In 2019/20 we continued to realise our ambition for a more targeted, responsive and collaborative approach to regulation, so more people get high-quality care.
We focused on our four strategic priorities which were set at the beginning of the year, concentrating on a programme of business and cultural change and improvement to deliver our strategy.
2019/20 was the first year of our strategic change programme that will enable us to meet the ambition of current and future strategy, by evolving our operating model to ensure we remain a fit for purpose regulator in a changing world of health and social care provision.
We have been focused on modernising our technological capabilities to make it easier for people to do their jobs, for example rolling out Office 365 across the organisation, ensuring we have equipment that enables mobile working for our workforce and preparing for migrating our IT managed service in the first quarter of 2020/21.
Alongside this we have reviewed our digital capabilities, internal processes and operating model, which enables us to respond more flexibly when we identify changes that will impact the quality of our work. As part of this work we have made substantial progress on transforming registration, which will see community-based adult social care providers invited to use our new registration digital service.
In the last month of the year as part of our response to COVID-19 we temporarily and rapidly change our approach to regulation, as well as how we physically worked as an organisation. The process of change in March was achievable due to our investment in year on digital tools and our enhanced culture for quality improvement and change.
Whilst the EU Exit has a relatively low impact directly on the operation of CQC, during the year we ensured that our planning was robust and that we had followed Government guidance. This also included regular conversations with the Department of Health and Social Care to ensure appropriate system wide preparations are in place.
Priority One: Encourage improvement, innovation and sustainability in care
Our ambition is to work with others to support improvement, adapt our approach as new care models develop, and publish new ratings of NHS trusts’ use of resources.
We have made good progress towards this priority and have continued to encourage services rated inadequate or requires improvement to improve. We continued to publish reports targeted towards sharing best practice and improvement of services. Through academic research we now know different types of impact that our regulation can have on providers, extending beyond inspection and rating.
Throughout the year we have engaged our key stakeholders through external coproduction which helps to understand the effect strategies, policies, tool and methodologies will have and how they will work in practice. The goal of our external coproduction is to ensure the changes we make as an organisation are based on the needs of providers, the public and other key stakeholders.
We have started to make progress in encouraging innovation across the sectors and will continue this into 2020/21. We have published a joint set of principles, with NHS England and NHS Improvement, on how to enable successful innovation in health and social care providers. We have published the results of our first two ‘sandboxing’ projects. A sandbox provides a space for CQC to work collaboratively with a small number of providers and innovators over a limited period of time to set out what good looks like for a particular area of care, and to provide clarity on CQC’s regulatory activity. Our projects in year have been on the use of digital triage tools in healthcare services and the use of machine learning applications in diagnostic services.
Key areas of performance from Priority One in 2019/20:
- Of the providers that told us their services had improved in the last 12 months, 81% said CQC helped them to improve, we continue to monitor the impact and effectiveness of our approach.
- On re-inspection a total of 2,332 services improved their ratings from inadequate or requires improvement. 79% of the services that we re-inspected, and were previously rated inadequate, improved, compared with 74% in 2018/19. We continue to have regular conversations with key stakeholders, which includes inspection outcomes, risks identified and ongoing monitoring.
- In our 2019 stakeholder survey, our stakeholders told us that we work with them effectively and that our information is useful in supporting improvements to services.
- Public organisations tell us they value working in partnership with us and that it supports their efforts to bring about improvements to care services.
- We have continued to work with NHS England and NHS Improvement to assess NHS trusts’ use of resources (such as finances, people, estates, facilities and procurement). We carried out 119 inspections in NHS trusts focused on ensuring sustainable performance through leadership, management and culture at a trust-wide level.
Priority Two: Deliver an intelligence driven approach to regulation
Our ambition is to use our information from the public and providers more effectively to target our resources where the risk to the quality of care is greatest and to check where quality is improving.
Our business plan focused on transforming our registration and enabling ourselves to become intelligence driven. We have made progress in both areas, and they will continue to progress in 2020/21. We are on track to launch our first registration transformation beta (pre-release given to a group of users to try under real conditions) in Spring 2020, which will see community-based adult social care providers invited to use our new registration digital service. The team will also analyse real-time feedback from users on how the service is working, which will be used to make quick changes to the new service.
We set out to develop our culture and invest in processes and technology to deliver a step change in how we use information and how providers, public and partners experience sharing of information with CQC. We have made substantial changes to our core data systems and underpinning technology – improving how we collect, manage, use and share data from the public, providers and CQC colleagues to support consistent decision making. We have reached some important milestones including: iHub (Intelligence Hub which is a data warehouse designed to enable effective use of internal and external data) going live in December 2019; CQC Insight products being available for all sectors; and OBIEE (our application for gathering, storing and providing access to data) upgrade being complete in February 2020.
In our review of restraint, seclusion and segregation for people with a mental health problem, a learning disability or autism, we stressed the urgent need to fix a failed system of care and to strengthen the safeguards that protect the rights of people held in segregation. The treatment of people at Whorlton Hall in County Durham reinforced how difficult it can be to uncover abusive practices in such institutions. An independent review into our regulation of Whorlton Hall found that, while we followed our procedures, there were a number of reasons why we didn’t detect abusive behaviour of patients. The review made a number of recommendations to strengthen our inspection and regulatory approach of similar services, which we welcomed.
