ARA 2020 to 2021: Performance Report

Published: 20 January 2022

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Part 1: Performance report

This section contains:

• Foreword from CQC’s Chair and Chief Executive
• Key highlights
• Performance summary
• How we used our money

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Foreword

This reporting year has been like no other for CQC. With services under such intense pressure from the impact of the COVID-19 pandemic, our role has been more important than ever.

It has been a time of unprecedented threat to public health, with a huge focus on infection prevention and control, immense challenges in protecting people who are in vulnerable circumstances, and the need to balance different aspects of care such as people’s physical safety and mental wellbeing.

Our core purpose and our regulatory role did not change. We continued to do our work and adapted to the unprecedented situation in which we all found ourselves.

Understanding the enormous stresses that providers and their teams have been under, our focus has remained on responding to the risks of poor care, and making sure that people continued to receive safe, effective, compassionate, high-quality care.

We have responded to information from people who use services, carers, and health and social care professionals and workers, specifically on safeguarding and whistleblowing. A record number of people told us they believed we were trusted to be on the side of people who use services, and with it a strong recognition for the work we do to improve care for people.

In a year when everything was changing so quickly, including advice for care providers, our people helped to support providers, stakeholders and government with data, information and insight – gathered from providers, the public and stakeholders – to help shape the national and local response to the pandemic. Where necessary we intervened to protect the safety and wellbeing of people who use services, examples of which included highlighting that the use of blanket do not resuscitate orders should never be imposed on groups of people.

We also had to respond and adapt our work to the significant changes in the ways that many services were delivered to people – for example, the increase in digital and online services.

The pandemic has accelerated the changes that were already underway at CQC to transform the way we regulate – to be more relevant to the way care is now delivered, more flexible to manage risk and uncertainty, and able to respond in a quicker and more proportionate way as the health and care environment continues to evolve. Throughout the year, we continued to put in place the systems, technology and culture we need for the future. The work we carried out to create and implement a transitional model for regulation has given us the springboard to develop further our new ways of working.

In May 2021, we published and embarked on our new and ambitious strategy, and we are fully committed to implementing and delivering on that strategy over the next few years.

Peter Wyman CBE DL
Chair

Ian Trenholm
Chief Executive

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Performance summary

The last year has been a period of intense activity for us. In supporting the health and care system to respond to the COVID-19 emergency, we have continued to develop and transform the way the work. Throughout, we have maintained our focus on responding to the risk of poor care and acting to protect people who use health and care services.

When the pandemic was announced and the first national lockdown occurred in March 2020, we paused routine inspections and focused our activity in response to risk.

We developed and adopted a transitional monitoring approach that maximised our effectiveness during the pandemic but also accelerated our longer-term plans to become a more intelligence-led, responsive regulator. We regularly and consistently reviewed our approach, with priorities set each quarter to reflect the evolving pressures across health and social care and to ensure we could continue to respond to any evidence of significant risk of harm to the public.

The completion of the digital foundations programme that was underway before the pandemic gave us the tools to be more responsive to change and innovate in this period, and to accelerate our journey to become a more intelligence-led responsive regulator. Our focus on digital capabilities have also enabled us to respond more flexibly to COVID-19 and to introduce across the year a transitional approach to regulation.

Over the last year, driven by a need to adapt to the pandemic, we made substantial progress in our ability to monitor services. The launch of our emergency support framework (ESF) gave us a structured way to have conversations with providers to help monitor risk and support them, and we built on this with our transitional monitoring app (TMA). Together these have enabled us to have contact with more providers than we had in previous years through our inspection methodology alone. We are continuing to build on our learning over the year to improve our ability to monitor risk, which will help us be more targeted in our regulatory activity.

We published our new strategy in May 2021 and our programme of business change and improvement to deliver the strategy will develop further in 2021 to 2022, and beyond.

The performance against our existing strategic priorities is set out as follows.

