Annual report and accounts 2022/23

The performance analysis for 2022/23 is a detailed explanation of our performance during the year, with evidence to support the performance overview. It is arranged under the priorities, ambitions and outcomes of our strategy.

Priority 1: People and communities

Our ambition is to be an advocate for change, with our regulation driven by people’s needs and their experiences of health and care services. This means focusing on what matters to the public, and to local communities, when they access, use and move between services.

Outcomes:

• Our activity is driven by people’s experiences of care.
• We clearly define quality and safety in line with people’s changing needs and expectations. This definition is used consistently by all people, and at all levels of the health and social care system.
• Our ways of working meet people’s needs because they are developed in partnership with them.

During 2022/23, we carried out over 10,000 on-site inspections of health and social care services across all sectors to ensure people receive safe, effective, compassionate, and high-quality care (10,356 in 2022/23 compared with 10,306 in 2021/22).

We use a risk-based approach to prioritising our inspection activity. During 2022/23, we used this approach for over 7,300 of our service inspections. In September 2022, we introduced a new way of capturing the risk trigger that led us to inspect. This includes both new and emerging risks, for example information from whistleblowing enquiries or complaints and from inherent risk, or a provider’s previous rating and the length of time since the previous inspection. Over 50% of inspections triggered by new and emerging risk have resulted in a rating of inadequate or requires improvement since we started tracking this in September 2022.

As well as our inspections, we also carried out further regulatory activity for over 32,000 registered services. This involved reviewing data and evidence that informed our regulatory judgements and supported our prioritisation. For over 15,000 services, we carried out more direct monitoring activity to gather further evidence, for example through a telephone call with the provider.

Specialist professional advisors are health and social care professionals who offer knowledge and expertise to our inspections when needed. We carried out more inspections using specialist advisors to over 4,100 in 2022/23 (compared with 3,027 inspections during 2021/22).

We are responsible for inspecting all registered health services provided to children; during 2022/23, we completed 61 inspections of children's services.

We also monitor, inspect and regulate health and social care in the criminal justice and immigration detention system, to make sure people who use services in secure settings receive the same quality of care as the rest of the population. The services we inspect range from health services that form part of youth offending teams to prison healthcare. We work in partnership with other inspectorates and use different frameworks to inspect different types of service. In 2022/23, we carried out 125 inspections of health and care services in this sector.

During 2022/23, we also focused our regulatory activity around specific population groups and types of services. This was to gather further evidence to inform our regulatory activity and to target improvements to reduce inequalities. This work included:

• services for autistic people and people with a learning disability
• services for people using maternity services
• observations for people receiving mental health treatment
• oral health services for people in care homes.

Autistic people and people with a learning disability

We undertook a programme of work to transform the way we regulate services for autistic people and people with a learning disability. This was aimed at improving people’s experiences and outcomes from health care as our inspection work has consistently shown higher risks for these groups of people, and unacceptable levels of poor-quality care.

We completed 947 inspections and spoke with 220 people using these services and 227 family members to gather evidence to inform our regulatory actions. Approximately a fifth (21%) of our inspections were carried out outside of normal hours to check the consistency of the quality of care throughout the day.

Evidence from our inspections also informed our review Who I am matters: experiences of being in hospital for people with a learning disability and autistic people, published in November 2022. This focused specifically on:

• access to care
• communication
• care and treatment in hospital
• other equality characteristics and quality of care
• workforce skills and development.

Our review concluded that there is a real need for more meaningful engagement with autistic people and people with a learning disability at a local level to understand their experiences of acute hospital care and the improvements needed. There are opportunities to learn from both positive and negative experiences and to use this learning to drive improvements in services.

To strengthen our regulation of services for autistic people and people with a learning disability, we imposed a new routine condition on providers who are either registering to carry on certain regulated activities or applying to vary a condition of their existing registration. This is to ensure that all registered providers that deliver specialist services meet the principles in our statutory guidance, Right Support, right care, right culture.

We also improved our ability to identify and take appropriate regulatory action in services that fail or are failing to meet people’s needs, aspirations and skills development. To do this, we developed a framework and published a quality of life tool. This supports CQC colleagues to assess quality and safety indicators when inspecting specialist services for autistic people and people with a learning disability. We developed the tool in collaboration with academic colleagues from Warwick University and Bangor University. We are currently piloting the tool and will evaluate findings from the pilot.

People using maternity services

During the last year, we continued to focus on our regulation of maternity services. Again, our inspection work has consistently shown too many areas of higher risks, and unacceptable levels of poor-quality care for maternity service users. We launched a national inspection programme to support frontline staff in their delivery of care, help accelerate improvements and facilitate wider learning across NHS trusts. Overall, we gathered evidence from 104 maternity services as part of 54 inspections. For the national inspection programme, we developed an assessment framework using views and experiences of frontline maternity staff and key stakeholders. We have since shared emerging themes from inspections at 20 trusts and will continue to share wider themes and good practice that we identify across the programme. The inspection programme continues to be one of our priorities.

