Business plan 2023-26

Our 2023-2026 business plan sets out our position during the third year of our 2021 corporate strategy.

The plan is focused on achieving our ambitions. We have written it in line with our strategy to give a clear link between our day-to-day regulatory activities and the strategy.

It sets out our key objectives, what we want to achieve and how we will know we are there – either through key results or milestones.

The key results are measurable metrics that we will report on through our board meetings. The milestones are key deliverables from our work that help set up our future ways of working.

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Contents

• Foreword
• Introduction
• Our objectives
• Our key results
• Appendix A – Risks
• Appendix B – Budget
• Appendix C – Detailed objectives and key results

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Foreword

We are entering a vital period in our transformation with a determined focus on smarter regulation.

Moving from 2023 to 2024, we will deliver more reliable, flexible processes and technology – and we will measure that this works for our organisational needs and priorities, focused on being an insight-driven regulator.

Our new framework for data governance will underpin our ambitions for better use of data in realising our key strategic commitments.

Making progress on the People and Communities theme of our strategy, and in line with the recommendations of our listening, learning and responding to concerns Review, we will improve how we gather, listen and act on people’s experiences of care. This is about providing a better customer service to people who take the time to share information with us and our ambition to deliver regulation driven by people’s needs and experiences.

Through our work on Safety through Learning, we will continue to improve how we regulate for stronger safety cultures across health and care. We will prioritise safety, creating stronger safety cultures, focusing on learning, improving expertise, listening and acting on people’s experiences, and taking clear and proactive action when safety doesn’t improve.

This year we are working to deliver on the Accelerating Improvement theme of our strategy. Our improvement campaign approach will test and develop our skills and capacity to identify areas for improvement, using our range of regulatory impact mechanisms to create change – and using insight-driven approaches to understand and strengthen our impact. We will continue to embed improvement throughout our ways of working and to build our approach to supporting innovation.

As we progress towards the end of transforming our organisation, we continue to design our new ways of working and build the technology to support how we work.

Our new regulatory governance processes will come into play - we will see our Regulatory Governance, Regulatory Leadership and Outreach services work together to identify and prioritise our regulatory activities. We are focused on strengthening our engagement with providers, stakeholders and people who use services – and we will be better at using our insight to determine where we focus our independent voice to drive improvement in health and care services.

Reviews and updates to our single assessment framework and our new regulatory approach will continue, using feedback from providers and people who use services – this helps ensure our effectiveness and impact, delivering the right activity in the right place at the right time.

We are working with providers, the public and stakeholders to build trust and confidence in how we make sure that services are providing safe and good quality care – and we are using improved data and insights, shared with us by providers and the public, to give a better understanding of how and where we can influence improvement.

Finally, but essentially, we are committed to progressing on safety by listening, learning, and responding to people’s concerns within our own organisation. This includes how we have identified and how we will make improvements following our recent independent review. We are committed to working with our trade unions, our staff networks, and our colleagues to achieve lasting improvements in our relationships and improve colleague involvement and engagement across our organisation.

This plan explains how we will do this and how we will measure our achievements.

Ian Dilks OBE, Chair

Ian Trenholm, Chief Executive

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Introduction

This business plan reflects our position during the third year of implementation of our 2021 corporate strategy. It is focused on achieving CQC’s ambitions – chief among these is the organisational transformation to become an insight-driven regulator that is better able to drive good and outstanding health and care services for people.

The purpose of this business plan is to set out our key objectives across the three years, what we want to achieve and how we will know we are there – this could be either through key results or milestones. The key results are measurable metrics that we will report on regularly through our board meetings. The milestones are key deliverables from our projects and transformations that help set up our future ways of working.

This business plan is structured in line with our strategy, so we have a clear link in our planning and performance between our day-to-day regulatory activities and the strategy. Through our annual report and accounts, and strategy assurance, we will evaluate our delivery against the plan and in particular the key results to ensure they still meet the priorities and requirements of the strategy and our business.

CQC continues to support services to improve. Our focus remains on services that may be struggling, concentrating our efforts where there is more risk for people who use services. However, we will increasingly use our unique position in the system to seek out innovation that supports services and systems to think differently.

The context for our work in the year ahead is that the legacy of the pandemic continues to affect the services we regulate and the people who work in care services.

There are longstanding issues around workforce capacity and planning – this affects the people who need these services. Care pathways and people’s experiences of care are affected by different issues in different parts of the system.

