Care Quality Commission (CQC) Quality Improvement Progress Update - February 2025

Meeting: Trust Board – Public Meeting

Date: 12 February 2025

Report Title: Care Quality Commission (CQC) Quality Improvement Progress Update

Agenda Item: PUB25/02/5.1

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 from the last inspection (2022) 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.

Recommendation: The Trust Board is asked to:

• Note the status of completed actions within the MUST and SHOULD Do action plan (2022).
• Note the ongoing reasonable assurance regarding the progress against the MUST Do and SHOULD Do action plans.
• Note the recent feedback, Section 64 and S29A warning notices received from the CQC.

Purpose: The purpose of the update is to provide the Trust Board with the progress made against the MUST Dos and SHOULD Dos since the last CQC core inspection in 2022. Furthermore, it provides the CQC feedback and Trust response to the ongoing current inspection of both the Emergency Operation Centres and Urgent and Emergency Operations, while the Trust waits to receive the full draft report. The feedback letter and response can be found in the Appendices for reference. It also provides a notification of a recent CQC requirement for an information request applied under Section 64 of the Health and Social Care Act and a Warning Notice served under section 29A of the Health and Social Care Act 2008 regarding the findings provided by the ongoing inspection.

Executive Summary:

To date, 93% (+6%) of all MUST and SHOULD Do actions contained within the 2022 plan have been closed, with two actions currently overdue which relate to the delivery of C1 and C2 performance (due date 31 October 2024) and the establishment of safe staffing requirements (due date 30 September 2024). The remaining three open actions are due to close on 31 March 2025.

During the period 19-21 November 2024, the CQC inspected the Trust and provided feedback in a letter dated 29 November that indicated that all staff were open, honest and welcoming of the inspection and remain passionate about doing the best for patients.

Within the letter, a number of areas of improvement were highlighted that covered medicine management, culture, staffing levels and training.

The Trust welcomed the feedback and provided a response in acknowledgement of the areas of improvement and best practice to support the CQC with their ongoing inspection.

The feedback letter and Trust response can be found at Appendix 1 and 2 and have been shared at the request of the CQC whilst the draft report is under construction.

Since the feedback letter was responded to, further communication was received:

• On December 2024 a letter was received from the CQC highlighting concerns around
• Category 2 performance that had been provided during the inspection information request.
• On 23 January 2025 the Trust received a Section 29a warning notice of the Health and Social

Care Act 2008 that indicated that:

1. Staff training was not up-to-date
2. Waiting times for calls was below the national standards
3. Staff numbers within Emergency Operational Centres was not at the required levels
4. Cultural issues still existed
5. Not all controlled medicine incidents were investigated and/or acted upon
6. Staff feedback was not acted upon to further develop or improve

• On 27 January 2025 the Trust received a Section 64 notice in relation to Regulation 17a&b and Regulation 12 of the Health and Social Care Act 2008 that indicated:

1. The Trust found the systems and processes had failed to ensure compliance in not meeting national standards in relation to Category 2 response times. The Trust accepts the position of the CQC and has begun work to address the areas for improvement and continue to support the CQC with the ongoing inspection.

Introduction/background

Following the last CQC inspection in 2022, an 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 Dos and 25 SHOULD Dos. To date, the Trust has closed 93% of all actions (64/69) and has two actions overdue, which relate to:

• 4.9 The delivery of C1 and C2 performance (due date 31 October 2024)
• 7.6 The establishment of safe staffing requirements (due date 30 September 2024)

Information relating to the remaining three open actions (due date 31 March 2025) is provided in the following table.

On 23 January 2025, CQC issued a Section 29A Warning Notice against the Trust. Concerns were as follows:

• The service did not ensure that staff kept up-to-date with their mandatory training.
• Waiting times for calls were below national standards which meant the service did not ensure people could access the service when they needed it.
• The service did not have enough staff to keep service users safe from avoidable harm and/or provide the right care and treatment.
• The service had cultural issues across the three Emergency Operations Centres sites and the emergency and urgent care sites.
• Not all controlled medicine incidents were investigated, appropriate action taken and recorded to mitigate further risks or lessons identified to improve future practice.
• Ambulance station areas did not all adequately act on information about staff opinion of the service to develop and take actions for improvement.

The CQC has stated that the Trust needs to make improvements in the Emergency Operations Centres and emergency and urgent care core services by 21 April 2025.

In addition, on 27 January 2025, the CQC issued a Section 64 letter which detailed findings from the recent assessment (please note, the Trust is awaiting receipt of the draft inspection report).

This included a breach of Regulation 17 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 (Good Governance)) and Regulation 12 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 (Safe care and treatment). The Section 64 letter focussed primarily on Category 2 response times. Under Regulation 17(3)(a)(b), the Trust is required to describe clearly the action it will take to meet the regulation and what it intends to achieve by 19 May 2025 (4-months).

Action taken:

Due to the timing of the paper submission and the activity, which is ongoing, the following has already been put into place:

• Training – expected improvements in mandatory training to reach the required levels by 31 March 2025 (monitored through Accountability Meetings).
• Performance – review of modelling to improve both call waiting and Category 2 performance (monitored through the Transformation Programme Board).
• Cultural/Staff Engagement – develop local plans and publish activity and improvements after the release of latest NHS staff survey results (monitored through the Transformation Programme Board).
• Medicine Management – Medical Director oversight of review of systems and processes of Medicine Management Group and activity (monitored through Accountability Meetings).

Key Issues / Risks:

QUA0007: Inability to monitor and evidence compliance with regulatory standards (CQC, DPA 2018, Hygiene Code of Practice, EDS2, DSPT).

STR0003: SR2: If we do not deliver operational and clinical standards then there is a risk of poor patient outcomes and experience.

As previously reported, the completion and update of CQC action plans is key to manage risk. 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 Trust Board is asked to discuss the current position in relation to the feedback provided and offer support/challenge to content of addressing the CQC findings that continues to be monitored via the new action plan through the Continuous Improvement and Regulatory Group, Quality Governance Committee, and the Executive Clinical Group. Regular updates will be provided as progress develops against the remaining actions to be closed.