Observations of cultures in mental health services

In early 2023, we continued a programme of work to explore high-risk mental health services and whether their culture is safe and caring. In this programme, we use observation as a primary method to observe the culture of the services we visit. We evolved our ongoing observational framework to develop a short observational framework for inspection tool (SOFI 2) in collaboration with the University of Bradford’s School of Dementia Studies. It allows us to capture the experiences of people who may not be able to express these for themselves.

We want to use our findings to influence providers to identify warning signals of unsafe and uncaring cultures on their own wards and encourage them to carry out their own observations. We also want to be able to identify services ourselves where wards are not safe and caring and take the necessary enforcement action.

Oral health for people in care homes

We know that good oral health not only enhances people's quality of life, but is vital to making sure they can eat, drink, take their medicines and stay healthy. As a follow-up to our previous work in 2019, between April and June 2022, we inspected 50 care homes, asking in-depth questions about oral health care. We published the findings in our report Smiling matters: Oral health in care homes - progress report. The report found that, although there were some examples of good practice between care homes and dental practices, many people living in care homes were not being supported to maintain and improve their oral health.

Further work to gather people’s experiences

As well as targeting our regulatory activity across certain population groups, we've continued to gather wider information about people's experience of care across all types of health and care services. This is to ensure our regulatory activity is driven by people's experiences of care and that our ways of working meet people's needs.

We received over 96,300 contacts from people giving us feedback on care in 2022/23, compared with 64,600 contacts the previous year.

Figure 13: Monthly volumes of 'Give feedback on care' received

Some examples of our activity to gather more experiences include:

• promoting our public participation platform to encourage people and organisations to connect with us and share their expertise and experience
• involving Experts by Experience in more than 4,000 regulatory activities and in over 600 engagement activities, speaking with approximately 40,000 people, and capturing people’s views and experiences at our corporate speaking engagements
• improving the accessibility of our website to enable people to contact us and give feedback using British sign language; we partnered with Disability Rights UK to specifically encourage people who are deaf and hard of hearing to contact us about their experiences
• launching our 'Because we all care' campaign, to encourage people to share their thoughts on the standards of their care from GPs, dentists, hospitals and care homes; we ran specific campaigns focusing on gathering information from people who are hard of hearing and people aged over 55
• trialling a new webchat service for the public where people can start a live chat to a member of our Customer Services team
• providing written information such as letters, summaries of inspection reports and other information in other languages.

We continue to monitor the impact of our publications and accessibility work through our annual surveys covering the views and awareness of the public, stakeholders and providers.

In our annual provider survey for 2022/23, three-quarters of respondents agreed that we used people’s experiences effectively in regulatory decisions and judgements about their service. Over three-quarters of respondents (82%) also agreed that we make sure they involve people in decisions throughout their health and care journey. We carried out our provider survey between October 2022 and December 2022. Over 13,700 providers responded (a response rate of 27.7%) and survey results are weighted to represent the population surveyed.

Priority 2: Smarter regulation

Our ambition is to be smarter in how we regulate. We’ll keep pace with changes in health and care, providing up-to-date, high-quality information and ratings for the public, providers and all our partners. We’ll target our resources where we can have the greatest impact, focusing on risk and where care is poor, to ensure we’re an effective, proportionate and efficient regulator.

Outcomes:

• we are an effective, proportionate, targeted, and dynamic regulator
• we provide an up-to-date and accurate picture of quality
• it is easy for health and care services, the people who use them and stakeholders to exchange relevant information with us, and the information we provide is accessible, relevant, and useful.

Our regulatory approach

To deliver the ambitions in our strategy, we are continuing to develop our regulatory approach to provide further benefits for the public and those we regulate. Our new assessment framework is the result of over 2 years of careful co-production and consultation with a range of people. As well as publishing details about our assessment framework in summer 2022, we have been working with health and care providers to develop a new online provider portal. This will make it much easier for providers to submit information and keep their details up to date, allowing them to focus on delivering high-quality care.

During 2022/23, we updated our guidance on the Scope of Registration. This explains in a more accessible way who and what needs to be registered with us and sets out all the regulated activities and exemptions to registration.

Following a joint consultation with Ofsted, we implemented a new assessment framework to inspect services for children and young people with special educational needs and disabilities (SEND) in a local area. This emphasises the importance of hearing from children with special educational needs and their families. The new framework will allow inspectors to better understand what it’s like to be a child or young person with SEND in a local area. We also signed a new memorandum of understanding (MoU) agreement with NHS Resolution, setting out how we will work together to share information. The agreement confirms that we will act in the public interest by sharing information about the quality of NHS services.

Our new responsibilities: care in a local area

The Health and Care Act 2022 gave us new responsibilities from April 2023, allowing us to provide a meaningful and independent additional assessment of care in a local area. This includes assessing the performance of local authorities in meeting their duties under Part 1 of the Care Act 2014, and assessing whether integrated care systems are meeting the needs of their local populations. During 2022/23, we undertook a range of activity to develop our approach and test our methodology.

