CQC Quality Improvement Plan – Progress Report - July 2024
Meeting: Public Meeting
Date: 10 July 2024
Report Title: CQC Quality Improvement Plan – Progress Report
Agenda Item: PUB24/07/3.1
Author: Natalie Mudge, Head of Compliance
Lead Director: Simon Chase, Chief Paramedic and Director of Quality
Purpose: Discussion Review / Information Noting
Link to CQC domain:
- Caring
- Responsive
- Effective
- Well Led
- Safe
Link to Strategic Objective:
- Be an exceptional place to work, volunteer and learn
- Provide outstanding quality of care and performance
- Be excellent collaborators and innovators as system partners
- Be an environmentally and financially sustainable organisation
Link to Strategic Risk:
- SR1: Failure to deliver a timely service to our patients in line with commissioned national standards, to ensure a safe level of service
- SR2: Failure to achieve continuous quality improvements and high-quality care delivery
- SR3: Failure to embed a culture focused on staff safety and wellbeing
- SR4: Failure to deliver an efficient, effective and economic service
- SR5: Ability to embed EEAST’s place within the changing system to support delivery of the NHS Long Term Plan
- SR6: Ability to ensure sufficient capacity and capability to ensure sustainable change
- SR7: Failure to ensure a well governed and accountable trust
Equality Impact Assessment: No negative impact identified
Previously considered by: Actions to close the MUST Dos and SHOULD Dos are reviewed at the Continuous Improvement and Regulatory Group (CIRG) and Executive Clinical Group. The Quality Governance Committee (QGC) has also regularly received quarterly assurance updates in relation to the CQC progress.
Purpose: The purpose of the update is to provide the Trust Board with the improved progress made against the MUST Dos and SHOULD Dos since the last CQC core inspection in 2022 and support the recommendations made at the CIRG meeting on 27 June 2024 and Executive Leadership Team (ELT) on 02 July 2024
Recommendation: The Trust Board is asked to note the improved status of completed actions within the MUST and SHOULD Do action plan, and to also note the ongoing moderate assurance regarding the progress against the MUST Dos and SHOULD Dos action plans.
Executive Summary
Following a presentation of a number of action recommendations to the Executive Clinical Group on 11 June, the Group requested further information to be presented to ELT for discussion and consideration of refreshing the agreed recommendation timeframes. This exercise has been undertaken and the following position provides the status of activity which has shown a further improvement on closure of actions moving from 45 to 56/69 closed on the last report.
The current improved position shows the Trust has completed 56/69 (81.2%) actions contained within the plan which comprises of the Must and Should Dos following the 2022 CQC Core Inspection report, as well as the two actions transferred from the 2020 plan.
| Total | Completed | Overdue | Not yet due / in progress | |
|---|---|---|---|---|
| MUST | 44 | 35 | 0 | 9 |
| SHOULD | 25 | 21 | 0 | 4 |
| TOTAL | 69 | 56 | 0 | 13 |
The remaining thirteen open actions (not yet due/in progress) relate to: leadership and staff development, category 1 and category 2 response times, culture programme including the inclusivity plan, appraisals, staffing, estates programme and the Datix Cloud IQ upgrade. All actions, bar one, are in progress however these are not currently in a position for closure. The action relating to response times was recently amended to ensure this remains a focus within the CQC plan aligning with our current priority objectives and our Operational Performance Improvement Plan (OPIP).
Introduction/Background
The following tables provide more information for each open action, along with the due date and current completion % that has been supported by ELT.
During the exercise to review all open actions, each Directorate has evidenced what is required to close the actions and this is supported by the Executive Directors who have agreed the timeframe to close. This information is held within the InPhase Database that supports our Key Lines of Enquiry (KLoE).
MUST Dos
| Action | Due date | Completion |
|---|---|---|
| 3.2: Implement a talent management process to ensure that leaders are recruited in an approach that ensures transparency and merit-based appointments. | 31/03/2025 | 30% |
| 4.9: Deliver the long term C1 and C2 progress trajectory actions to ensure productivity of patient facing staff hours per week (percentage relating to PFSH to be provided), both C1, C2 and PFSH progress monitored through OPIP | 31/10/2024 | 0% |
| 6.1: Continue to progress the Culture Oversight Group within Fit for the Future, including the delivery of the task and finish groups within this which address deep rooted issues that staff have identified | 31/03/2025 | 30% |
| 7.4: Participate and complete the national programme to convert the call handler role profile to band 4, in order to improve retention. (It should be noted that this is a nationally driven project which has been delayed by the upcoming election (PURDAH in place) | 30/09/2024 | 90% |
| 7.6: Based on UEC strategy - establish safe staffing requirements and monitoring approach across all clinical areas; phased approach to new ways of work | 30/09/2024 | 40% |
| 8.1: Review the appraisal process and documentation to ensure it is fit for purpose, accessible and supports delivery of an effective appraisal for all | 31/03/2025 | 50% |
| 8.2: Improve appraisal rate compliance to 85% | 31/03/2025 | 75% |
| 9.1: Estates EOC improvement programme (and digital) | 31/03/2025 | 50% |
| 9.2: EOC scoping review to understand design maintenance and use of facilities as part of programme Review. | 31/03/2025 | 50% |
SHOULD Dos
| Action | Due date | Completion |
|---|---|---|
| 3.4: Deliver the WRES and WDES action plans, focused upon the objectives relating to bullying, harassment and concerns that our staff have raised | 31/03/2025 | 50% |
| 4.1: Raising of concerns - monitored in line with the Fit for the Future programme and the culture dashboard | 31/03/2025 | 50% |
| 5.1: Establish a clear policy and approach for training applications and approval, that ensures equity in development. This must include ensuring that local variation cannot occur or is accounted for as part of the process. This must include audit and monitoring of compliance with the policy | 30/09/2024 | 75% |
| 7.4: Adoption and implementation of Datix Cloud IQ to ensure easier identification of incident trends and patient experience | 30/09/2024 | 90% |
Key issues/risks
1791: Inability to monitor and evidence compliance with regulatory standards (CQC, DPA 2018, Hygiene Code of Practice, EDS2, DSPT).
