CQC Quality Improvement Plan Progress Report - September 2025
Meeting: Trust Board – Public Meeting
Date: 10 September 2025
Report Title: CQC Quality Improvement Plan Progress Report
Agenda Item: PUB25/09/3.1
Author: Natalie Mudge – Associate Director of Clinical Quality & Regulatory Assurance
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:
- SR1 Demand and Capacity
- SR2 Quality Governance
- SR3 Infrastructure
- SR4 Finance and Resources
- SR5 Cyber Security
- SR6 System Partnership
- SR7 Workforce Sustainability
- SR8 Staff Retention
- SR9 Organisational Development
Equality Impact Assessment: No negative impact identified
Previously considered by: Regular reports have been presented to both the Trust Board and the Quality Governance Committee.
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 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.
With the exception of call waiting (call pick-up) at the 95th centile, which has shown a slight dip in performance during June and July, all metrics remain on track.
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 latter of which is due to close by the end of September. Remaining actions will be merged with any new action plan driven by the CQC 2024 inspection report.
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.
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 led by the lead commissioners at 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 July 2025.
| Concern | Completion Target | March 2025 | April 2025 | May 2025 | June 2025 | July 2025 |
|---|---|---|---|---|---|---|
| Mandatory Training | >90% Statutory and Mandatory Training >85% CSFT subjects | Green | Green | Green | Green | Green |
| Call waiting | < 5 second mean and 95th percentile | Green | Green | Green | Green | Green |
| (Call pick-up) | < 5 second 95th percentile | Green | Green | Green | Amber | Amber |
| EOC Staff Recruitment | 85% of target | Amber | Amber | Amber | Amber | Amber |
| Emergency Operations Culture | +10% increase in management of sexual harassment cases. 85% compliance sexual safety training. Increase in sexual safety related question within the NHS Staff survey. 3%+ increase in staff speaking up about sexual harassment. | Amber | Amber | Amber | Amber | Amber |
| Medicines Management Investigations | Zero incidents not closed appropriately | Green | Green | Green | Green | Green |
| Staff Engagement – Action plans | Roll out of engagement plan from 01/04/2025 | Amber | Amber | Amber | Amber | Amber |
Call waiting (call pick-up) The number of 999 calls during June and July exceeded expectations, and with an increase in staff turnover within the Emergency Operations Centre, the 95th centile for calls being picked up increased to 27 seconds in both June and July. For the financial year to date, EEAST has achieved an average of 16 seconds for this metric, an improvement on the previous year which closed with an average of 1 minute 25 seconds. It should be noted that for the first week of August, call pick up improved to 0 seconds for this metric.
EOC staff recruitment Recruitment and training capacity have been increased to address the unexpected increase in staff leaving. At the end of July, the pipeline demonstrated that for call handlers, there were 25 at offer stage and 21 agency staff transitioning to permanent roles. For dispatchers and CAS staff, 4 and 11 are at offer stage respectively.
Emergency Operations culture and staff engagement It has been acknowledged that these areas will require a longer timeframe to show improvement. All metrics remain on track for now.
Must Dos – 2022 CQC inspection**
To date, 66 of 69 actions (95.7%) have been closed: 41 of 44 ‘Must Dos’ and all 25 ‘Should Dos’. The remaining three actions relate to; C1 and C2 response performance, safe staffing and the appraisal process, the latter of which is due to close by the end of September. Outstanding actions will be merged with any new action plan driven by the CQC 2024 inspection report.
CQC Inspection update
The Trust is still awaiting the inspection report and decision outcomes regarding the lifting of the three remaining conditions applied following the 2020 inspection. These conditions relate to Private Ambulance Services (PAS), processes for managing complaints raised with HR, and sexual safety.
Key Issues / Risks:
As previously reported, the completion and updating of CQC action plans is essential to driving risk down. There is a risk that a decline in the improvements already seen following the S29A warning notice, together with a failure to improve the organisation’s culture 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 also mean that other areas of concern remain identified for improvement.
Options:
Not applicable