To do this work, we are applying a consistent assessment methodology using specific elements of our new assessment framework. We gathered views and insights from stakeholders firstly through a survey and by working closely with a wide range of partners to develop our approach. Examples of partners include:

• people who use health and social care services and their families and carers
• groups representing communities
• government departments, including the Department of Health and Social Care and Department of Levelling up, Housing and Communities
• groups that represent providers
• other strategic partners.

We undertook 2 ‘test and learn’ projects for local authority assessments, in Hampshire and Manchester, during summer 2022. Using our learning from these projects, we published interim guidance on our approach and a draft version of the local authority assessment framework in February 2023. We also carried out 2 test and learn activities to inform our assessment approach to integrated care systems in North East London and South Yorkshire, and have used feedback to refine our approach. We published interim guidance on our approach to assessing integrated care systems in March 2023.

We will continue to pilot our approach and review data and published evidence for local authorities and integrated care systems before starting formal assessments over the next 2 years.

Using our independent voice

We used our independent voice to publish several reports in 2022, summarising what we know from our assessments of health and social care. We use the findings of these reports to focus our regulatory activity to improve care for the public.

We have a statutory duty to publish some reports including:

• The State of health and social care in England. Our annual overall assessment of health and social care in England highlights trends, shares examples of good and outstanding care, and highlights where care needs to improve.
• Our report on Monitoring the Mental Health Act. This annual report reviews how providers are caring for patients who are detained and treated under the Mental Health Act, and whether patients’ rights are being protected.

We completed 850 inspections related to the Mental Health Act and the report summarises evidence from our findings. We also carried out focused visits to review how Mental Health Act community treatment orders (CTOs) were being implemented in 9 London boroughs. Our report highlights areas of concern including:

• a lack of care planning and access to advocacy services
• people being on CTOs for years
• a disproportionate use of community treatment orders for Black British people.

Under the Mental Health Act, we have a statutory duty to administer a second opinion function as a safeguard for patients whose rights are restricted under the Act. Although we administer the process, we are independent and not involved in clinical decisions within second opinions. When we receive a request for a second opinion, we arrange for a suitable doctor to visit the patient, organise the bidding for a doctor, and track the outcome. In 2022/23, we arranged over 11,300 second opinion appointed doctor (SOAD) visits to patients, which took place in just under 3 and a half days once the SOAD was appointed.

We also reported on our activities under other legislation.

Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R): The regulations protect people against the dangers of being exposed to ionising radiation in a healthcare setting. Our IR(ME)R annual report 2021/22 provides details from:

• reviewing statutory notifications from healthcare services about significant accidental or unintended exposures to patients
• our inspection and enforcement activity
• our programme of themed inspections in specific areas.

The report highlights areas of concern and provides examples of actions that employers have taken to improve safety, so that other employers, healthcare professionals and academic bodies can learn from them.

Controlled Drugs (Supervision of Management and Use) Regulations 2013: We are also responsible for making sure that service providers, and other regulators, maintain a safe environment for the management and use of controlled drugs in England. As part of our responsibilities under these regulations, we report annually on what we find through our oversight. Our annual update on the Safe management and use of controlled drugs in 2021 captured insights to help to strengthen arrangements for safely managing controlled drugs in health and adult social care.

Business Impact target: We also published our Business impact target 2021 to 2022, which was a requirement under the Small Business, Enterprise and Employment Act 2015.

Registrations

We expect our new online provider portal (being implemented during 2023) to help to speed up the process of registering new providers as well as making it easier for them to apply to register, and to vary conditions of their registration.

In total, we processed over 35,600 types of registrations during 2022/23. These new registrations increase capacity in health and social care services, and ensure more people have access to health and care services. We improved our efficiency and speed in processing a range of registrations for different types of providers.

We define applications into 3 types:

• Simple applications: These are minor registration amendments, such as changing company details. We processed 17,619 registrations, taking an average of 24 days to complete – a reduction of 6.3% over the previous year.
• Normal applications: These require a registration inspector to carry out a registration application review. We processed 17,042 registrations, taking an average of 53 days to complete – a reduction of 3.6% over the previous year.
• Complex applications: These may result in enforcement activity. We processed 944 registrations, which took an average of 88 days – a reduction of 25% compared with the previous year.

 Figure 14: Average days taken to complete applications by type

Projects with other government departments

During the year, other government departments and organisations commissioned us to carry out inspection programmes in other areas. This is an opportunity to apply the benefits of our expertise and assessment capabilities to improve the quality of services for people.

The Home Office commissioned us to inspect safehouse and outreach support services in England and Wales. These services are used by people who are survivors of human trafficking and modern slavery. We developed an assessment framework in collaboration with the Home Office specifically for this programme and inspected 26 safehouses. We designed the framework to reflect our human rights-based approach and have since updated our statement on modern slavery and human trafficking.

