CQC Quality Improvement Plan – Progress Report

Meeting: Public Meeting

Date: 8 May 2024

Report Title: CQC Quality Improvement Plan – Progress Report

Agenda Item: PUB24/05/2.2

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 ratified at Executive Clinical Group. The Quality Governance Committee has regularly received quarterly assurance updates in relation to the CQC progress.

Purpose: The purpose of the update is to provide the Trust Board with an end of year (2023/24) position for progress made against the MUST Dos and SHOULD Dos since the last CQC core inspection in 2022. The report aims to provide moderate assurance.

Furthermore, an update has been provided on the current status of the regulatory conditions in relation to the s.29 and s.31 CQC improvement notices.

Recommendation: The Trust Board is recommended to discuss and note the progress made and position and the end of 2023/24 regarding the CQC MUST Do and SHOULD Do action plans.

The Trust Board is also asked to note ongoing moderate assurance regarding the progress against the MUST Do and SHOULD Do action plans, the continued work on lifting the s.29 and s.31 improvement conditions, and the Trust’s plans in moving to the new CQC assessment framework.

Executive Summary

At the end of the financial year 2023/24, 46 out of 69 actions (66.7%) have been completed and are now closed, with no actions being overdue at the end of March.

The majority of the remaining 23 actions relate to the Trust’s long-term strategic goals, ie. culture, response times (C1 and C2 categories) staffing, training, supporting staff, etc. There are also two long-term actions relating to systems (CAD supplier and Datix IQ).

Four conditions to the Trust’s CQC registration have been lifted relating to safeguarding, allegations, DBS and pre-employment checks. At the time of this report, the Trust is awaiting the outcome of a fifth relating to how People Services manages complaints about staff. We remain on target to submit for a further two conditions; relating to the contract of private ambulance services and sexual harassment/assault will be submitted in Quarter 1, 2024/25. The remaining two outstanding notices relate to action plans closure and HR governance will be assessed during the next core inspection.

The closure of actions, lifting of conditions and other improvements has been recognised by the NHSE resulting in the Trust moving from level 4 to level 3 within the NHS Oversight Framework (NOF) and coming out of the Recovery Support Programme in January 2024.

Work will continue embedding the actions already implemented and closure of those still ongoing, as well as establishing what will be needed to move to achieve level 2 of the NHS Oversight Framework. This will be linked with the production of quality statements as defined by the CQC in their revised assessment framework.

Introduction/Background

Following a CQC inspection in 2022, 67 actions were set against the MUST and SHOULD dos identified within the report. In April 2023, two long-term actions from the previous inspection were merged with these to provide single oversight and monitoring bringing the total actions to 69 (27 MUST and 17 SHOULD).

All due actions are discussed at the monthly Continuous Improvement and Regulatory Group and rationale provided to the Executive Clinical Group (ECG) with recommendations to either close or extend the deadline of each action. It should be noted that for those where an extension is recommended, work is in progress, however the Group feel that there may not be enough evidence to demonstrate change or full implementation to recommend the action to be closed.

MUST Dos and SHOULD Dos - Update

The following information provides the Trust’s end of year position in relation to the MUST and SHOULD Dos following the 2022 CQC Core Inspection report as well as the two actions transferred from the 2020 plan.

In summary, 46/69 actions (66.7%) have been completed and are now closed, with no actions being overdue at the end of March.

It should be noted that the majority of the remaining 23 actions relate to the Trust’s long-term strategic goals, ie. culture, response times (C1 and C2 categories) staffing, training, supporting staff, etc. There are also two long-term actions relating to systems (CAD supplier and Datix IQ).

(Further breakdown information relating to action status against each key objective can be found in the Appendix.)

S.29 and s.31 condition - Update

Evidence and applications for lifting conditions continues. From the original notices, the process requires each individual notice to be applied to be lifted. Once the evidence is collated, it is checked with each SRO and quality assured by NED and ELT before application is submitted.

In relation to the lifting of conditions following the CQC 2020 inspection, the table below demonstrates the current position.

NHS Oversight Framework (NOF)

The hard work the Trust has undertaken regarding the closure of actions, lifting of conditions and other improvements has been recognised by the NHSE resulting in the Trust moving from level 4 to level 3 within the NHS Oversight Framework (NOF) and coming out of the Recovery Support Programme in January 2024.

Moving forward - new assessment

Work will continue embedding the actions already implemented and closure of those still ongoing, as well as establishing what will be needed to move to achieve level 2 of the NHS Oversight Framework.

The CQC have started to implement their new assessment process and have published guidance relating to:

• how often they will carry out assessments and calculate ratings
• their single assessment framework, and
• evidence categories.

The new framework retains the five key questions: Safe, Effective, Caring, Responsive and Well-Led, but these will be assessed through quality statements which are replacing the KLoE prompts.

These statements will give organisations an opportunity to express the commitments that they will live up to, showing how services and providers will work together to plan and deliver high quality care.

Work will commence on publishing the Trust statements in quarter one which will be supported by data outcomes as well as patient and staff stories and will link to our ambition to move to NOF2.

Key Issues/Risks

1791: Inability to monitor and evidence compliance with regulatory standards (CQC, DPA 2018, Hygiene Code of Practice, EDS2, DSPT).

The completion and update of CQC action plans is key to drive risk down. Consideration of risk change will occur once all outstanding MUST Dos and SHOULD Dos are cleared and this is expected for further review in Quarter 1 of the 2024/25 financial year. Closure and change of risk will assist a move to high assurance around Regulatory compliance and the Trust remain hopeful of further improvement around regulatory scrutiny at the next core inspection.

Options

The Trust Board is asked to discuss and note the improvements made, the plans to further improve in the coming year, and to accept the current moderate assurance position that continues to be monitored via the new action plan through CIRG, QGC and ECG.

Summary

As per Executive Summary.

MUST Dos and SHOULD Dos Appendix