This is a rolling three-year business plan with clear objectives, themes and strategic ambitions. As we deliver on our transformation programmes, we will be revisiting the key results to ensure they align to our new methodology and are clear in our delivery and commitments.

Our plan is to tackle inequalities in health and care, and we are doing this by developing our approach to health and care inequalities - working with our partners, aligning our evidence base and improving our skills for assessment of providers and local systems.

This year, we will substantially progress our Transformation programme which is essential to our ability to achieve our other objectives. We will also assess local systems using our new powers to examine and understand how quality of care is experienced across integrated care systems. We will use our findings to share the good practice we see – it will also help us to challenge the variation we find and drive improvement.

The plan will continue to evolve in line with changes affecting CQC. One of these is the Department of Health and Social Care (DHSC) announcement earlier this year that the Healthcare Safety Investigation Branch’s (HSIB’s) maternity programme will be hosted later this year by CQC. These new hosting arrangements will come into force this October, and we are working through the arrangements for the smooth transition of this work and the colleagues who undertake it.

We will continue to monitor our success against our objectives and this plan will be refreshed again in 2024.

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Our objectives

People and communities

• Objective 1: We will respond to information we receive and incorporate it into our regulation.
• Objective 2: Through our regulation we will work in partnership and collaboration with other sectors and regulators.

Smarter regulation

• Objective 3: We will manage our organisation well, determining and measuring this through appropriate assurance.
• Objective 4: We will use insight to measure risk at service and national level and use the insight to prioritise our activities.
• Objective 5: We will have an 'always on' regulation and ensure only services assessed as able to provide appropriate safe care are registered.
• Objective 6: We will protect people who use services from risk of harm, by using systematic findings from assessment and enforcement powers where there is poor practice.
• Objective 7: We will train and develop our people, so they have appropriate capabilities and personal and career development. We will respond to their wellbeing needs and reinforce our equalities ambitions, whilst ensuring the key results for our people are supportive of cultural expectations.
• Objective 8: We will manage within our financial resources and measure that we are delivering effectively, efficiently and economically.
• Objective 9: We will deliver reliable, flexible processes and technology and measure that that they are responding to our needs and priorities.

Safety through learning

• Objective 10: We will regulate for stronger safety cultures across health and social care.
• Objective 11: We will listen, learn and respond to people’s concerns about our organisation.

Accelerating improvement

• Objective 12: Using our independent voice, we will communicate our findings on the health and social care sectors and poor practice, and develop our knowledge of what good looks like.
• Objective 13: We will spotlight priority areas that need to improve and enable access to support where it’s needed most and where relevant.

Core ambition: Tackling inequalities in health and care

• Objective 14: We will develop our approach to reducing inequalities in health and care through work with our partners, aligning our evidence base and improving our skills for assessment of providers and local systems.

Core ambition: Accessing local systems

• Objective 15: We will examine and understand how quality of care is experienced in local systems and use our findings to share best practice, challenge unwarranted variances and drive improvement.

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Our key results

People and communities

Objective 1: We will respond to information we receive and incorporate it into our regulation

Milestones:

• Review our triage and categorisation of Safeguarding and Whistleblowing and define meaningful measures for this information in future, in line with the timing of the regulatory transformation connect. (November 2023)
• We will create and test quality measures for NCSC by July 2023.

Key results:

• Achieve a 60-80% response rate on NCSC call lines.
• Process time from receipt to transferred to Operations (where required).
• Monitor and improve the timeliness of Mental Health Act reviews.
• Ninety-five per cent of safeguarding alerts and priority 1 whistleblowing will have action recorded within 1 day, priority 2 whistleblowing will have action recorded with 3 days and safeguarding concerns and priority 3 and 4 whistleblowing concerns have action within 5 days.
• Monitor the percentage of assessment triggered by people’s experience and feedback.

Objective 2: Through our regulation we will work in partnership and collaboration with other sectors and regulators

Key results:

• Deliver volume of commitments on partnership assessments per quarter.

Smarter regulation

Objective 3: We will manage our organisation well, determining and measuring this through appropriate assurance

Milestones:

• We will develop, test and then implement a new quality framework by September 2023.
• We will also deliver the internal audit programme within the financial year. To do this, we will design and develop productivity metrics.

Key results:

• 90% of audit recommendations are complete within agreed timescales.
• Design and develop productivity metrics.

Objective 4: We will use insight to measure risk at service and national level and use the insight to prioritise our activities

Milestone:

• We will launch national and service level profiles by October 2023.

Key results:

• Increase the percentage of inspections triggered by risk.
• Monitor and analyse trends around the percentage of risk inspections resulting in a rating less than good.