We are incorporating the recommendations into our new strategy, to ensure we improve how we regulate mental health, learning disability and/or autism services to get it right for people who use these services. Some of the recommendations relate to work that is already in progress but there is more to be done. We are committed to working closely with people who use services, families and professionals to develop our approach in a way that more effectively safeguards their human rights.
Key areas of performance from Priority Two in 2019/20:
- In our public awareness survey, of those who were aware of CQC reports, 57% held a positive view of CQC, compared to 55% in 2018.
- We introduced a new service, called Give Feedback on Care, making it easier for people to tell us about their experiences of health and social care. We made it more intuitive to use and to improve the quality of information we collect.
- We carried out more than 16,000 inspections across all sectors. This includes our public commitment to re-inspect services based on their inspection rating, as well as inspection of newly registered services and those that we inspected due to intelligence we receive.
- We inspected just under one in 10 (9.6%) of dental locations – a total of 1,210, of which 1,028 counted towards our programme. This was against a target of 10% (1,075).
- Our registration performance against agreed timescales was below our KPI target for all application types. The registration operational programme was placed in recovery in November 2019 while work was focused on clearing a backlog of historic applications. Initial progress on registration recovery was made by the year end and will continue into 2020/21. In addition, new performance indicators for registration are included within our 2020/21 business plan to ensure it remains a key focus.
- We made 1,052 visits to keep the operation of the Mental Health Act (MHA) under review. The frequency of MHA visits is depending upon the patient group, however regional teams can make an assessment to visit outside of frequency.
- We use safeguarding alerts to quickly inform local authorities of the most urgent and serious information of concern that we receive. In 2019/20, 96% of alerts were referred within one day, just ahead of our target of 95%.
- It was identified during the year that our process for recording our action for safeguarding concerns requiring mandatory action needed improvements. Improvements were implemented in August 2019 and our performance improved continuously ending the year at 92% against a target of 95%.
- When we took urgent enforcement, 75% were served within three days against our KPI target of 70%.
- 67% of Experts by Experience who responded to our inspection team survey in 2019 thought that the views of people who use services and the public are given sufficient weight in CQC judgements and ratings. This has deteriorated slightly from 73% in 2018. During the year we have worked with inspection staff to develop new guidance on the use of views obtained by experts by experience and ensuring user voice is captured in report writing.
Priority Three: Promote a single shared view of quality
Our ambition is to work with others to agree a consistent approach to defining and measuring quality, collecting information from providers, and delivering a single vision of care that can help the public understand the quality of care they receive.
We set out to deliver our role in whole system regulation, putting a greater emphasis on partnership working and system-wide quality in our regulation activity. We have made considerable progress against this priority and we are pleased to see the vast majority of health and care providers use CQC’s five key questions in carrying out their own governance, assurance and communication. We need to ensure that the work continues with other system partners to reduce the demands of regulation on providers. The proportion of providers saying that completing CQC’s provider information return is demanding remained broadly the same: 56% in 2020 compared with 57% in 2019.
Key areas of performance from Priority Three in 2019/20:
- 91% of providers said that they use our five key questions when conducting quality control and assurance, compared with 90% in 2019.
- 81% of people in our 2019 public awareness survey told us they trust that CQC is on the side of people who use services. This is an increase from 74% in the previous year.
- Public awareness of CQC has remained broadly the same compared with 2019: spontaneous awareness reducing from 25% to 23%, and total awareness reducing from 62% to 59%.
- To help build trust and understanding among people who use services, we have carried out public campaigns during 2019/20 and we are monitoring how our new online service developments, such as Give Feedback on Care, help to build further awareness.
Priority Four: Improve our efficiency and effectiveness
Our ambition is to work more efficiently, achieving our planned savings each year, improving how we work with the public and providers, and supporting our people to do their jobs well.
We have made progress under some areas of this priority, including our transformation programme, delivering within budget and implementation of new digital technology. However, we have more to do, especially in improving the experience of our people.
To support our strategy, we have begun work to design a new operating model that will build on the successes of our current model, keeping what works and including learning from our work during the COVID-19 response. Underpinning this is our organisational culture and our people. We have already seen impressive new ways of working at pace to design, test and iterate in response to COVID-19, and working with stakeholders to look at health and care from regional and national standpoints. We want to embrace and develop this collaborative approach to problem solving and evaluating risk.
Much of our focus in 2019/20 has been on building an overarching transformation programme that will take us towards our ambition of being a leading 21st century regulator. The programme and strategy are organised in three key areas that intersect and gradually build to our future CQC.
In 2020 our people survey results showed that colleagues continue to feel positively about our work, teams and managers, and a large proportion continue to consider the work of CQC as vital for people who use services: 88% said that CQC makes a positive difference to people’s lives.
