Performance Report: August 2018

Transcription

1 Performance Report: August 218

2 Reporting Our Performance Annual Cycle Quarterly: Board Report Strategic Measures / Surveys Operational Performance / Risk / Internal Audit / Business Plan Delivery /Finance Are We Delivering Our Commitments? Monthly: ET Report & Board Summary / SLTs Operational Performance and Quality Improvement Deep Dives / Finance Are We Efficient? Are We Consistent? Are We Effective? Annual: State of CQC Report Impact and Outcomes (Internal) Annual Report and Accounts Do We Learn and Improve? Weekly: Operational Delivery / Activity Reporting 2

3 Reporting Our Performance Audiences SLTs ET ACGC RCG Board Annual Performance Products State of CQC Report Impact and Outcomes State of CQC Report /Governance statement Management assurance process summary State of CQC Report Impact and Outcomes (Private) Annual Report and Accounts Quarterly Performance Products Operational Performance and Surveys Performance report: Operational performance and Impact (products as for Board see last column) Deep dives on performance Risk Report Internal Audit Report NAO/PAC Action Plan and Progress Report Deep Dives on Risk Risk Report covering those within RCG remit (e.g. Consistency) (to be agreed) Performance report: Operational Performance and Impact: Strategic Measures and Surveys Operational Performance Risk Internal Audit Business Plan Delivery Finance Monthly Performance Products Monthly performance report Operational performance Monthly performance report to ET (and summary to Board) Operational performance N/A N/A Summary report on Operational performance Purpose Operational Performance Management (includes delegation of improvement priorities to Operational improvement groups eg: CIG) Assurance on Operational performance management (and focus on improvement priorities) Assurance on Strategic Change delivery Assurance regarding risk management and assurance processes Assurance regarding regulatory risk management processes Assurance on CQC overall performance 3

4 Performance Annex - Legend Manage Our Resources Illustrates the operating model component Commonly Used Acronyms ASC Adult Social Care; PMS Primary Medical Services; HSP Hospitals; MH Mental Health; NCSC National Customer Service Centre; IH Independent Health; YTD Year To Date (Financial Year); KPI - Key Performance Indicator; Enf Enforcement; RI Requires Improvement; Fac Acc Factual Accuracy Arrow colour measures YTD performance against target Arrow direction measures trend against previous month performance YTD performance 3% (6%) Monthly performance C= The Slide gives context M= The slide is a performance measure (KPI) Trend: improving; deteriorating; or no change C Title & Content Information about the timescales of the data Graph Additional information relevant to the content of the graph Performance: green or red only. Measures with no target will have a white background 4

5 Manage Our Resources 1% 3% 3.8% 27% 1 95% 1.3% (3.4%) (1) (99%) Finance: Pay Forecast Finance: Non-Pay Forecast Sickness: 12 Month Average Turnover: 12 Month Average Turnover: Avoidable Reasons Last 12 Months Complaints: Acknowledged Information Access: Responsiveness Register 98% (98%) 68% (68%) 89% (9) (142) Applications: NCSC Processing Applications: New Reg Assessment Applications: Var & Can Reg Assessment Notices of Proposal: Last 12 Months Unregistered Provider Enquiries Monitor, Inspect & Rate 97% (93%) NCSC: Correspondence 94% (97%) 86% (84%) NCSC: General Calls 89% (91%) 88% (84%) NCSC: Registration Calls 63% (63%) 96% (93%) NCSC: Mental Health Calls 78% (75%) 95% (94%) NCSC: Safeguarding Calls 91% (79%) 1 (1) NCSC: Alert Triage 57% (48%) 98% (98%) NCSC: Concern Triage Alerts: Referred to Local Authority Alerts/Concerns: Mandatory Action Inspection Timeliness: ASC Productivity: ASC Inspection Timeliness: PMS Productivity: PMS Enforce 992 (192) % 95% Enforcement Actions Issued Special Measures: Current Total 4Q+ In Breach With Actions: ASC 4Q+ In Breach With Actions: PMS Independent Voice 82% (84%) N/A (76%) N/A (2%) N/A (91%) Report Publication Timeliness Engagement: Positive Coverage Engagement: Negative Coverage Engagement: CQC Themes Data From August Static Cut; 218/19 Financial Year, unless otherwise stated

