CQC and HSE Quality Improvement Plan Progress Report - November 2025
Meeting: Public Board
Date: 5 November 2025
Report Title: CQC and HSE Quality Improvement Plan Progress Report
Agenda Item: PUB25/11/3.1
Author: Simon Chase – Chief Paramedic and Director of Quality
Lead Director: Simon Chase – Chief Paramedic and Director of Quality
Purpose: Decision/Approval
Assurance: Reasonable
Link to CQC domain:
- Caring
- Responsive
- Effective
- Well-led
- Safe
Link to EEAST Strategic Mission:
- Patient Mission
- Partnership Mission
- People Mission
- Productivity Mission
Link to Strategic Risk:
- SR1 Demand and Capacity
- SR2 Quality Governance
- SR3 Infrastructure
- SR4 Finance and Resource
- SR5 Cyber Security
- SR6 System Partnership
- SR7 Workforce Sustainability
- SR8 Staff Retention
- SR9 Organisational Development
Equality Impact Assessment: No
Previously considered by: Regular reports have been presented to both the Trust Board and the Quality Governance Committee and shared with Regulators through relationship meetings that have been established.
Purpose: To provide an update against CQC progress for the:
- Rapid Quality Review process, including agreed exit criteria metrics regarding the CQC Warning Notices received in January 2025.
- Outstanding Must Dos from the 2022 CQC inspection action plan.
- Lifting of remaining conditions from the 2020 CQC inspection.
To provide an update against Health and Safety Executive (HSE) progress for the: Notice of Contravention received in April 2025
Recommendation: The Board is asked to discuss and review the continued progress made as detailed within the report.
Executive Summary:
CQC
Rapid Quality Review Process In line with the Rapid Quality Review process following the receipt of a Section 29A Warning Notice and a Section 64 (Regulation 17) letter issued by the Care Quality Commission (CQC), the Trust continues to monitor the exit criteria metrics and provide monthly updates to the Integrated Care Boards (ICBs) via the commissioner led Regional Quality and Safeguarding meetings.
All areas have maintained improvements with mandatory training remaining above 90% since January 2025, improvements in medicine management with only one reopened investigation since further monitoring has been introduced by the Chief Pharmacist and strengthening of the recruitment pipeline within the Emergency Operational Centres remains on target to achieve full recruitment this financial year. A number of cultural schemes have launched as previously reported and the Trust waits to review the impact through staff survey feedback early next year to measure the impact of the activity.
Must Dos – 2022 CQC inspection To date, 66/69 (95.7%), 41/44 Must and 25/25 Should dos have been closed. The remaining three actions relate to: C1 and C2 response performance, safe staffing and the appraisal process. Any remaining actions will be merged with any new action plan driven by the CQC 2024 inspection report, upon receipt. Meaningful Appraisal completion remains a priority of the Trust.
CQC Inspection update The Trust is still awaiting receipt of the inspection report and decision outcomes for the lifting of the three remaining conditions applied following an inspection in 2020 which relate to; Private Ambulance Services (PAS), processes for managing complaints raised to HR and sexual safety.
HSE
Notice of Contravention Following the HSEs inspections in September 2024 followed up with a Notification of Contravention (NoC) specifically associated to the Management of Work-Related Stress within the Trust. The Trust has actively been in engagement and consultation to provide evidence/assurance of change management with the implementation of specific processes against the Actions identified. In the last relationship meeting, the HSE have verbally confirmed the Trust has met the actions outlined within the NoC and will continue to work with the Trust to help evidence and embed the actions identified.
Introduction / Background:
Rapid Quality Review Process Following the receipt of a Section 29A Warning Notice and a Section 64 (Regulation 17) letter issued by the Care Quality Commission (CQC), the Trust moved into the Rapid Quality Review process which was led by the leading commissioners, Suffolk and North Essex Integrated Care Board (ICB).
In April 2025 it was agreed that due to the improvements seen since February 2025, the Trust could move into the exit criteria stage of this process with monthly outcomes reported to all ICBs, the CQC, NHS England and the College of Paramedics.