There has been a significant improvement in colleagues’ experience of equipment and technology (from 42% to 57%). People also feel there has been an improvement in the ability to speak up and believe that the behaviours of leaders support our values. In our people survey 2019, the question ‘I think it is safe to challenge the way things are done in CQC’ increased by 6% and ‘I believe the values and behaviours of leaders are consistent with the values of CQC’ increased by 4% from 2018.
However, some overall perceptions of working for CQC have declined, and this has resulted in our ‘Say, Stay, Strive’ employee engagement index score decreasing by five percentage points, to 66%. Experience of change and communications continued to score very low, despite our efforts to target action in these areas. Perceptions of executive and senior leadership have seen significant decreases.
Our people survey reflected fewer people feeling engaged or involved in change and a downward trend on views of leadership. In contrast, our response to COVID-19 was positively received.
A cultural Inquiry launched in March 2020 and took place during Q1 of 2020/21. The process of talking about culture together and developing a shared understanding of how we see it currently, will shape the way everyone does things. All colleagues are invited to take part in online workshops. The workshops were aimed to build a collective view of culture by reflecting on assumptions, recognising shared beliefs and creating an open space for change.
Our estates strategy aims to provide a working environment that best supports our people to perform at their best, aligns with our regulatory approach, meets our cost constraints, and supports Office of Government Property guidance. Our current estate comprises seven buildings in Birmingham, Bristol, Leeds, London, Manchester, Newcastle and Nottingham. We also have access to three satellite ‘drop-in’ offices. More than 65% of our people are home-based workers, and those who are office-based are encouraged to adopt smarter working principles.
We have planned a range of efficiency savings and during 2019/20 we have:
- Contributed to the project to move our London office to a much smaller and more cost-effective building in Stratford (East London) from late 2020.
- Closed our Preston office and consolidated it with the Manchester office.
- Continued to hold wellbeing events to support colleagues to connect better within offices and to create welcoming office environments for visiting home workers.
- Actively sought public sector bodies to share under-utilised space.
- gas used: 207,933 kwh
- water used: 592 m3
| Method of travel | miles | kilometres |
|---|---|---|
| Staff cars | 3,661,046 | 5,891,882 |
| Car hire | 128,880 | 207,412 |
| Rail | 2,296,272 | 3,695,492 |
| Flights | 44,496 | 71,609 |
- number of flights: 496
- waste (recycled): 12 tonnes
- waste (landfill): 11 tonnes
| Paper size | reams |
|---|---|
| A4 | 8,895 |
| A3 | 175 |
| A5 | 0 |
Our aim is to reduce the impact of our business on the environment. Efficient use of our IT systems and accommodation is an important strand of this work. We have established an Environmental Sustainability Steering Group, are reviewing our sustainability development management plan, and have an ongoing dialogue with our suppliers of goods and services to make sure that they have sustainable working practices with supporting policies. We report our environmental performance on a quarterly basis to DHSC and are currently exploring how we can promote sustainability in our role as a regulator.
Key areas of performance from Priority Four in 2019/20:
- We delivered within budget, with a 3.7% underspend on revenue budget and 9.8% underspend against our capital budget. Our revenue budget position was driven by several contributing factors including inspector vacancies carried towards the end of the financial year, the resolution of a disputed prior year property charge, lower depreciation charges in year than planned and delivery of certain planned change programmes straddling financial years, which is also the driver for the capital underspend.
- We have strengthened the technology we have in place so that we have the baseline technical capabilities to evolve and build new, exciting digital systems in the future. This investment meant that we could relatively easily move to home working for our whole organisation, including our National Customer Services Centre, in response to the COVID-19 emergency. We were also able to use our technology platforms to offer direct support to the DHSC’s COVID-19 testing service, accelerating its use in social care by a number of weeks.
- 90% of Adult Social Care and 93% of Primary Medical Service inspection reports were published on time, which meets and exceeds our 90% KPI respectively. We have further to go to meet our targets overall, with just 54% of Hospital reports being published on time. Quality Improvement projects are ongoing to concentrate on this area of performance.
- In 2020, Stonewall announced that CQC has moved up 68 places in the annual index of workplace equality – from 204th to 136th out of the 504 organisations that applied.
- We remain committed to reporting on the Workforce Disability Equality Standard (WDES) for CQC, addressing any inequality of opportunity and improving the experience of our people. We published our first WDES report in 2019/20.
- We now have six equality and diversity networks for colleagues, that are an inspirational driver for our diversity and inclusion work across the organisation.
- 55% of colleagues were positive that they could make improvements happen in their area of work (up 1% on 2018). We have begun our ‘Silver’ Quality Improvement Champions in-person training, with the aim of reaching 600 people by the end of 2020/21, although COVID-19 is expected to impact on this figure.
- We continued to support the Cabinet Office’s four principles of HQ, Home, Host and Hub and we worked closely with DHSC to make sure that we align our efforts wherever possible, particularly to the Government Hub Strategy which encourages a smarter, leaner, more fit-for-purpose estate, with a focus on efficiency and people.
- In 2019/20 we have withdrawn use of single plastics, reduced the volume of paper we use and through digital transformation promoted e-working and facilitated less travel.