stress and load testing in preparation for go -live.
Helpdesk performance remains steady and consistent with calls being answered and emails responded
to within target times. Resolution of incidents reported to the Helpdesk remain high with a small drop in
performance for lower priority calls which is in part the result of an initiative to close old, orpha ned calls.

Key Performance Information for each activity area

IT and information governance – 2/2                                              Quarter         Quarter
                                                                                   3               4

See notes above, no further issues reported.

Mitigating actions against Issues

1) Risk to effective data handling and information governance within CQC leading to possible statutory
breaches, censure and reputational damage.
2) Risk to the ongoing challenge to match IT solutions with business requirements .
3) Risk to the business continuity within the Commission due to IT systems failure, or public health

Mitigating actions against Risks
1) The Information Governance and Information Security Teams have created policies and have
established processes and procedures for the effective and efficient responses to data access requests
and overseeing the secure handling of data.
2) IT Programme and Project Teams are working across CQC to improve the use and benefits of IT
systems. An IT strategy setting out ways of improving the efficient and effective use of IT is being
3) CQC has an established business continuity plan. ET has established a Crisis Management Team to
coordinate responses to major crises.

Key Performance Information for each activity area

Engagement Activity 1/3                                                       Quarter          Quarter
                                                                                3                4

The level of involvement across our activities was maintained in Quarter 4, and we started to receive
feedback on our work, although more detailed feedback from our stakeholders is scheduled for reporting
in early 2010-11. Usage of the website has continued to increase, and there has been good progress on
our programme of surveys, with the results of two being published in Quarter 4.
We completed an Expert by Experience pilot for the service inspections of telephone interviews of people
using domiciliary care – 7 out of the 9 anticipated were completed. An evaluation of the programme was
completed at the end of March. The summary showed that the outcomes were good in both registered
service and council service ins pections with a high proportion of inspectors saying that they found
Experts by Experience to be of value. The Experts by Experience themselves valued highly their input
into making a difference to the inspection proc ess.

  Key Performance Indicators                                               Quarter 3       Quarter 4

  Expert by Experience resource utilisation                                446 / 958       543 / 958
                                                                            (46.6% )        (56.7% )
  Provider and Commissioner Reference Group feedback:
          Our information is understandable and useful                       91%             83.6%
          Our easy read public ations for registration are accessible        100%            100%
                                                                                           128 of 130
  Independent corporate providers signed up to a voluntary MOU
                                                                           62 of 125      2 agreed in
  through business meetings with CQC‟s Provider Relationship Team
                                                                             YTD          principle but
  (Target 95%)
                                                                                          chose not to
  Visitors to the website                                                  1,294, 940      1,351, 722
  Unique visitors to the website                                            645,465         596,299
  A verage length of visit                                                   07:38       Not recorded
  Inspection reports – number downloaded                                    534,775         620,690
  Newsletter subscribers (running total)                                     39,806          43,943

Survey of MPs
We asked 86 MPs “How favourable or unfavourable is your overall opinion of CQC?” The results were:
6% favourable (of which 25% were Labour MPs, 6% Conservative)
21% unfavourable (of which 2% were Labour MPs, and 37% Conservative)
64% no opinion (66% of Labour MPs, and 57% of Conservative MPs stated „no opinion‟)

Key Performance Information for each activity area

Engagement Activity – 2/3                                                               Quarter     Quarter
                                                                                          3           4

Survey development
Learning disabilities survey: first draft of pilot report completed, final version due in April.
Survey development is on schedule.
Community health services rehabilitation surveys: questionnaire development nearing completion; ethics
submission for pilot likely to be delayed to May (instead of April as planned) due to requests from
stakeholders in cardiac rehab survey for more time to contribute to development
Survey development has been delayed by around a month.
Ambulance survey: agreed to focus on category B and C calls. Further stakeholder consultation and focus
groups underway to inform development of survey instrument. Survey development is on schedule.
NHS staff survey: development of 2010 survey has commenced and is on schedule.

Survey delivery
Acute inpatient survey: has been completed on schedule.
Community mental health survey: fieldwork underway in all eligible trusts and due to be completed in
second week of April on schedule.
Maternity survey: guidance has been published and fieldwork will c ommence in second week of April on
Local surveys: continuing to support local surveys. New local surveys for mental health trusts with DH for
comments and due to go live in April/May on schedule.

Survey reporting
Outpatient survey: published on the 25th February on schedule.
NHS Staff Survey: publication of national overview of individual trust benchmark reports completed on 17th
March on schedule.
Acute inpatient survey: is due to be published on 19th May. Briefing note is currently in sign-off process,
press release to be drafted, all other outputs completed.

Key Performance Information for each activity area

Engagement Activity – 3/3                                                           Quarter          Quarter
                                                                                      3                4

1) The Expert by Experience programme had not achieved its target by the year end due to a number of
factors including the earlier transition to CQC, changes to inspection scheduling, and bad weather resulting in
cancelled inspections that could not be rescheduled this year.

Mitigating actions against Issues
1) The Involvement Manager updates the regions on a monthly basis by providing the PI figures for Expert
by Experience inspections, encouraging Regional Change Managers to talk to inspectors in the team and
make the Regional Director aware of any shortfall, and advise inspectors on an ongoing basis about using
experts by experience.

1) Strategic risk from major change of policy on regulation of health and social care after the election.

2) Strategic risk to CQC‟s strategy and business plans resulting from the current Treasury and DH review
of Arms Length Bodies.

Mitigating actions against Risks
1) Manage and influence key stakeholders in Government and regulated sectors.

2) Staff in Regulation and Strategy and Finance and Corporate Services are working with Treasury and
DH to assist in their work on improving regulat ory efficiencies.