The monitoring of the Trust’s position against each KLoE is to provide reassurance on the work on the actions under Section 29a and Section 31 which are vital to ensure the Trust’s compliance with the Health and Social Care Act.
As previously reported, the completion and update of CQC action plans is key to drive risk down. All evidence collected for the evidence log for CQC core inspection has supported a strong position, but it remains important to review the evidence regularly and this action is now a standing agenda item through the Compliance and Risk Group (CRG). Consideration of risk change will occur once all outstanding MUST Dos and SHOULD Dos are cleared. Closure and change of risk will assist a move to high assurance around Regulatory compliance and the Trust remains hopeful of further improvement around regulatory scrutiny at the next core inspection.
Summary
The Board is requested to discuss and support the current position and to accept the current status of moderate assurance position that continues to be monitored via the new action plan through CIRG, QGC and ECG. Regular updates will be provided as progress develops against the remaining actions.
Appendix 1 – CQC Quality Improvement Plan: Key Objective status (end Q1, 2024-25)
MUST Do
| Key Objective | Total | Complete | Overdue | Not yet due / In progress |
|---|---|---|---|---|
| 1. The service must ensure it provides mandatory training in key skills to all appropriate staff and volunteers. (Regulation 17 (1) (2) (b)) - EUC/EOC | 4 | 4 | 0 | 0 |
| 2. The service must improve access to resources to support local managers to take action to manage behaviours that do not meet the trust values. (Regulation 17 (1) (2)) - EUC | 4 | 4 | 0 | 0 |
| 3. The service must ensure the application and recruitment process for internal promotion is open and transparent. (Regulation 17 (1) (2)) - EUC | 3 | 2 | 0 | 1 |
| 4. The service must ensure people can access the service when they needed it, and that response times for calls are in line with national standards. (Regulation 17 (1) (2) (a)) - EUC/EOC | 9 | 8 | 0 | 1 |
| 5. The service must ensure staff complete risk assessments for each patient comprehensively to remove or minimise risks and update the assessments. (Regulation 17 (1) (2) (b) (c)) - EOC | 4 | 4 | 0 | 0 |
| 6. The service must ensure it continues to develop its staff engagement processes to improve staff wellbeing and respond to staff concerns within the service. (Regulation 17 (2) (a)) - EUC/EOC | 7 | 6 | 0 | 1 |
| 7. The service must ensure that it has enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and or to provide the right care and treatment. (Regulation 18 (1) (2) (a) (b) (c)) - EUC/EOC | 6 | 4 | 0 | 2 |
| 8. The service must ensure that all staff receive appraisals, one - to one support and that clinical staff receive clinical supervision. (Regulation 18 (2) (a)) - EUC/EOC | 4 | 2 | 0 | 2 |
| 9. The service must ensure the design, maintenance and use of facilities, premises always keep people safe. (Regulation 15 (1)) - EOC | 3 | 1 | 0 | 2 |
| MUST Do Total | 44 | 35 | 0 | 9 |
| OVERALL TOTAL | 69 | 56 | 0 | 13 |
SHOULD Do
| Key Objective | Total | Complete | Overdue | Not yet due / In progress |
|---|---|---|---|---|
| 1. The trust should ensure all staff are informed and engaged with in relation to the Fit for the Future programme. - Trust wide | 4 | 4 | 0 | 0 |
| 2. The trust should ensure there is policy in place to support women, including those who are breast feeding back into the workplace following maternity leave. - Trust wide | 2 | 2 | 0 | 0 |
| 3. The trust should ensure they engage with and act on feedback from all staff, particularly from those represented with protected characteristics. - Trust wide | 9 | 8 | 0 | 1 |
| 4. The trust should continue with the pace of addressing cultural issues. - Trust wide | 1 | 0 | 0 | 1 |
| 5. The service should ensure that training opportunities are available and that the application process for training places is open and transparent. - EUC | 1 | 0 | 0 | 1 |
| 6. The trust should ensure there are systems and processes in place to support staff when skill mix is adjusted due to operational demands. - EUC | 4 | 4 | 0 | 0 |
| 7. The service should ensure that it introduces and uses electronic information and data systems to improve performance regarding patient waiting times and to dispatch resources in line with national standards. - EOC | 4 | 3 | 0 | 1 |
| SHOULD Do Total | 25 | 21 | 0 | 4 |
| OVERALL TOTAL | 69 | 56 | 0 | 13 |