The Defence Medical Services Regulator continued to commission us to undertake a programme of independent inspections of defence medical treatment facilities. This is to ensure armed forces personnel and their families have access to the same high-quality health care as the rest of society. Last year, we published our annual report highlighting key findings from 31 inspections.

The Isle of Man Department of Health also commissioned us to develop a regulatory framework and to undertake a programme of inspections of health services on the Isle of Man. During 2022/23, we carried out 75 inspections and produced assessment reports for Isle of Man health services.

Enforcement activity

Our Enforcement policy sets out a wide range of enforcement powers that allow us to protect the public and hold registered providers and managers to account. If we find that a registered provider or manager is in breach of the regulations, we take action to make sure they improve. Our powers enable us to act, with both criminal and civil enforcement, where we identify poor care or where registered providers and managers do not meet the standards required by the regulations. This will be proportionate to the impact of the breach on the people who use the service and how serious it is.

During 2022/23, we issued 1,391 Warning Notices to a registered person where the quality of the care they are responsible for fell below what is legally required and to make sure they improved. We served 2,775 notices during this period, which includes Notices of Proposal and Notices of Decision. To protect the public, our enforcement activity included 215 urgent enforcements and we cancelled 127 provider registrations. From our inspection activity, approximately:

• 2% resulted in civil enforcement.
• 6% led to a Warning Notice.
• 23% led to a Requirement Notice.

We received and processed information relating to 355 complaints during 2022/23 (a 21% increase over the previous year). For 96% of these complaints, we agreed a regulatory action within 7 days.

Priority 3: Safety through learning

Our ambition is for all services to have stronger safety and learning cultures. We want to prioritise safety: creating stronger safety cultures, focusing on learning, improving expertise, listening, and acting on people’s experiences, and taking clear and proactive action when improvement takes too long, or changes won’t be sustainable.

Outcomes:

• there is improvement in safety cultures across health and care services and local systems that benefit people because of our contribution.
• people receive safer care when using and moving between health and social care services because of our contribution.

The importance of a culture of safety

We strengthened our regulatory approach to make clear that we expect services and providers to have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

To inform the implementation of our new assessment approach and wider regulatory activity, we undertook research to deepen our understanding of safety cultures. We completed a research project on safety cultures, which explored current understanding of how safety cultures are defined across health and social care, and the conditions required for safety cultures to develop. We also completed 2 rapid reviews that drew on learning from other safety-critical sectors: The characteristics of safety cultures and Improvement cultures in health and adult social care settings. These reviews further support our understanding of what safety cultures look like, the processes and structures that underpin safety cultures and the regulatory approaches that can support them.

We are currently evaluating our national maternity inspection programme. This explores what a good safety culture looks like in maternity care as well as maximising learning from the programme to inform our future approach.

Using our independent voice

To support all services to have stronger safety and learning cultures, we publish regular learning from safety incidents bulletins. These enable registered persons to learn from recent prosecutions and make relevant improvements, to improve how they can prevent such incidents from happening in their service. Each bulletin describes a critical safety issue including what happened, what we and the provider did about it, and the steps a provider can take to avoid it happening. During the last year we published safety bulletins on the following areas:

• capacity and consent
• promoting sexual safety
• unsafe management of sepsis

We also carried out extensive research and surveys to gather evidence and better understand the quality of care across different areas in health and care. We embedded the findings into our regulatory activity to help improve safety cultures. The following are some research and survey findings published during 2022/23:

• Maternity survey 2022: capturing experiences of women and other people who had a live birth in early 2022 (we are also undertaking another maternity survey for 2023). At a national level, the 2022 maternity survey shows that people’s experience of care has deteriorated in the last 5 years. However, there has been a positive upward trend for women and other people reporting there was no delay with discharging them from hospital.
• Adult inpatient survey 2021: exploring experiences of people who stayed at least one night in hospital as an inpatient. Most respondents reported a positive experience in their interactions with doctors and nurses, such as being included in conversations and having confidence and trust. This generally remained consistent with the previous year, although those receiving clear answers to questions has decreased slightly.
• Community mental health survey 2022: capturing experiences of people who use community mental health services. This report shows that people’s experiences of mental health services provided in the community remain poor. Many of those areas with the poorest historical results, are still the poorest in 2022.
• 4,000 voices: a survey of 4,013 people aged 65 and over about their experiences of using health and social care services. The questionnaire was undertaken over the phone and covered use of health and social care services, experience when accessing these, waiting lists for health services and/or care assessment, as well as social networks.
• Adult social care services survey: exploring views (2,411 responses) from registered managers on: current capacity; staff recruitment and retention challenges; financial stability; support required to increase capacity; current support from local authorities and the wider system.
• Annual provider survey: capturing responses from providers in areas relating to staffing, demand, and issues affecting a provider’s ability to deliver good quality care or to improve.