Priority one: Encourage improvement, innovation and sustainability in care

Our ambition is to work with others to support improvement, adapt our approach as new care models develop, and publish new ratings of NHS trusts’ use of resources. We have supported this through the following areas:

Insight reports

In May 2020 we published the first of our regular CQC Insight reports, highlighting COVID-19 related pressures on the services that we regulate. In our reports we have analysed and shared insights from people who receive care, staff, data we collect and regular conversations with providers and partners. The documents are intended to: help everyone involved in health and social care to work together to learn from the pandemic: share and reflect on what has gone well; understand and learn from the experience of what hasn’t gone well; and help health and care systems prepare for the future.

Across the year Insight reports have covered topics such as COVID-19 outbreaks, availability of personal protective equipment (PPE), financial viability of adult social care services and the changing face of primary care. Of the providers who completed our annual provider survey, 95% told us that Insight reports covered topics and issues that interested them, and 43% told us they took action to make changes and improvements as a result of reading the documents.

Review of DNACPR decisions

During the beginning of the pandemic there were concerns that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions were being applied to groups of people, without consideration of each person’s individual circumstances – and without appropriately involving people, or their families and/or carers. In October 2020, the Department for Health and Social Care (DHSC) commissioned us to conduct a special review into these concerns.

In our review, which took place between November 2020 and January 2021, we looked at how DNACPR decisions were made in the context of advance care planning, across all types of health and care sectors including care homes, primary care services and hospitals. We listened to the experiences of over 750 people. It was clear that, while the concerns raised were not new, the pressures of the pandemic had exposed them more widely and more clearly demonstrated the lasting impact on people. In our report we made a number of recommendations, including an action for us to ensure a continued focus on DNACPR decisions through our monitoring, assessment and inspection of all health and social care providers.

Closed cultures

A key focus in 2020 to 2021 was our regulation of services for people with a learning disability and autistic people, with a particular focus on closed cultures, restraint, seclusion and segregation. Across the year we have introduced additional guidance, training and support for our inspectors to enable them to better identify services that might be at risk of being or developing into a closed culture. We improved how we use and analyse data, and we have commenced a pilot of inspections to support the review on our approach to inspections of services for people with a learning disability and autistic people. We published our ‘Out of Sight-who cares?’ report in October 2020 and made a series of recommendations for government, CQC, NHS England, local authorities and more to improve the provision of support for people with a learning disability and autistic people.

Safe houses

We have been working closely with the Home Office since 2019 to consider how we might help them monitor the quality of support offered to people who are in safe houses. Safe house residential and outreach support services support people who are victims of modern slavery, which includes human trafficking, slavery, servitude and forced or compulsory labour. The programme commenced in December 2020 and by the end of March 2021 we completed inspections of 16 services, which were reported on in nine reports. The reports are not published on our website but shared with providers and commissioners.

Future approach

At the end of January 2021, we launched a proposal for more flexible and responsive regulation, building on our transitional approach developed during the pandemic and accelerating the changes that we were already seeking to adopt, in order to become a more intelligence-led, responsive regulator. The proposal was the first step in changing the way we consult and engage on any changes to our methods of inspection and regulation. The new approach allows us to hear people’s views constantly through a range of ways and to engage with stakeholders in a collective approach to solution design.

Priority two: Deliver an intelligence-driven approach to regulation

Our ambition is to use information from the public and providers more effectively to target our resources where the risk to the quality of care is greatest and to check where quality is improving.

Pandemic response

Throughout the pandemic, our core purpose of keeping people safe has been the driver in our decisions. As the risks of the pandemic have changed across the year, we have responded and continued to invest in how we use technology to assess risk and expand our approach to regulatory activity. During the year we used information we held about services to ensure our priority and regulatory activity was targeted at risk in the sector. We inspected where it was necessary but, recognising the pressure on the sector and the risk of COVID-19, we used new approaches.

We launched our Emergency Support Framework (ESF) in May 2020. This was developed for use when COVID-19 was impacting our routine inspections. The ESF provided a structure for the conversations that we were having with providers and for the escalation of concerns either to inform system partners, to target additional support and resource, or to trigger inspections.

Our transitional approach built on the work of the ESF to look at more areas where quality needs to improve. Central to this are the experiences of people who use services, their families and their carers. To promote this, we launched a year-long campaign with Healthwatch England, voluntary sector partners and others to encourage people to share their experience through our Give Feedback on Care service. Leveraging this experience, our inspectors monitored and reviewed information from all available sources, collecting further information where necessary.