6 Manage Our Resources Finance: Pay Forecast KPI: 2% variance Finance: Non- Pay Forecast KPI: 2% variance Sickness: 12 Month Average KPI: Below 5% Turnover: 12 Month Average No current benchmark in place Turnover: Neg Reasons Last 12 Months Incl. work life balance, lack of opportunities, better reward package. Complaints Acknowledged KPI: 3 Days Target: 95% Information Access Responsiveness Benchmark: 9 Based on statutory time limits of diff. legislation Register Applications: NCSC Processing KPI: 5 days Target: 9 Applications: New Reg Assessment KPI: NOP/NOD sent in 5 days Target: 8 Includes all reg applications Applications: Var/Can Reg Assessment KPI: NOP/NOD sent in 5 days Target: 9 Includes all reg applications Notices of Proposal Last 12 Months Most cases of NOPs are where we are refusing an application. Unregistered Provider Enquiries 147 (147) Alerts of services not assessed to ensure they are safe to operate Monitor, Inspect & Rate NCSC: Correspondence KPI: 3 days Target: 9 Safeguarding Alerts: Referred to Local Authority KPI: 1 day Target: 9 NCSC: General Calls KPI: 3 seconds Target: 8 Safeguarding Alerts/Concerns: Mandatory Actions KPI: 5 day Target: 9 NCSC: Registration Calls KPI: 3 seconds Target: 8 Productivity ASC/PMS KPI: 2 inspections (any type) a month HSP KPI: average of 238 units a month Productivity Target: 1 NCSC: Mental Health Calls KPI: 3 seconds Target: 9 Inspection Timeliness: ASC RI/I Returns: 9 G/O Returns: 8 1 st Inspections: 8 NCSC: Safeguarding Calls KPI: 3 seconds Target: 9 Inspection Numbers: Hospitals Units A unit is equivalent to 1 independent location or 1 core service NCSC: Safeguarding Alerts Triage KPI: 1 day Target: 95% Inspection Timeliness: PMS Target: 9 NCSC: Safeguarding Concerns Triage KPI: 1 day Target: 95% Enforce Enforcement Actions Issued Includes Warning Notices, Civil Actions and Criminal Actions. Actions may still await outcomes. Special Measures: Current Total Services enter and exit during the month 4Q+ In Breach With Actions: ASC Inspections in progress or scheduled and current/recent enforcement 4Q+ In Breach With Actions: PMS Inspections in progress or scheduled and current/recent enforcement Independent Voice Report Publication Timeliness KPI: 5 days Except HSP 3+ Core Services: 65 days Target: 9 Engagement: Positive Coverage Target: >7 Engagement: Negative Coverage Target: <1 Engagement: CQC Themes Target: >8 Data From August Static Cut; 218/19 Financial Year, unless otherwise stated

7 Applications: Volumes received C Volume of applications received and Actual Inspector Strength 43,32 applications have been received in the last 12 months Applications Received Actual Strength Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Rolling 12 months; Data from August cut *Actual Strength is the number of FTE in post, discounting those that are out of the business, which includes those 7 on long-term sick, on parental leave, suspensions, and external secondments.

8 Are Our Registration Assessment's Timely? M Volume and timeliness for completion of Registration processes by month* Year to date, 68% of New Registration applications and 89% of Variations and Cancellations have been completed within KPI, compared with 77% and 89% respectively in 217/18 New Var & Can Target (New) Target (Var & Can) Actual (New) Actual (Var & Can) Variance to Establishment 87% 91% 91% 88% 9 65% 69% 68% 69% 68% % 14% 9% 8% 7% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 8 218/19 Financial Year; Data from August cut KPI: Notice of Proposal or Decision sent within 5 days *includes data where the employees directorate was unspecified