Dealing with complaints and safeguarding concerns

During 2022/23, we received and processed 15,792 enquiries from workers speaking up. Workers speaking up is the term used when someone who works for an employer raises a concern about malpractice, risk (for example, about patient safety), wrongdoing or possible illegality, which harms, or creates a risk of harm, to people who use the service, colleagues or the wider public. We triage the information in each enquiry, according to the level of risk to people and apply an appropriate risk-based regulatory action. As well as enquiries from workers speaking up, we also receive and process other wider complaints and safeguarding concerns from the public and other stakeholders. We triage each enquiry based on risks to people and take appropriate regulatory action. During 2022/23, we referred 97% of safeguarding risks to the relevant organisation within one day of receiving the information (this is an increase from 95% in the previous year).

Listening, learning, responding to concerns

We know that, when the public and health and care workers raise concerns with us, it can also often be a last resort following a lack of response from the provider or other parts of the health and care system. Speaking up is invited, welcomed, celebrated, inclusive, and listened to. We aim to deliver outstanding customer service to the public when raising concerns about care with us. We want everyone to feel safe to speak up and we want to respond humanely and openly and take appropriate action.

In March 2023, we published 2 reports designed to improve how we listen to, learn from and act on concerns raised in the sector. These reports followed the outcome of an employment tribunal in October 2022 where the findings were highly critical of the Care Quality Commission. We since commissioned and published a barrister-led independent review to determine whether we took appropriate regulatory action when health and care staff shared information with us.

We also published a second listening, learning, responding to concerns review to explore wider issues of culture and processes. The review has a focus on inclusivity, including understanding whether race or any other protected characteristic has an impact when we receive information of concern.

We want to build a strong and vibrant culture at CQC and make it a place where speaking up is a way of life. We want people to share their thoughts and ideas and raise concerns knowing these will be welcomed and heard. Earlier in 2023, we updated our freedom to speak up policy, which we prepared in line with guidance from NHS England and the National Guardian’s Office. Our updated policy is clearer, more succinct, and more person-centred.

In line with recommendations from the listening, learning and responding to concerns review, we are also investing in our freedom to speak up guardian roles, providing an increased number of roles and more protected time within the role, to support colleagues and enable effective coverage across the organisation (see governance report section for further detail about our freedom to speak up work).

We know we are most effective when we are open and honest with our colleagues and stakeholders, building and sustaining trust by doing what we say we will do. We acknowledge there is much for us to do to improve our listening skills internally and externally, and it is essential we deliver on the 80 recommendations from the review. We are continuing to work through the recommendations to ensure the actions we take are embedded into our ways of working and the systems we use. We will develop and improve our approaches where they need to change to achieve the overarching aims of the review.

Priority 4: Accelerating improvement

Our ambition is to do more with what we know to drive improvements across individual services and systems of care. We’ll use our unique position to spotlight the priority areas that need to improve and enable access to support where it’s needed most.

Outcomes:

• we have accelerated improvements in the quality of care.
• we have encouraged and enabled safe innovation that benefits people or results in more effective and efficient services.

Accelerating improvement: summary for 2022/23

• We initiated 2 research projects to better understand improvement cultures and offers of improvement support across health and adult social care.
• We published several thematic reviews including PEOPLE FIRST: a response from health and care leaders to the urgent and emergency care system crisis to encourage innovation and accelerate improvements in urgent and emergency care and a follow up piece to our 2019 work on access to oral health care in care homes, ‘Smiling Matters’.
• We partnered with Yorkshire and Humber Academic Health Science Network with funding from the Regulators’ Pioneer Fund to encourage innovation and improvement in NHS GP practices through partnership working and published our findings in Regulatory recognition and sharing of innovative practice by NHS GP providers to reduce health inequalities. 
• We began work to explore and pilot ways of developing the right regulatory environment for innovation to flourish with further funding from the Regulators' Pioneer Fund.
• In partnership with the National Institute for Clinical Excellence, Medical Healthcare products Regulatory Agency and Health Research Authority, with funding from the NHS AI Lab, we delivered the AI & Digital Regulations Service to support AI innovators through the regulatory pathway.

To accelerate improvements and protect the public, our enforcement activity during 2022/23 included 215 urgent enforcements and we cancelled 127 provider registrations.   

Research and evidence

We know the importance of having an approach based on evidence. We committed to investing in research to gain a better understanding of the conditions and activities that accelerate improvement. In line with this, our research programme received an uplift in funding in June 2022. We selected 5 priority areas to focus our research, including ‘accelerating improvement’.

In December 2022, we kicked off a research project reviewing improvement cultures in health and adult social care settings and in March 2023, we initiated research into improvement support offers across the sectors. These deliver findings in Summer 2023.

This year, we have built on previous research into our impact on provider performance to inform our approach to accelerating improvement. This research identified the ways we can create change in health and care provision using 8 regulatory impact mechanisms (informational, lateral, stakeholder, directive, anticipatory, organisational, relational and systemic). We have used this evidence to develop an approach to improvement that uses all our impact mechanisms. This year we have laid the groundwork for our next research to understand how we create change most effectively and how our impact mechanisms apply at a local system level. We have particularly made use of our informational impact mechanism by publishing reports and information to support improvement in care provision, and our stakeholder mechanism by using our convening ability to bring stakeholders together to address key issues.