The table below demonstrates the status for each of the six concern topics at the end of September 2025.
| Concern | SRO | Completion target | Mar-25 | Apr-25 | May-25 | Jun-25 | Jul-25 | Aug-25 | Sep-25 |
|---|---|---|---|---|---|---|---|---|---|
| Mandatory Training | Chief Paramedic and Director of Clinical Quality | >90% Statutory and Mandatory Training | Green | Green | Green | Green | Green | Green | Green |
| >85% CSFT subjects | Green | Green | Green | Green | Green | Green | Green | ||
| Call waiting (Call pick- up) | Chief Operating Officer | < 5 second mean | Green | Green | Green | Green | Green | Green | Green |
| < 5 second 95th percentile | Green | Green | Green | Amber | Amber | Amber | Green | ||
| EOC Staff Recruitment | Chief Operating Officer | 85% of target: Call handlers | Green | Green | Green | Green | Green | Green | Green |
| Dispatchers | Green | Green | Green | Green | Green | Green | Green | ||
| CAS | Amber | Amber | Amber | Amber | Amber | Amber | Amber | ||
| Emergency Operations Culture | Chief People Officer | See relevant slide | Amber | Amber | Amber | Amber | Amber | Amber | Amber |
| Medicines Management Investigations | Medical Director | Zero incidents not closed appropriately | Green | Green | Green | Amber | Green | Green | Green |
| Staff engagement – action plans | Chief People Officer | Roll out of engagement plan from 01/04/2025 | Amber | Amber | Amber | Amber | Amber | Amber | Amber |
Call waiting (call pick-up) Call pick has improved and stabilised with calls for the last two months being less than 5 seconds which helps provide reassurance the changes being made are working.
EOC staff recruitment Recruitment and training capacity has increased again and at the end of September the pipeline demonstrated that for call handlers, there were 225 and 15 agency staff moving to permanent. For dispatchers and CAS staff, 7 and 11 are at offer stage respectively meaning only CAS staffing is slightly behind trajectory.
Emergency Operations Culture and staff engagement It has been acknowledged that these areas will require a longer timeframe to show improvement. Work continues to be underway to improve staff engagement and a focus on attending EOCs has started through the monthly time to listen events.
Must Dos – 2022 CQC inspection To date, 66/69 (95.7%), 41/44 Must and 25/25 Should dos have been closed. The remaining three actions relate to: C1 and C2 response performance, safe staffing and the appraisal process. The Trust is still awaiting receipt of the inspection report and decision outcomes for the lifting of the three remaining conditions applied following an inspection in 2020 which relate to; Private Ambulance Services (PAS), processes for managing complaints raised to HR and sexual safety.
HSE – Notice of Contravention Following an announced visit to numerous EEAST Locations and interviews with Staff in September 2024. EEAST received a Notice of Contravention from the Health & Safety Executive in April 2025 relating to Material Breaches of the Management of Work-Related Stress.
The HSE was of the opinion that EEAST have breached the Management of Health & Safety at Work Regulations 1999 – Specifically Regulations 3, 4 and 5. Employers have a legal duty to protect workers by assessing the risk from causes of work-related stress and acting upon their findings. HSE defines stress as “the adverse reaction people have to excessive pressure or other types of demands placed on them”. The Management of Health & Safety at Work Regulations 1999 required the East of England Ambulance NHS Trust (EEAST) to implement appropriate arrangements for the effective planning, organisation, control, monitoring and review of preventive and protective measures.
Following engagement and consultation, the HSE:
- Verbally agreed the Trust have met the actions outlined within the NoC
- Will be meeting to evaluate the information provided and will provide a written update in the future.
- Wished to continue to collaborate with the Trust in how to understand how best practice can be measured nationally.
| Actions Required by Health & Safety Executive (NoC) | RAG Rating (Red, Amber, Green, Blue) | |
|---|---|---|
| 1 | Ensure staff complete their shifts on time – do more to remove enforced/incidental overtime | Agreement with HSE to review (Amber) |
| 2 | Ensure staff are protected from verbal and physical abuse – review Violence/Prevention & Reduction process | Completed (Blue) |
| 3 | Ensure staff have suitable and sufficient training and development – mentoring & appraisals | Ongoing Engagement (Green) |
| 4 | Ensure staff are supported – appropriate line management systems and training, 1:1s, behaviour training, advertise policies | On Target for 398 Leaders (ratio 1 to 9.5) (Green) |
| 5 | Strengthen arrangements for tackling unacceptable workplace behaviours - bullying | Ongoing Engagement (Green) |
| 6 | Improve communication between frontline staff and senior management | Ongoing Engagement (Green) |
| 7 | Make arrangements to monitor the measures put in place for stress management | Ongoing Engagement (Green) |
| 8 | Carry out a suitable and sufficient assessment of the risk associated with work-related stress. | Completed (Blue) |
Key Issues / Risks:
As previously reported, the completion and update of CQC action plans is key to driving risk down. There is a risk that a decrease in the improvements already seen following the S29A warning notice and failure to improve the culture of the organisation and engage with staff may result in enforcement notices and criticism of the organisation.
The delay in the CQC issuing the 2024 inspection report may mean that other areas of concern remain identified for improvement