9 Rejection rate for applications M Volume of applications received by type and rejection rates In the last 12 months, 24% of applications have been received via the provider portal, with the rejection rate for provider portal applications being 22% compared with 41% for applications received by other methods in the last 12 months. Top 5 provider application rejection reasons: Provider Section Location Section Declaration/Data protection section Invalid Supporting provider/manager app Application not required % 48.6% 45.2% 46.9% 4.9% 39.6% 38.5% 38.4% 41.1% 43.7% 4.8% 41.1% Rolling 12 months; Data from August cut Portal Applications Overall Rejection Rate Non Provider Portal Apps Rejection rate Top 5 manager application rejection reasons: Provider Section Application not required Invalid Supporting provider/manager app Manager section(s) invalid/incomplete Location section Non Provider Portal Provider Portal Apps Rejection rate 36.4% 38.6% 37.6% 36.7% 36.2% 35.9% 34.4% 33.3% 31.9% 34.5% 33.8% 31.8% 25.7% 27.6% 26.4% 22.9% 2.9% % 18.6% 19.6% 22.5% 18.9% 18.3% % 23% 24% 24% 24% 27% 24% 26% 27% 25% 2 27% Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

10 Inspections: CQC productivity M Average inspections undertaken by available inspectors against target Correspondence received by NCSC and timeliness of response Year to date, ASC has achieved an average productivity rate of 78% and Year to date, NCSC has answered 86% of its correspondence promptly PMS have achieved an average productivity rate of 57% 1 ASC PMS Target % 8 79% 81% 75% 79% 71% 66% 67% 4 48% 2 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 218/19 Financial year; Data from mid-august cut Target: ASC & PMS 2 inspections (any type) a month per inspector; HSP average of a total of 238 units a month

11 Published Reports: CQC Timeliness & Influences M 2 Proportion and volume of reports published within timescales Year to date, 82% of reports have been published within KPI Draft Final In KPI Out KPI % Within KPI Enf. Fac. Acc. Target Perf Enf % 81% 81% 82% 84% 9 81% % 16% 17% 17% 17% % 7% 9% 8% 9% 9% 9% % 134 8% Over. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar KPI: ASC, PMS & HSP -2 Core Services including Independent Health 5 working days after last visit date; HSP 3+ Core Services 65 working days after last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage. 218/19 Financial Year; Data from Aug cut

12 Changes in Quality over time C Current and previous ratings profile of active services 1 8 Outstanding Good Requires Improvement Inadequate % 3% 2% 2% 2% 1% 1% 5,61 4,96 4,421 4,249 4,68 4,145 1,926 26% 21% 17% 14% 14% 15% ,975 63% 11, ,65 75% 22,24 23,527 23,879 24,337 79% 81% 81% 82% Data from August cut 1% 1% 2% 2% 3% 3% 3% ,6 215/16 - Q2 215/16 - Q4 216/17 - Q2 216/17 - Q4 217/18 - Q2 217/18 - Q4 Current - Aug 18/19 12

13 Do We Respond Promptly to Information of Concern? CQC M 1 95% 9 85% 8 75% 7 Volume of Safeguarding Alerts referred to a Local Authority and timeliness of action Year to date, response has been timely for 94% of Alerts compared to 96% of Alerts in 17/18 Volume Outside KPI Volume Within KPI Alerts - Referral to LA Alerts - 217/18 Average 89% 24 95% % Target 218/19 Financial Year; Data from August cut KPI: Alerts (required to be referred to the Local Authority) 1 days to make referral 36 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 96% 95%

14 Do We Respond Promptly to Information of Concern? CQC M Volume of Safeguarding Alerts and Concerns received requiring a mandatory action and timeliness of action Year to date, response has been timely for 89% of Alerts/Concerns compared with 9 in 17/18 Volume Outside KPI Alerts & Concerns - Mand Actions Target 87% 89% 89% 89% 91% Volume Within KPI Mand Actions - 217/18 Average Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 95% /19 Financial Year; Data from August cut KPI: Alerts (not required to be referred to the Local Authority) & Concerns 5 days to undertake a mandatory action 5

15 Inspections: ASC Activity M Inspections undertaken and scheduled against forecast Correspondence received by NCSC and timeliness of response Year to date, ASC has undertaken 4,492 inspections 63% of inspections Year to date, NCSC has answered 86% of its correspondence promptly have been undertaken within KPI. 18 Overdue In KPI Out KPI No KPI Not scheduled Capacity O/D U - Apr U - May U - Jun U - Jul U - Aug S - Sep S - Oct S - Nov S - Dec S - Jan S - Feb S - Mar 218/19 Financial year; Data from August cut