Using our independent voice: thematic reports and publications

We have produced a number of thematic reports to support innovation and improvement.

We published our follow up piece to the 2019 work on access to oral health care in care homes, ‘Smiling Matters’ in March 2023. Responding to our recommendations, the review found that care homes are much more aware (increasing from 31% to 61%) of oral health guidelines from NICE, and more than double the proportion of care plans fully covered oral health needs.

We know that encouraging and recognising innovation in our regulatory processes can improve health outcomes for the public, as well as leading to cost savings for providers as they develop more efficient ways of working and contribute to the government's levelling up agenda.

With Yorkshire and Humber Academic Health Science Network, we won a joint bid to the Department for Business, Energy & Industrial Strategy (BEIS) through the Regulators' Pioneers Fund. Our successful bid was for project funding to explore how our regulatory process could capture and consider innovation in GP practices to respond to health inequalities. Our findings are published in Regulatory recognition and sharing of innovative practice by NHS GP providers to reduce health inequalities. 

We are committed to championing and enabling innovation and want to accelerate our own learning to be an innovation-friendly regulator. We published examples from GP providers about their successful innovation to address health inequalities. We want these examples to help other providers to recognise what innovation is and to share it. We also designed and launched an innovation hub as a central place to capture and share evidenced innovative good practice with internal and external stakeholders. 

Engaging and collaborating

We continued to engage closely with the system to shape our work on accelerating improvement. In our 2022 annual provider survey, 77% of providers agreed or strongly agreed that they had the right support from CQC to help them to improve. Similarly, 74% of providers agreed or strongly agreed that their service knows when they need to contact us in relation to innovation, adopting an innovation, and trying new ways to deliver care, and 68% felt CQC provides an environment where their service feels they can innovate and try new ways to deliver safe care.

In January 2022, we published the findings from our research to explore whether ethnic minority-led GP practices receive the same regulatory outcomes from us as providers led by GPs of a non-ethnic minority background. We did not identify any causal link between ethnic minority-led GP practices and regulatory outcomes, such as ratings and frequency of inspection. However, the report, Ethnic minority-led GP practices: impact and experience of Care Quality Commission regulation identified several contextual factors that can disproportionately affect ethnic minority-led practices and their ability to demonstrate how they provide good care. We are fully committed to being a fair regulator for all health and care providers and have since focused on embedding the recommendations into our new regulatory approach.

We also collaborated with health and care leaders to co-produce resources to support improvement and encourage innovation. In October 2022, we published PEOPLE FIRST: a response from health and care leaders to the urgent and emergency care system crisis. This is a practical resource to help system leaders and service providers support the design of person-centred urgent and emergency care services, and to encourage innovation across integrated care systems. We developed the resource with contributions from over 250 colleagues and stakeholders from across health and social care, who attended an urgent and emergency care workshop, and members of our National Emergency Medicine Specialist Advisor Forum.

In November 2022, we were awarded further funding from the Regulators’ Pioneer Fund. This will help continue the conversation about how CQC encourages and enables innovation to support providers to improve. We will work with a group of innovators and partners within the health and care system to make it easier for health and social care to design and adopt high quality innovation and ensure that regulation is seen as an enabler, not a barrier, to innovation. This project explores the way we can use our impact mechanisms to share learning about innovation in the most impactful way and includes a number of rapid pilot projects to test potential of different impact mechanisms to support innovation.

We have continued our partnership with the National Institute for Clinical Excellence, Medical Healthcare products Regulatory Agency and Health Research Authority to deliver the AI & Digital Regulations Service, a multi-agency project funded by NHS AI Lab to ensure an effective regulatory pathway for AI and data-driven innovations for health and care and to support innovators through the regulatory pathway

Core ambition: assessing health and social care systems

We will provide independent assurance to the public of the quality of care in their area. We will review  how the care provided in a local system is improving outcomes for people and reducing inequalities in their care. This means reviewing how services are working together within an integrated system, as well as how systems are performing as a whole.

Outcome:

• we have contributed to an improvement in people receiving joined-up care.

Core ambition: Tackling inequalities in health and social care

We will push for equality of access, experiences and outcomes from health and social care services. Everyone in health and social care has a role to play in tackling the inequalities in health and care. We’re committed to regulating to advance equality and protect people’s human rights.

Outcome:

• we have influenced others to reduce inequalities in people’s access, experiences and outcomes when using health and social care services.

Improving organisational efficiency and effectiveness

Our approach

During 2022/23, we continued to drive forward our ambitious transformation programme that will support us to deliver our strategy. In December 2022, we updated our timescales and communicated our revised plan and approach for transformation.

We are changing our technology, our processes and our ways of working to be a smarter regulator, accelerating improvements in how people experience health and care services, for a safer future.

We are making some important changes including:

• introducing a new regulatory approach for health and care providers, integrated care systems and local authorities
• establishing a new Regulatory Leadership team to shape our priorities and drive improvement
• changing how our operational teams and corporate services are structured to better deliver and support our regulatory activity
• delivering a new and improved online provider portal.

