CQC Quality Improvement Plan Progress Report

Meeting: Trust Board – Public Meeting

Date: 7 May 2025

Report Title: CQC Quality Improvement Plan Progress Report

Agenda Item: PUB25/05/2.1

Author: Natalie Mudge, Head of Compliance

Lead Director: Simon Chase, Chief Paramedic and Director of Quality

Purpose: Discussion/review Assurance: Reasonable Link to CQC domain: Caring, Responsive, Effective, Well-led, and 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: An earlier version of the Rapid Quality Review (RQR) slide pack has previously been presented to the Trust Board. This version was presented to the Executive Leadership Team on 01 April 2025.

Purpose: To provide the Trust Board with progress against the:

• Performance metrics identified following the receipt of a S29A warning notice and S64 Regulation 17 notification and to provide an update following the last Rapid Quality Review (RQR) meeting held on 17 April 2025.
• Must and Should Dos following the 2022 CQC inspection.

Recommendation: The Trust Board is asked to:

• Discuss and note the improvements made to date in relation to the concerns raised by the CQC.
• Note the current position in relation to the Must and Should Do actions.

Executive summary:

The Rapid Quality Review (RQR) slide pack contains the latest version of data for the quality metrics demonstrating the improvements made, and current direction of travel to meet the requirements contained within the S29A and S64 notices from the CQC.

At the RQR meeting held on 17 April 2025, members acknowledged the improvements made to date, however there was challenge in relation to:

• Sustaining achievements made
• Culture, what more can the Trust do to increase the professionalism of staff
• Improving sexual safety and harassment
• Further indicators, both short and long term
• Staffing within the Clinical Advice Service (CAS)

A further point raised related to sight of Key Performance Indicators (KPIS) for both culture and staff engagement.

It was agreed to discuss proposed exit criteria requirements, including further measurable KPIs, for approval at the next meeting to be held on 27 May 2025.

Introduction/background:

Section 29A Warning Notice and Section 64 (Regulation 17) Following the receipt of a Section 29A Warning Notice served by the Care Quality Commission (CQC) on 23 January 2025 and a Section 64 (Regulation 17) letter received on 27 January 2025, the Trust is required to make significant improvements in relation to; staff training, waiting times for call, ensuring enough staff are in place to keep service users safe, strengthen governance and lessons learned from medicines incidents (particularly controlled drugs), culture and acting on information from staff to improve the service.

As per NHS guidance organisations are required to participate in Rapid Quality Reviews so that oversight of monitoring is in place. For EEAST, the review meetings are chaired by the Medical Director for the Trust’s lead commissioners Integrate Care Board (SNEE) and representatives from the CQC, NHS England and interested parties (quality leads for ICBs within the East of England, HCPC) also attend.

Meetings have been held on a monthly basis since February 2025 with progress updates presented for each of the six areas of concern within the S29A and also the Section 64 (slide pack presentation attached).

At the meeting held on 17 April, members acknowledged the improvements made to date, however there as challenge relating to; sustaining achievements, what more can EEAST do to improve culture and sexual safety as well as staffing within CAS.

It was agreed that a set of further KPIs would be developed as part of the exit criteria. These will be discussed and presented for approval at the next meeting to be held on 27 May 2025.

Must and Should Dos To date 64/69 (93%) actions are closed. There has been no change relating to the four remaining open Must Do actions since the last report.

Key issues/risks:

1791: Inability to monitor and evidence compliance with regulatory standards (CQC, DPA 2018, Hygiene Code of Practice, EDS2, DSPT).

As previously reported, the completion and update of CQC action plans 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. 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 Trust Board is asked to discuss and note the RQR slide pack as well as the current position in relation to the Must and Should Dos.

Regular updates will be provided as progress develops.

Appendix 1. – EEAST Rapid Quality Review