16 Published Reports: ASC Timeliness & Influences M 14 Proportion and volume of reports published within timescales Year to date, 82% of reports have been published within KPI Draft Final In KPI Out KPI % Within KPI Enf. Fac. Acc. Target Perf Enf % 81% 82% 22 83% 84% % % 17% 18% 17% 19% % 9% 1 9% % 87 6% 224 9% Over. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 218/19 Financial Year; Data from Aug cut KPI: ASC, PMS & HSP -2 Core Services 5 working days after last visit date; HSP 3+ Core Services 65 working days after last visit date; Enf.: where the 16 report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage

17 ASC: Changes in Quality over time C Current and previous ratings profile of active services 1 8 Outstanding Good Requires Improvement Inadequate % 3% 2% 2% 1% 2% 1% 4,36 4,14 3,96 3,82 3,626 3,739 1,741 29% 24% 2 17% 16% 18% 34% ,18 59% 8,684 67% 13,5 73% 16,12 16,845 17,16 17,61 77% 78% 79% 79% Data from August cut 1% 1% 2% 2% 2% 3% /16 - Q2 215/16 - Q4 216/17 - Q2 216/17 - Q4 217/18 - Q2 217/18 - Q4 Current - Aug 18/19 17

18 Published Reports: HSP Timeliness & Influences M Proportion and volume of reports published within timescales Year to date, 48% of Hospital reports overall, 45% of those with less than two core services and 63% of those with three or more core services have been published within KPI Draft Final In KPI Out KPI % Within KPI (-2) % Within KPI (3+) Enf. Fac. Acc. Target Perf Enf % 32% 31% 27% % 26 7% 3% 4% 4% 4% 6% 173% 7 Over. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 218/19 Financial Year; Data from Aug cut 67% 65% 69% 49% 4 21% 43% 48 33% 64% 61% 22% 26 7 KPI: ASC, PMS & HSP -2 Core Services including Independent Healthcare 5 working days after last visit date; HSP 3+ Core Services 65 working days after last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage

19 HSP: Changes in Quality over time C Current and previous ratings profile of active services 1 Outstanding Good Requires Improvement Inadequate 24 5% 14 2% 16 2% 15 2% 8 1% % % 3 28% 28% % % 62% 63% 4% 5% 6% 7% 8% /17 - Q2 216/17 - Q4 217/18 - Q2 217/18 - Q4 Current - Aug 18/19 Data from August cut 19

20 Inspections: PMS Activity M Inspections undertaken and scheduled against forecast Correspondence received by NCSC and timeliness of response Year to date, PMS has undertaken 1,515 inspections 91% of inspections Year to date, NCSC has answered 86% of its correspondence promptly have been undertaken within KPI. Deregistrations Overdue In KPI Out KPI No KPI Indep. Prog. Dentist Prog. Not scheduled Capacity /19 Financial year; Data from August cut Dereg O/D U - Apr U - May U - Jun U - Jul U - Aug S - Sep S - Oct S - Nov S - Dec S - Jan S - Feb S - Mar

21 Published Reports: PMS Timeliness & Influences M Proportion and volume of reports published within timescales Year to date, 88% of reports have been published within KPI Draft Final In KPI Out KPI % Within KPI Enf. Fac. Acc. Target Perf Enf % 91% 88% 88% 87% 9 85% % 12% 11% 1 8% % 6% 4% 5% 5% 6% 2% 28 5% Over. Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar KPI: ASC, PMS & HSP -2 Core Services 5 working days after last visit date; HSP 3+ Core Services 65 working days after last visit date; Enf.: where the report involved enforcement; Fac. Acc.: number of reports where we have received a Factual Accuracy challenge. Draft/Final: shows reports that are overdue or due and whether they are at draft of final stage. 218/19 Financial Year; Data from Aug cut