An important achievement during the year was publishing our new assessment framework. The framework is at the centre of our new regulatory approach and has been designed around what people want from health and care services. We also published our interim guidance for assessing local authorities and integrated care systems, and we created our new integrated assessment and inspection team structure.

Our people survey

We conducted our annual people (pulse) survey in September 2022 and received a completion rate of 79% (our highest response rate for 2 years). We used the survey results to understand how colleagues feel about working at CQC, and how their experiences align with our 3 cultural principles of trust, confidence, and empowerment. The survey also included questions regarding colleague engagement as part of our transformation change programme.

The results provide an important point from which to measure and develop the work on developing our culture. From colleagues responding to the survey, 73% felt trusted to carry out their job effectively, and 70% felt they have a choice in how to manage their work. In general, there was an overall reduction in positive responses, with a higher proportion of colleagues strongly disagreeing with statements compared with our previous survey, and colleagues had less positive responses to questions relating to change and transformation.

Senior management and Board are committing to learning lessons and making improvements as required. Following results from our people survey, a new cross organisational people-centred advisory group was set up, to develop an action plan and drive the implementation of necessary changes. The 'pulse survey advisory group' includes colleagues at all levels of the organisation. Colleagues will work across directorates, engage with senior leaders, and play an active role in shaping change. Implementing the action plan will happen alongside implementing recommendations from our ‘listening, learning, responding to concerns’ review and within our overarching organisational people plan (see People section later in the report for further information).

We will continue to conduct regular surveys to gather and understand colleagues’ views and use these results to drive change.

Recognition

Everyone is encouraged to notice and celebrate the good work of colleagues and use the tools to say thank you and to celebrate success throughout the organisation. We want to nurture a culture of recognition that engages, motivates, and inspires us to excellence. In 2022/23, 885 individual colleagues (27.9% of the organisation) received one or more vouchers in recognition of their demonstration of our values and success profile behaviours.

Our estate

We’ve continued to make changes to ensure our estate matches our requirements. During the year we have:

• refurbished one floor of our Newcastle office to provide a more modern working environment that better supports flexible working
• surrendered the lease on our Leeds office a year early and moved into a significantly smaller space with the Department of Health and Social Care office
• closed our 2 smaller satellite offices in Plymouth and Penrith
• provided accommodation for colleagues from the United Kingdom Health Security Agency in our Birmingham office
• given notice to the Government Property Agency that we intend to vacate our Bristol office at the end of March 2024.

Our sustainability

A Sustainability Fellow joined the team on secondment in September 2022 followed by a Sustainability Manager who joined CQC in January 2023. To support our sustainability, we aim to actively promote this among our colleagues through our internal engagement processes, and we have an Environmental Sustainability Steering Group (ESSG) to help in this process.

We are transitioning our 5-year Green Plan into a Net Zero Plan and we are improving our governance through more frequent updates to our Executive Team, the Board, and the Department of Health and Social Care.

Greening Government Commitments (GGCs): As part of our work towards achieving net zero by the 2050 GGC target, we have analysed our travel. As a result, we have changed permissions for colleagues travelling by air and updated the travel policy because, as is shown in the ‘Sustainability Data’ section below, this is an area with increasing emissions at CQC. We are, therefore, working to ensure we can reduce these emissions for our domestic flights to adhere to the GGC standards. Due to our lack of fleet, we have no need to convert to ULEVs.

We are also working to ensure our overall, and direct, greenhouse gas emissions are reduced from the GGC set 2017/18 baseline. However, due to improvements in data collection and wanting to be more ambitious in our comparisons / targets, as detailed in the ‘Sustainability Data’ section below, we are using a 2019/20 year to determine our performance in reducing travel emissions and a 2021/22 year to determine performance in reducing our ICT emissions. This is intended, in part, to ensure we have an aggressive approach to emissions reduction by setting ourselves more ambitious but, importantly, feasible targets.

To help achieve our goal to minimise waste and promote resource efficiency, we have undertaken a successful RCCO project to reduce the use of printers. Our current target is to reduce the consumption of printer ink and paper in the coming year by 20%. We have made significant changes in how we manage our information communication technology (ICT) assets across their lifecycle by using KOcycle, an organisation that has ensured we send none of our ICT waste to landfill. We do not promote single-use plastic among colleagues. Instead, information on our intranet and our Green Plan has outlined our position of removing all single-use plastic from our offices. Colleagues can still use their own single-use plastic, if they wish. As part of our position against using single-use plastic, all our offices, except one, have Zip HydroTaps installed rather than plastic water coolers.

To help with our current water, energy, and carbon management, we have reduced the overall size of our estate, and plan to reduce this further in the coming years. The majority of CQC colleagues also work from home, with 184.49 full-time equivalents (FTEs) in our offices and 2,922.26 FTE working from home.

