CQC Quality Improvement Plan

Meeting: Trust Public Board

Date: 08.11.2023

Report Title: CQC Quality Improvement Plan (Update)

Agenda Item: 4.2

Link to strategic risk(s):

• 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: If we do not deliver operational and clinical standards then there is a risk of poor patient outcomes and experience
• 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: If we do not resolve long standing organisational inefficiencies we will be unable to deliver an effective, sustainable, value for money service to our public
• SR5: If we do not clearly define our strategic plans we will not have the agility to deliver the suite of improvements needed
• SR6: If we do not deliver sustainable regulatory compliance and develop positive relationships, we will have limited ability to deliver our strategy

Equality Impact Assessment: No negative impact identified

Recommendation: The Board are recommended to note and approve the ongoing moderate assurance regarding the submitted CQC QIP and progress against the MUST Dos and SHOULD Dos action plans and the continued work on lifting the s.29 and s.31 improvement conditions.

Previously considered by: The CQC Quality Improvement Plan (QIP) along with the actions to close the MUST DOs and SHOULD Dos have been reviewed at the Continuous Improvement and Regulatory Group (CIRG) and Executive Leadership Team/Executive Clinical Group (ELT/ECG) and 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 Board with the current progress made against the QIP since the last CQC core inspection in 2022. The report aims to provide moderate assurance on the current position in relation to the CQC QIP and progress towards closing the gaps on the 9 MUST Dos and 7 SHOULD Dos. 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.

Executive Summary

Since the last Board progress report, the Executive Clinical Group supported the re-alignment of the two remaining CQC QIP actions from 2020; relating to staff survey outcomes and implementation of Datix Cloud IQ, have now been incorporated in to the current post-2022 CQC monitoring plan, with aim to provide single oversight and monitoring. As a result, the original CQC QIP plan presented at Board in 2022, had 175/178 actions successfully closed.

*Of the remaining three actions, one related to a review and update of the existing Datix software to enable automated triangulation from complaints and incidents. This is in progress and is due to be fully embedded by March 2024. The remaining two actions related to the long-term culture improvements, which was also identified by the CQC in 2022, who stated that the Trust should continue with the pace of addressing cultural issues.

Following agreement by the Executive Clinical Group, the three remaining actions were transferred to the new CQC action plan to enable clarity in relation to the monitoring and reporting of all outstanding CQC actions within a single framework.

As a result, in relation to the new CQC monitoring, this has increased the number of actions identified within the SHOULD Dos, from 23 to 25 (merged two Employee relation actions into one). The number of actions relating to the MUST Dos remains unchanged, therefore the number of actions within the plan now totals 69 (previously 67). A copy of the new monitoring plan has been provided as an appendix.

Currently, nine actions were expected for closure at the end of September 2023 (6 Must and 3 Should Dos) and although not fully complete, work is nearing completion with the majority of these actions being aligned to the ongoing transformation/cultural work plans.

The overdue Must Do actions relate to compliance with mandatory training and appraisals, these figures continue to be monitored within the Continuous Improvement Framework and at ECG.

Introduction/ Background

Following approval by the Executive Clinical Group the remaining two CQC QIP actions (2020) relating to staff survey outcomes and implementation of Datix Cloud IQ have been moved to the post-22 plan to provide single oversight and monitoring and the QIP action plan has been closed.

MUST Dos and SHOULD Dos - Update

The table below provides the Trust's current position in relation to the MUST and SHOULD Dos have identified following the 2022 CQC Core Inspection report as well as the two actions transferred from the 2020 plan.

**It should be noted that all overdue actions are in progress however they have not reached the position required to close the action. Confirmation of closure is recommended at the Continuous Improvement and Regulatory Group and forwarded to ECG for approval. The summary table below demonstrates the outstanding actions and progress to date supporting moderate assurance.<br>

MUST DOs Deliverables

2.1: Launch and implement the approved Leadership Development Framework with a clear plan for progression of leaders through, to support the impact of the Time to Lead Programme and improve access to training and development of effective leaders across the Trust

• Due date: 30/09/2023
• Current position: Time to Lead continues to be implemented, having approved a final structure in August 2023 following weeks of pre-consultation engagement events. This proposal is currently under the formal 30-day consultation with affected staff, but subject to outcomes, will see improved seniority at each hub across the Trust, increased support services aligned to each sector and 231 new Team Leader layer being introduced to the leadership structure. The cumulative impact on this is expected to improve line management, capacity to hold appraisals, wellbeing and career conversations and critically, reduce manager burnout and stress. The newly developed Leadership Development Programme is now at a critical delivery milestone, with approvals now being sought for programme content and abstraction/implementation plans. Subject to this approval, the programme will launch in November 2023 and will focus on Operational leaders in the first phase, before rolling through other directorates in sequence.

2.2: Ensure 95% compliance with the 5 modules within the mandated manager's training requirements to ensure a baseline level of understanding of policies for all active managers.

• Due date: 31/03/2023
• Current position: As of 5 September 2023, overall compliance is at 95% across the EHRC Values and Behaviours training. With the overall five manager mandated training packages at 88%.Overall statutory mandatory training is also at 90% (end of September 2023).

6.2: Implement phase One of the Wellbeing Strategy including the next phase of Wellbeing Champions to ensure sufficient support and access for staff who need it.

