CQC Quality Improvement Plan Progress Report - July 2025

Meeting: Trust Board – Public Meeting

Date: 9 July 2025

Report Title: CQC Quality Improvement Plan Progress Report

Agenda Item: PUB25/07/3.1

Authors: Natalie Mudge, Head of Compliance, Simon Chase, Chief Paramedic and Director of Quality

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

Purpose: Discussion/Review

Assurance: Reasonable

Link to CQC domain:

• Caring
• Responsive
• Effective
• Well-led
• Safe

Link to EEAST’s Strategic Mission:

• Patient Mission
• Partnership Mission
• People Mission
• Productivity Mission

Link to Strategic Risk:

• SR2 Quality Governance
• SR6 System Partnership
• SR7 Workforce Sustainability
• SR8 Staff Retention
• SR9 Organisational Development

Equality Impact Assessment: Negative impact identified

Previously considered by: Trust Board Public Meeting (May 2025), Quality Governance Committee (June 2025), Rapid Quality Review Meeting with Commissioners (June 2025).

Purpose: To provide an update against 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.

Recommendation: The Board is asked to discuss and review the progress made as detailed within the report.

Executive Summary

Rapid Quality Review

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 has participated in monthly meetings chaired by the Medical Director of our leading commissioners. The meetings were also attended by representatives from the CQC, NHS England (NHSE), the Health Care Professions Council and Quality leads from all Integrated Care Boards (ICBs) within the East of England.

Following sustained improvements evidenced since February 2025 relating to training, the investigation of medicines incidents, staffing within Emergency Operating Centres (EOCs) and call pick-up time, in June, an agreement was made that the Trust could move to the exit criteria stage with an acknowledgement that concerns raised relating to culture and staff engagement would take longer to address.

A set of metrics were developed in partnership with the lead commissioner and agreed at the final Rapid Quality Review meeting on 05 June 2025 (attached – Appendix 1).

Moving forward, the metrics will be monitored through the bi-monthly regional Quality and Safeguarding meetings with regular updates provided to Trust groups and Committees in line with our governance framework. The next review will happen in September 2025.

Must Dos – 2022 CQC inspection

To date, 65/69 (94.2%), 40/44 Must and 25/25 Should dos have been closed. The remaining four actions relate to: C1 and C2 response performance, safe staffing levels, appraisal process, and estates surround Emergency Operations Centres.

Following discussion by the Executive Leadership Team (ELT) at the recent Executive Clinical Group, it has been agreed that the remaining four actions will be split into two groups: the first group will be merged with any new action plan driven by the CQC 2024 inspection report, when received – as currently all areas are under review through productivity monitoring to improve performance and it is expected that improvements will be realised through the actions and monitoring undertaken through the Performance Delivery Improvements meetings with NHS England. The second group shows completion or time to complete by 30 September 2025, which will move completion to 67/69 (42/44 must dos).

s.29 and s.31 condition – 2020 CQC inspection

To date, the Trust is awaiting a decision outcome for submitted applications for the lifting of the three remaining conditions applied following an inspection in 2020, these relate to: Private Ambulance Services (PAS), processes for managing complaints raised to HR, and sexual safety.

The Trust has been made aware that the first two have been considered and the third, relating to sexual safety, is currently under review in line with CQC processes.

At the time of submitting the report, the Trust still awaits the CQC inspection report in relation to the visit in November 2024.

Introduction / Background

Rapid Quality Review

Following the receipt of a Section 29A Warning Notice served by the 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 (RQR) 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 Integrated Care Board (SNEE) and representatives from the CQC, NHSE and interested parties (quality leads for ICBs within the East of England, the HCPC) also attend.

A set of metrics were developed to take into account the CQC’s findings and the Trust’s ambition to drive improvement and close identified gaps. Due to the improvements achieved and sustained in relation to statutory and mandatory training, the investigation of medicines incidents, staffing within EOC and call pick-up time, it was agreed at the RQR meeting held on 17 April 2025 that the Trust could consider a move to the exit criteria stage with an acknowledgement that improvements relating to culture and staff engagement would require additional time. In discussion with the lead commissioners, a set of exit criteria metrics (attached – Appendix 1) were developed and presented to the final Rapid Quality Review meeting on 05 June 2025 for agreement. The metrics will continue to be monitored through the bi-monthly regional Quality and Safeguarding meetings with regular updates provided to Trust groups and Committees in line with our governance framework.

Must Dos – 2022 CQC inspection

Following a CQC inspection undertaken in 2022, 67 deliverable actions were identified which were merged with two long-term actions from the previous plan. To date, 65/69 (94.2%), 40/44 Must and 25/25 Should dos have been closed. Information relating to the four Must dos, two of which relate to concerns raised within the S.29A Warning Notice, can be found within the following:

Outstanding 4 MUST Dos:

Following discussion by ELT at the recent Executive Clinical Group, it has been agreed that the remaining four actions will be split into two groups: the first group will be merged with any new action plan driven by the CQC 2024 inspection report, when received – as currently all areas are under review through productivity monitoring to improve performance and it is expected that improvements will be realised through the actions and monitoring undertaken through the Performance Delivery Improvements meetings with NHSE.

The second group shows completion or time to complete by 30 September 2025, which will move completion to 67/69 (42/44 must dos).

Group 1 – merging with new action plan from expected CQC report

• 4.9 Deliver the long-term C1 and C2 progress trajectory actions to ensure productivity of patient facing staff hours (PFSH) per week (percentage relating to PFSH to be provided), both C1, C2 and PFSH progress monitored through OPIP.
• 7.6 Based on the Urgent Emergency Care (UEC) strategy – establish safe staffing requirements and monitoring approach across all clinical areas, phased approach to new ways of work.

Group 2 – actions to close on or before 30 September 2025.

• 8.1 Review the appraisal process and documentation to ensure it is fit-for-purpose, accessible and supports delivery of an effective appraisal for all.
• 9.1 Estates EOC improvement programme (and digital).

s.29 and s.31 condition – 2020 CQC inspection

To date, the Trust is awaiting a decision outcome for submitted applications for the lifting of the three remaining conditions applied following an inspection in 2020, these relate to: Private Ambulance Services (PAS), processes for managing complaints raised to HR, and sexual safety.

The Trust has been made aware that the first two have been considered and the third, relating to sexual safety, is currently under review in line with CQC processes.

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.

How does this report link with EEAST’s vision, purpose and values?

Link to patient, people, partnership and productivity missions.

Summary

As per the executive summary.