We have started to assess the need for a procurement policy for the small number of supplies and services we procure through our own systems. This is because sustainability is not currently formally embedded within our procurement processes. We have stopped our procurement of single-use plastic, including for example, coffee cups, plastic water cups, plastic cutlery and plastic document wallets. We are also planning on re-negotiating a contract with our vehicle hire company to ensure it includes electric and hybrid vehicles.

As our estate does not have any form of green spaces and does not intend to acquire any, we have not made any developments regarding nature or biodiversity at CQC.

We have been working on several initiatives regarding the impact of our current ICT and travel, which is one of the few sustainability areas of the organisation we can actively control. We are currently assessing potential ICT systems to help us have a better understanding of our environmental impacts. This system should also give us oversight on the impact of cloud-based services. We are also assessing our current ICT equipment and whether we can improve them to be less energy-intensive when in use. The assessment is focused on ensuring that we include eco-friendly elements in selecting equipment for colleagues.

At the moment, we do not have a formalised climate change adaptation strategy.  However, as part of ensuring climate change impacts are mitigated within our governance processes, CQCs commercial approach is framework first and most of our procurement activity is undertaken via government frameworks through which the framework operator assesses potential supplier policy and environmental credential as part of their selection criteria for inclusion on the government framework. We are currently also working to ensure we embed climate change adaptation is embedded throughout the organisation. We will do this by examining guidance from the Task Force on Climate-Related Financial Disclosures (TCFD) and determining the best way to align CQC with this guidance, as well as developing guidance pieces for colleagues travelling for work, particularly our inspectors, on extreme weather events such as high winds and extreme temperatures.

Sustainable Development Goals (SDGs): The main SDGs that our action contribute towards are:

• SDG 12 – Ensure sustainable consumption and production patterns. We contribute to SDG 12 through our targets to reduce consumption of paper, ink, and printers as well as by using KOcycle, a zero-to-landfill organisation, for our ICT equipment.
• SDG 15 – Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss. We contribute to SDG 15 through our work with KOcycle, which uses our contribution to support sustainable projects throughout the world that focus on sustainability education and the support of ecosystems.

Sustainability data

This section discusses two types of sustainability data: Emissions and Finances.

Unlike previous years, this year’s data does not include the impact of utilities, waste, and paper. This is due to us only reporting externally on our 2 leased office locations and sharing our other 5 office locations with other public sector bodies, with no separate data available. This results in less clarity in determining ownership over improvements or failings regarding sustainability data in our shared office spaces, due to our lack of ability to control our impact in these areas. So, instead, we describe this in the narrative for these areas of operations in ‘Greening Government Commitment (GGCs)’. However, this data is provided to the Department of Health and Social Care and the Department for Environment, Food & Rural Affairs as part of our GGC compliance. Therefore, only the impact of travel and ICT is included.

Also, unlike previous years, the data being shown will be in emissions of tonnes of carbon dioxide equivalent (CO2e) generated by the activities. (CO2e covers all greenhouse gas emissions that contribute to climate change, including carbon dioxide (CO2), methane (CH4), nitrous oxide N20), and refrigerant gases like hydrofluorocarbons (HFCs)). This is to align with a shift in CQC towards using more comparable values for sustainability and taking an emissions-first approach.

Emissions:

* All domestic and international flights are economy class, and all international flights are short haul

** The significant increase in this figure is due, in part, to the substantial increase in the number of international flights post-COVID as well as the increased flight distance due to inspections taking place in locations such as overseas military bases

*2019/20 was chosen as the comparison year to compare the pre-COVID and post-COVID travel numbers with a year as recent as possible.

**Emissions from flights include both direct (CO2, CH4 and N2O) and indirect (non-CO2 emissions e.g., water vapour, contrails, NOx) climate change effects

*** The significant increase in this figure is due, in part, to the substantial increase in the number of international flights post-COVID as well as the increased flight distance due to inspections taking place in locations such as overseas military bases

*2021/22 was chosen as the comparison year to reflect changes in our emissions since last year, as COVID would not have an impact on our ICT data and our data quality, and confidence in the data, for ICT improved immensely in 2021/22.

The emissions difference between our 2019/20 figures for Travel and our 2021/22 figures for ICT compared with our recent 2022/23 figures demonstrates improvement across all fronts except international air travel. We have managed to generate feasible emissions reductions across each area examined when compared against our chosen baselines. However, our air travel emissions have risen, largely due to an increase in international air travel post-COVID and the distance to overseas destinations.

We intend on continuously improving the quality of our data collection by: Working with our two main landlords, the Department of Health and Social Care, and the Government Property Agency to better our estate data. Working with our Digital team, and our 3^rd party suppliers, to generate more detailed reports on our ICT data. We also plan to generate guidance pieces and establish strict workflows on how data collection should be undertaken to reduce mistakes and improve upon the overall quality of the data.

Finances:

All the below figures refer to expenditure for 2022/23 financial year.

Estate expenditure

Travel expenditure

Kate Terroni
Interim Chief Executive
23 July 2024