Feedback about services

Some of the information we receive is shared with us by people who work (or who have worked) for health and social care organisations that are registered with us, or who provide services to those organisations (such as agencies). It is important that people who work in health and care organisations feel they can speak to us about any issues that cause them concern and that they know our response will be prompt and appropriate. People can contact us through all our communication channels. We describe any concerns we receive as ‘whistleblowing’ enquiries.

When we receive a concern, we consider the information carefully and prioritise which action to take according to the level of risk. The most serious concerns, for example where there may be a risk of harm to an individual, will trigger a safeguarding process that may include a referral – this might be to a local authority, for example. Other actions might include carrying out an inspection, working jointly with other partners or taking enforcement action. There are some enquiries that remain completely anonymous and, in these instances, it may be harder for us to progress an action due to lack of information.

Throughout the year we received an increase in contacts from people who work or have worked in regulated services. In 2020 to 2021 we received 15,829 whistleblowing enquiries, an increase of 4,841 from the 10,988 received in 2019 to 2020. The total volume of whistleblowing enquiries increased by 44.1% compared to the previous year.

On average, 45% of the information shared is addressed through our safeguarding procedures and led by other agencies. The remaining contacts are addressed through our regulatory processes as appropriate.

Sharing data across the sector

Throughout the year we have been working closely with other bodies and stakeholders to collect, share and reuse data in relation to the social care sector. Across the year we have led a data coordination group to bring agencies and providers together to ensure the data collection requirements for information were clear, proportionate and minimised burden.

Priority three: Promote a single shared view of quality

Our ambition is to work with others to agree a consistent approach to defining and measuring quality, collecting information from providers, and delivering a single vision of care that can help the public better understand the quality of care they receive.

Designated settings

In October 2020 we started to work with DHSC, local authorities and individual care providers, to provide assurance of safe and high-quality care in designated settings (DS). DS are for people leaving hospital who have tested positive for COVID-19. For inspections of DS, we used our infection, prevention and control (IPC) framework, inspecting DS locations against eight areas of reporting, including adequacy of PPE, staff training, shielding and social distancing. The work on DS was in response to the government’s aim for each local authority to have access to at least one DS as soon as possible after the scheme launched.

At the end of the year we had conducted 175 inspections of proposed DS sites and approved 144, equating to 2,253 beds available to people diagnosed with COVID-19. In February 2021, using a new digital solution, we began assurance calls for those locations that had previously been approved. At year-end, we had completed calls for 77% of DS locations. The average time between approval and call was 101 days. The work on DS and the regular supportive calls with providers continues into 2021/22.

Death notifications

One of the significant actions we have taken in response to the pandemic has been to publish provider-notified information on overall number of reported deaths and COVID-19 caused deaths of care home residents, by place of occurrence. As the scale of the pandemic was growing in 2020, we decided it was important for the aggregated information to be made public, to aid transparency and highlight the impact on residential adult social care. We worked closely with the Office of National Statistics (ONS) so that the information could be published alongside its weekly publication of care home deaths, based on death certificates.

The first weekly publication began on 28 April 2020 and we continued to publish throughout the year.

Since 23 March 2020 we have been sharing data on death notifications with DHSC on residential adult social care services, as well as community adult social care services. This information is sent every weekday and has been used to inform government policy responses to the pandemic. We have also provided approval for NHS England/Improvement and Public Health England to have access to this data to support their own responses to the pandemic. Additionally, we have given access to some academics, who are part of a Scientific Advisory Group for Emergencies (SAGE) sub-group, to help them inform and advise SAGE on the impacts of COVID-19 on care home residents.

Priority four: Improve our efficiency and effectiveness

Our ambition is to work more effectively, achieving our planned savings each year, improving how we work with the public and providers, and supporting our people to do their jobs well.

Pandemic response

Much of our focus in 2020 to 2021 has been on building an overarching transformation programme that will take us towards our ambition of being a world class regulator. Our new operating model and blueprint were agreed by our Executive Team (ET) in December 2020. Work has since focused on finalising the business case to set out the strategic intent that will help define our portfolio delivery in the future and the benefits this approach will deliver for our operation, the providers we regulate and people who use services. Our ET started hosting engagement sessions with colleagues from across the business led by our Chief Executive, sharing an early version of these plans for the future.

