CQC Quality Improvement Plan Progress Report - November 2024
Meeting: Trust Board – Public Meeting
Date: 6 November 2024
Report Title: CQC Quality Improvement Plan Progress Report
Agenda Item: PUB24/11/5.1
Author: Natalie Mudge, Head of Compliance
Lead Director: Simon Chase, Chief Paramedic and Director of Quality
Purpose: 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:
- SR1a: If we do not ensure our people are safe and their wellbeing prioritised, there is a risk that we will be unable to attract, retain and keep all our people safe and well
- SR1b: If we do not ensure our leaders are developed and equipped, there is a risk that we will not be able to change our culture, and value, support, develop and grow our people
- SR2: Failure to achieve continuous quality improvements and high-quality care delivery
- SR3: If we do not ensure we have the ability to plan, influence and deliver across our systems to secure change, we will not be able to meet the needs of our public and communities
- SR4: Failure to deliver an efficient, effective and economic service
- SR5: If we do not clearly define our strategic plans, we will not have the agility to deliver the suite of improvements needed
- SR6: Ability to ensure sufficient capacity and capability to ensure sustainable change
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 has also regularly received quarterly assurance updates in relation to the CQC progress. The Trust Board received a positional report in July 2024. It was requested to provide a more focused review on the actions that remain open and timeline to close at the next update.
Recommendation: The Trust Board is asked to note the improved position regarding the completed actions within the MUST and SHOULD Do action plan. The Trust Board is also asked to note ongoing moderate assurance regarding the progress against the MUST Dos and SHOULD Dos action plans.
Purpose: To provide the Trust Board with current progress made against the MUST Dos and SHOULD Dos since the last CQC core inspection in 2022, in particular the improvement from the last report in July 2024 with a focus on what remains open and why it remains open.
Executive Summary:
Presently, the Trust has completed 60/69 (87.0% = +4% increase from last report) 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 (in progress) | Not yet due (in progress) | |
|---|---|---|---|---|
| MUST | 44 | 38 | 1 | 5 |
| SHOULD | 25 | 22 | 1 | 2 |
| TOTAL | 69 | 60 | 2 | 7 |
The remaining nine open actions (not yet due/in progress) relate to: leadership and staff development, Category 1 and Category 2 response times, the Culture programme including the Inclusivity Plan, improving appraisals, increasing staffing, supporting the Estates programme and the Datix Cloud IQ upgrade. All actions are in progress, however these are not currently in a position for closure.
Introduction/background
The following tables provide a focus regarding each action and confidence regarding the estimated completion:
MUST Dos
| Action | Due date | Completion | Position as at 14.10.2024 |
|---|---|---|---|
| Implement a talent management process to ensure that leaders are recruited in an approach that ensures transparency and merit-based appointments. | 31/03/2025 | 40% | The leadership development framework (LDF) for clinical leaders is well underway with a 72% completion rate, and a 92% satisfaction rate. Operational teams have commenced talent succession mapping with leadership development managers. Any learning from this will be used to define the process for the future digital version. Increase of 10% in completion during September 2024. Confidence to close is high against due date. |
| 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 | 10% | Workstreams linked to Trust priorities supported by Trust Board (detailed through OPIP and recent PA Consultant ICB review will determine plan and timeframe to improve sustained performance). Increase of 25% since last reporting in September 2024. Confidence remains limited and links to overall performance monitoring by regional performance review. The action will fall due and is a primary focus of the Trusts priorities to improve. |
| 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% | National piece of work ongoing re 'Safe staffing for ambulance Trusts' based on hypothesis 60/40. Trust currently has 50/50 split and further review of Long-Term Workforce Plan and Trust Recruitment will continue to move towards a safe staffing approach (linked to 4.9 above). Currently national picture has slowed through AACE workstream. Increase of 10% since last reporting in September 2024. Action is overdue and unable to close due to external halting to further decision making – limited confidence. Mitigation is workforce planning and Connected Planning will provide recovery for performance and is linked to PA Consultant work which is under review. |
| 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% | The new digital appraisal system will ensure our talent management approach is transparent, fair and consistently applied. The expected launch of this is during Q4 in 2024-25, which will see a significant improvement in appraisal rates, and an ability to manage talent and succession much more pro-actively. Revised form to be shared at a number of Trust groups for comment by end December 2024 prior to full digital adoption end March 2025 Increase of 10% in completion in September 2024. Confidence to close is high against due date. |
| Improve appraisal rate compliance to 85%. | 31/03/2025 | 75% | With the new digital appraisal system in place and the correcting of structures across EEAST - which give management improved oversight of their teams, departments and directorates - we anticipate an improved compliance. In addition to this, within Time to Lead (TTL), there is now improved spans of control. Confidence to close is moderate to high against due date. |
| Estates EOC improvement programme (and digital). | 31/03/2025 | 50% | Partially complete - Digital support in regard to the Estate plan is now complete following funding agreement for the new desk and digital layout at the sites. Upgrade of the existing estate Phases 1 and 2 are complete. Due to the size and complexity (after discussion with Finance/Estates), date extended to March 2025. Confidence to close is moderate against due date. |
SHOULD Dos
| Action | Due date | Completion | Position as at 14.10.2024 |
|---|---|---|---|
| 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% | Trust Inclusivity Plan in place. The next update report on progress on this work will go to People Committee in October 2024. Confidence to close is high against due date. |
| Raising of concerns - monitored in line with the Fit for the Future programme and the Culture dashboard | 31/03/2025 | 50% | The Raising Concerns forum continues to review FTSU themes, ER cases, data from our EDI surveys, the quarterly pulse survey and national staff survey. In addition, the Trust is contracting with a new independent provider on FTSU which will extend the current in-hour service to a 24/7 service giving more of our people access and the ability to speak up. Confidence to close is high against due date. |
| Adoption and implementation of Datix Cloud IQ to ensure easier identification of incident trends and patient experience. | 30/09/2024 | 90% | Due to outstanding concerns, ie. critical system functionalities that remain untested or incomplete and stability concerns with some key process, the ‘go live’ date has been pushed back to 01 November 2024. Confidence to close is limited to moderate as the action is overdue but testing is currently now underway to close. |
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 re-assurance 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 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.