22 PMS: Changes in Quality over time C Current and previous ratings profile of active services 1 8 Outstanding Good Requires Improvement Inadequate 42 4% 15 3% 129 2% 118 2% 11 2% 75 1% 63 1% % 1 1 8% 5% 4% 4% ,632 4,321 5,82 6,287 6,363 6,289 82% 83% 84% 86% 89% 91% 91% 2 Data from August cut 3% 4% 4% 4% 4% 5% 5% /16 - Q2 215/16 - Q4 216/17 - Q2 216/17 - Q4 217/18 - Q2 217/18 - Q4 Current - Aug 18/19 22

23 What is the Quality of the Services Rated? C Current ratings profile of active services Outstanding Good Requires Improvement Inadequate HSP MH (IH) 15 7% % 39 18% HSP MH (NHS) 3 6% 33 65% 14 27% 1 2% HSP (IH) 21 8% % 66 25% HSP Acute (NHS) 15 9% 75 43% 76 44% 7 4% PMS 332 5% 6,289 91% 247 4% 63 1% ASC 62 3% 17,61 79% % 38 1% Data from August cut

24 Do Locations Rated Good Deteriorate? C Re-ratings of services previously rated Good In the last year, 23% locations previously rated Good deteriorated 1 8 Deteriorated to Inadequate Remained Good 198 4% 2 13% Improved to Outstanding 1 7 Deteriorated to Requires Improvement 4% 9% 2 2% % 11 69% 11 69% % 72% 83% % % 11% 31% 4 16% 17% 3 4% 43 4% ASC Acute Trusts MH Trust Locations IH PMS Rolling 12 months; Data from August cut 24

25 Do Locations Rated Requires Improvement Improve? C Re-ratings of services previously rated Requires Improvement (RI) In the last year, 51% locations previously rated RI improved Deteriorated to Inadequate Remained Requires Improvement Improved to Good % % 25% % 63% Improved to Outstanding % 5% 8% ASC Acute Trust MH Trust Locations IH PMS 6 35% 9 53% 25 63% % % 14% Rolling 12 months; Data from August cut 25

26 Do Locations Rated Inadequate Improve? C Re-ratings of services previously rated Inadequate In the last year, 72% locations previously rated Inadequate improved Remained Inadequate Improved to Good 34 7% % 2 67% % 33% Improved to Requires Improvement Improved to Outstanding % 38% 64% 5 ASC Acute Trusts MH Trust Locations IH PMS 13% 36 27% 56 42% 42 31% Rolling 12 months; Data from August cut 26

27 What Enforcement Activity Do We Undertake? C Volume of enforcement actions issued each month broken down by current status and type In the last 12 months, we have issued 2,278 enforcement actions, of which 1,153 (51%) are pending outcome All Actions Pending Outcome All Actions Published All Actions Completed Warning Notices Civil Actions Criminal Actions Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Rolling 12 months; Data from August cut 27

28 What Happens to Locations in Special Measures? C Number of services entering and exiting Special Measures this month and those remaining in Special Measures at month end ASC PMS HSP Trust IH in Special Measures were carried into August from July 462 in Special Measures at the end of August Sufficient Improvements Deregistered Registration Cancelled entered Special Measures in August 52 exited Special Measures in August Of those exiting Data from August cut 28

29 Whistleblowing volume and action taken C Volume of whistleblowing enquiries received and trend CQC has received 9,49 whistleblowing enquiries in the last year % Rolling 12 months; Data from August cut Other (such as information used to support future inspections) Triggered a responsive inspection Brought forward a planned inspection Referred to a more appropriate organisation (such as a local authority) % where a safeguarding record has been set up (safeguarding issue identitified) % where a management review record has been set up (could result in enforcement) 57% 55% 53% 48% 51% 48% 46% 46% 49% 49% 39% % 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 1% Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

30 Action Against Long-Term In Breach Adult Social Care & Primary Medical Services C Locations in breach for more than four quarters, categorised by inspection activity or enforcement actions in progress or undertaken against each % 5% % 14 9% 1 No active or planned inspection or enforcement Number identified by the directorate as de-registering % 65 42% Scheduled Inspection outside KPI Scheduled Inspection within KPI 4 2 Data from August cut % 144 9% 39 24% ASC 13 8% 9 6% 3 19% PMS Recent Enforcement (Published within last 12 months) Enforcement in progress - Started within last 12 months Inspection in progress 3