Throughout the pandemic we have regularly used our crisis management procedures to ensure our discussions and responses were timely and appropriate. Our governance structure allowed urgent issues to be discussed frequently and ensure timely and appropriate decisions could be made.

Throughout 2020 to 2021 we ensured the wellbeing of our people was a primary focus. We have aimed to ensure that our people have the right tools to be able to work effectively during the sudden transition to homeworking, and to provide the right support framework for our people to operate at their best, whatever their personal circumstances may be.

Our people

During the year we conducted three pulse surveys. These shorter, more frequent surveys enable us to check in with colleagues more regularly, in what has been challenging and uncertain times, and gather feedback on a range of themes, to help inform and refine our approaches to our work. In each pulse survey, we asked whether colleagues would recommend CQC as a good place to work. The responses were 74% in May 2020, 62% in October 2020 and 67% in March 2021. All of these were an increase from the 56% score in 2019 to 2020.

Our first pulse survey of 2020 to 2021 was unique because it was our first survey set during the pandemic. The focus of the survey was to see how colleagues were feeling and if they felt well-supported, informed and received appropriate communication. Colleagues reported that they felt well-supported by their manager and that they felt better supported by the organisation than before, particularly regarding their wellbeing. A total of 78% reported that they felt able to manage their health and wellbeing and 73% felt able to maintain a healthy work-life balance.

We conducted further surveys in October 2020 and March 2021 focusing on how change was managed and experienced, and on diversity and inclusion (D&I). Our March survey allowed us to test the impact of our D&I strategy, which was launched in June 2020, and to gather up-to-date information on race equality and disability equality. There were high levels of support for our diversity and inclusion agenda from among staff, with several scores in excess of 75% agreement.

We remain committed to reporting on the Workforce Disability Equality Standard (WDES) for CQC, addressing any inequality of opportunity and improving the experience of our people. The WDES is an NHS standard which helps us understand and improve the experiences of disabled colleagues. We are implementing the WDES for the first time this year and we have developed a robust action plan to address some of the key issues that have emerged.

The Workforce Race Equality Standard (WRES) also helps us understand and improve the experiences of colleagues from Black and minority ethnic backgrounds. We have developed an action plan for publication, linked to our D&I Strategy and supported by the newly formed Action for Race Equality Group, which includes members from our Race Equality Network and D&I experts.

COVID-19 meant we had to rapidly consider how we ensured colleagues’ safety. This included:

• guidance and training for colleagues in relation to COVID-19 and infection prevention and control
• risk assessments with all our people to understand individual risks, including circumstances where they may need additional support
• guidance on staying safe while working from home and how to support colleagues with caring responsibilities.

In January 2021 we began a programme of testing for our operational inspectors and provided people on inspections with home testing kits. This meant they needed to record a negative test before crossing the threshold of a service.

For further information on our approach to health and safety see section seven of the People report which is part of our Accountability report.

Digital approach

In 2020, we completed our digital foundations programme, which was designed to strengthen our IT service, improve how we work and lay the foundations for our new regulatory platform and further digital change. We have created a digital workplace that gives colleagues a modern, mobile, connected working environment. The programme completion has improved the way we work, making us more responsive to change, more innovative and better able to do the work that matters for people who use services.

Our estate

The use of our estate in 2020 to 2021 has been very limited due to COVID-19. We still have seven office locations, but we have made some significant planned changes in London and Newcastle, and to a lesser extent in Nottingham and Bristol.

Our way of working has changed too. Before the pandemic, there were more than 1,050 office-based employees ; this has now reduced to just under 500 and the expectation of smarter working arrangements for those who are office-based.

Overall, with our planned estate rationalisation and change ways of working, we have reduced the size of our estate in 2020 to 2021 by 34% while implementing efficient, effective and flexible home-working arrangements:

• In London we have moved office from Victoria to Stratford. This has meant a reduction of over 2,800 square metres (sqm), which will save almost £4m per annum (pa).
• In Newcastle we have given up one floor in our Citygate office, a space reduction of 551 sqm and a saving of £275,000 pa.
• In Nottingham we have moved office location – this has resulted in a space reduction of 162 sqm and a saving of £80,000 pa.
• In Bristol we now share an office with the Health Research Authority, which has taken 30% of our space. This has led to a more efficient use of the office and a saving of almost £100,000 pa.