• Due date: 30/09/2023
• Current position: Currently 63 Wellbeing Champions trained and spread out across the Trust.Two further training sessions planned in Sep 23. - awaiting closure update.

7.4: Participate and complete the national programme to convert the call handler role profile to band 4, in order to improve retention.

• Due date: 30/09/2023
• Current position: Having obtained LAS band 4 job Call Handler job description, this is being created in an EEAST template and then being placed through job evaluation process at EEAST. Further update expected to be provided at end of October.

8.1: Review the appraisal process and documentation to 30/09/2023. Work is currently underway to review possible digital solutions to further enhance this process, not only from a completion perspective but also from a reporting and complianceBoard/Committee coversheet template 0.2 Page 5 of 7 ensure it is fit for purpose, accessible and supports delivery of an effective appraisal for all

• Due date: 30/09/2023
• Current position: Work is currently underway to review possible digital solutions to further enhance this process, not only from a completion perspective but also from a reporting and compliance perspective. the budget for a digital solution has been included in the 2023/24 business planning process. (Date amended to reflect digital requirements and 2023/24 budget planning).

8.2: Improve appraisal rate compliance to 85%

• Due date: 31/03/2023
• Current position: As at the end of September 2023, appraisal compliance stood at 65% which is a deterioration of 2% when compared to July 2023.Reporting of Appraisal compliance has moved to ESR/OLM to ensure continuous up to date oversight.

SHOULD DOs Deliverables

3.4: Deliver the WRES and WDES action plans, focused upon the objectives relating to bullying, harassment and concerns that our staff have raised

• Due date: 30/09/2023
• Current position: Following development and endorsement by the Peoples Committee, the WRES and WDES actions will be incorporated into the EEAST Inclusivity Plan, which is to be managed via a monthly committee, starting on the 11 October 2023. People Committee will track progress on the inclusivity plan and escalate/oversee all activity. We have also recently just closed our annual Workplace Behaviours survey for 2023, which repeats some previous exploration into Bullying and Harassment. Our initial results analysis tells us we have fewer instances across the Trust compared to the two previous surveys. Any responses relating to EDI related Bullying, Harassment or discrimination will be reviewed by the EDI team and additional actions will be captured within the Inclusivity Plan. Awaiting closure update.

3.5: Implement and deliver on the Trust's Anti-Racism Charter

• Due date: 30/09/2023
• Current position: The anti-racism charter action plan is continuing to be implemented and is now incorporating the action plan into the inclusivity plan. A review of our existing recruitment EQIA process is underway to improve and streamline this procedure to ensure inclusion is part of the design. Following approval for funding for 30 new cultural ambassadors 14 are being recruited as of October 2023. Funding has also been awarded to recruit a BME Community Engagement Officer; this role will be a pivotal engagement resource for the communities we serve, helping remove blockers to accessing careers at EEAST. Finally, we are now starting to scope out conducting ethnicity pay gap reporting each year to ensure we actively understand and can address any gaps. By December 2023, we will also have developed our three-year EDI training plan which will cover both staff and managers to become more culturally aware and competent. Awaiting closure update.

3.7: Complete the Ambassador task and finish group to enhance and support growth of the ambassadors and their effectiveness

• Due date: 30/09/2023
• Current position: Proposals currently being reviewed to understand what is possible in terms of allowing time off / abstractions and what else we can do to promote our ambassador pool. Awaiting closure update.

S.29 and s.31 condition update.

Evidence and applications for lifting conditions continues. From the original 11 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.

2023 Core Inspection Preparation

Due to the Trust having its last inspection in April 2022, preparation work continues in readiness for its next core inspection. This includes communication updates and plan, online seminar and resources around the Key Lines of Enquiry, along with practice interviews for senior leaders by the NHS Improvement team. Feedback from the NHS Improvement team has been positive as the Trust prepares for its next inspection. In addition, both the CQC Guide and Operational Guidance for managers has been updated and is available on Need to Know. |

Key Issues/ Risks

SR7: Failure to ensure a well governed and accountable Trust that meets the inspection standards - SROs remain responsible for conditions with outstanding actions to review the timescales (as shown above) and provide regular narrative/metrics for measurement on the progress/work needed to bridge the gaps to completion.Completion of the interdependency between the CQC QIP and transition to the monitoring through ECG from FFF workstreams will enable clarity for the project team who have successfully mapped and communicated the transfer to FFF from the QIP. Assurance of closed actions re S31 and moving to complete EHRC actions will enable a proposal for risk reduction in the next quarter once the CIAF is established and INPHASE populated to enable tracking of agreed new actions.

1791: Inability to monitor and evidence compliance with regulatory standards (CQC, DPA 2018, Hygiene Code of Practice, EDS2, DSPT).The monitoring of the Trusts position against each KLoE is to provide reassurance on the work on the actions under Section 29a and Section 31 of the CQC QIP; which are vital to ensure the Trusts compliance with the Health and Social Care Act. As previously reported, the completion and update of CQC QIP 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 Dos and SHOULD Dos are cleared and this is expected for further review in Quarter 4 of current 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 Board are requested to support the option of closure of the original CQC QIP and accept the current moderate assurance position that will continue to be monitored through the new action plan through CIRG and ECG. Regular updates will return to Board as progress develops against the remaining actions to be closed.

Summary

As per Executive Summary.

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