CQC Quality Improvement Plan Progress Report - September 2024

Meeting: Trust Board – Public Meeting

Date: 11 September 2024

Report Title: CQC Quality Improvement Plan Progress Report

Agenda Item: PUB24/9/5.1

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:

• 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
• 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
• SR7: Failure to ensure a well-governed and accountable Trust

Equality Impact Assessment: No negative impact identified

Recommendation: The Trust Board is asked to:

• Note the improved status of completed actions within the MUST and SHOULD Do action plan.
• Note ongoing moderate assurance regarding the progress against the MUST Dos and SHOULD Dos action plans.
• Note the Trust’s timely response to a recent requirement received from the CQC under Section 64 of the Health and Social Care Act 2008.

Purpose: 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. It also provides an overview of a recent CQC requirement for information request applied under Section 64 of the Health and Social Care Act.

Executive Summary:

To date, 83% (an increase of 3% since last reported) of all MUST and SHOULD Do actions contained within the plan have been closed with no open actions overdue. The remaining open actions are all in progress with the majority pertaining to the Trust’s long-term culture programme. The Trust has recently submitted a narrative response to the CQC with associated evidence regarding the provision of Freedom To Speak Up to the CQC following notification of a requirement to provide the CQC with specified information and documentation under Section 64 of the Health and Social Care Act 2008. At the time of the Trust Board, the submission was provided in time and the Trust was awaiting feedback with regard to their submission which follows normal timeframes regarding these requests.

Introduction / Background:

Following the last CQC inspection in 2022, a robust action plan was set based on the recommendations made by the CQC within their report. Two outstanding additional actions from the previous inspection were also included, resulting in a total of 69 actions – 44 MUST and 25 SHOULDDos.

To date, the Trust has closed 83% of all actions and has no actions overdue. The remaining open actions are all in progress with the majority pertaining to the Trust’s long-term culture programme. Furthermore, following notification of a requirement to provide the CQC with specified information and documentation under Section 64 of the Health and Social Care Act 2008 relating to the provision of Freedom To Speak Up (FTSU) services, the Trust responded in line with the requested deadline and submitted evidence for the following points:

1. Formal arrangements for FTSU
2. Role holders’ details
3. FTSU Policy
4. Reports to Board
5. Handover
6. Outstanding case

The Trust is currently awaiting feedback from the submission and remains confident with the submission will answer all enquiries.

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 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.

Options:

The Board is asked to discuss and support the current position, and is requested to accept the current status of moderate assurance, a 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 to be closed.