Looking forward, we have engaged with the Government Property Agency to indicate interest in government hubs in Newcastle, Manchester and Birmingham. We are already located in what will become the Bristol hub.

Sustainability

Our aim is to reduce the impact of our business on the environment by reducing travel, reducing the size of our estate, and encouraging recycling. Ensuring sustainability is a key factor in the goods and services we procure. Our environmental sustainability steering group has been meeting throughout the year and has developed a five-year Sustainable Development Management Plan/Green Plan. Priority areas in the plan are:

• improved governance to drive sustainability
• reducing travel and promoting low carbon alternatives
• improving recycling
• reducing water and energy consumption
• promoting improved workforce behaviours
• modelling procurement and supply chain on best practice
• using our role as a regulator to promote sustainability with providers and across health and care systems.

In the future, we will also look at what we can do in our role as a regulator. Due to the impact of the pandemic on our work, performance data for the current year will be very skewed – our five-year green plan will re-establish targets based on new data when a new normal baseline can be established.

Future direction

Throughout the pandemic, we have worked closely with stakeholders and providers, ensuring that people who receive care are at the heart of everything we do. 2020 to 2021 provided us with an opportunity to fast track how we better use data and intelligence in our regulatory activities, while using the benefits of our digital transformation. This has accelerated our journey towards being a more intelligence-led, responsive regulator.

In January 2021 we published a formal consultation on our future approach to regulation, which led to over 10,000 interactions with stakeholders. Our new strategy is built on four themes that determine the changes we want to make in order to be a more intelligence-led, responsive regulator: people and communities, smarter regulation, safety through learning, and accelerating improvement.

Our transformation continues into 2021 to 2022 and the publication of our strategy in May 2021 was a key milestone.

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How we used our money

We are primarily funded through fees charged to registered providers, with DHSC providing grant-in-aid (GIA) for specific costs that we are unable to recover from fees. In 2020/21 our fees made up 88% of our revenue funding, with 11% from GIA, and the remaining 1% coming from other external sources. Capital expenditure was funded through additional GIA and utilisation of our retained earnings reserve (see note 14 to the financial statements).

Our current fees scheme became effective on 1 April 2019 and is set at a level to cover the cost of our chargeable activities. Fees have remained payable throughout the pandemic and we have worked with registered providers experiencing financial difficulties, offering revised payment plans. To provide stability, our fee scheme will remain unchanged for 2021 to 2022. See our Fees and charges section in our Accountability report for further details.

What we received

Our funding is broken down into the following areas:

What we spent

During 2020 to 2021 our total revenue expenditure (excluding non-cash items – see note 2.2 to the financial statements) was £212.2m with a further £14.7m invested through capital expenditure.

Overall, our revenue expenditure (excluding non-cash items) reduced by £8.9m (4%) compared to 2019 to 2020. The impact of the pandemic and national restrictions on our activities has resulted in significant savings relating to lower expenditure on travel and subsistence (£8.3m) and reduced costs relating to our flexible workforce as a result of reduced inspection activity (£4.0m). Our response to COVID-19 involved one-off costs of £2.2m, primarily relating to expenditure for establishing our emergency support framework, providing PPE to our people and equipment to enable our office based workforce to operate at home. This ensured that we were able to continue to carry out our regulatory duties, monitor risk while ensuring the safety of our people and providing a sustainable platform for us to operate going forward.

Despite the impact of the pandemic, we continued to accelerate our transformative change programme, investing an additional £7.0m (£5.8m revenue, £1.2m capital) compared to 2019/20. The benefits of which will ensure that our regulation is smarter, reducing the burden on providers and driving out a more economical and effective use of our operating budget providing greater value for money for providers we regulate and taxpayers.

Our expenditure relates to the following areas of our operating model, and reflects the impact of our COVID-19 response this year:

Ian Trenholm
Chief Executive, Care Quality Commission
10 January 2022

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Next section:
Part 2: Accountability report

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