Objective 5: We will have an always on regulation and ensure only services assessed as able to provide appropriate safe care are registered

Milestone:

• We will further explore and clarify the definition of ‘out of hours’ assessment and what future targets should look like. (Q3)
• We will create and test the process for understanding quality of registration services across Q1 and Q2.

Key results:

• Reduce the average time between assessments.
• Increase site visits out of hours by 5%.
• Monitor and improve days per quarter that Experts by Experience and Specialist Advisors are used as part of assessment.
• Reduce the volume of applications pending completion that are over 10 weeks old.

Objective 6: We will protect people who use services from risk of harm, by using systematic findings from assessment and enforcement powers where there is poor practice

Key results:

• Monitor the percentage of services that require enforcement action following regulatory activity.
• Improve the timeliness in taking civil enforcement action.
• Monitor the percentage of civil enforcement which receive representations.
• Baseline (and then improve) timeliness in criminal enforcement.
• Monitor the percentage of successful prosecutions and guilty pleas.
• Reduction in prosecution of common incidents.

Objective 7: We will train and develop our people, so they have appropriate capabilities and personal and career development. We will respond to their wellbeing needs and reinforce our equalities ambitions, whilst ensuring the key results for our people are supportive of cultural expectations

Milestone:

• We will monitor the volume of internal recruitment and promotion and undertake a quarterly review.
• Widening the People/Pulse Survey and ESR protected characteristics data capture (for example, trans and non-binary, disability and neurodivergence breakdown), and going further than the Equality Act characteristics, for example, menopause, social mobility.

Key results:

• Monitor the percentage of colleagues passing probation (equivalent for internal candidates)
• The percentage of colleagues with career development plan.
• Increase in completion of development opportunities.
• Increase in the percentage of colleagues with protected characteristics at all grades.
• Increase reporting of protected characteristics to 95%
• Increase positive sentiment on ‘recommend CQC as a place to work.’
• Baseline (then increase) positive sentiment on ‘I feel empowered by my line manager.’

Objective 8: We will manage within our financial resources and measure that we are delivering effectively, efficiently and economically

Key results:

• Within 1% of our available fee funded envelope.
• Within our available Grant in Aid funded envelope.

Objective 9: We will deliver reliable, flexible processes and technology and measure that that they are responding to our needs and priorities

Milestone:

• All staff and providers will be using the new single assessment framework, regulatory framework and regulatory platform by 31 March 2024.
• All staff in corporate functions will be working in a new organisational structure and using the latest cloud-based technology by 31 March 2024.

Key results:

• Availability of systems – target 99.9%
• Public and provider customer satisfaction on our systems – target 90%
• Increase in positive feedback during people survey, for question ‘I have the equipment / technology to carry out my role.’

Safety through learning

Objective 10: We will regulate for stronger safety cultures across health and social care

Key results:

• Complete research on safety cultures in 2023
• Establish a language and definition of safety culture 23/24
• Develop training to increase internal expertise on safety 23/24

Objective 11: We will listen, learn and respond to people’s concerns about our organisation

Milestones:

• We will create and test quality metrics on culture by December 2023.
• We will produce a quarterly analysis of ratings review.
• We will also support the COVID-19 inquiry.

Key results:

• Baseline the timeliness in our complaints responses.
• Baseline the timeliness and volumes of Freedom of Information requests we receive and respond to.
• Monitor the percentage of recommendations with progress and on track.
• Improve the sentiment scores for the Pulse survey question ‘I feel it is safe to challenge the way things are done here’ – from 29% to 51% over the three years of the business plan.

Accelerating improvement

Objective 12: Using our independent voice, we will communicate our findings on the sectors and poor practice and develop our knowledge of what good looks like

Milestones:

• We will use our people’s experience framework and pilot inequalities local outreach plans in Q3.
• We will also publish our major reports across the financial year.

Key results:

• Monitor and improve the number of people who access our major reports and publications through our website.
• Output of quarterly analysis.

Objective 13: We will spotlight priority areas that need to improve, enable access to support where it’s needed most and where relevant encourage innovation and research

Milestones:

• Launch improvement campaigns.
• Evaluate impact of improvement campaign.
• We will publish research on evidence-based practice, improvement cultures and innovation in services to inform our improvement approach across regulation.
• We will also produce our strategic improvement plan by the end of Q2.

Core ambition: Tackling inequalities in health and care

Objective 14: We will develop our approach to health and care inequality reduction through work with our partners, aligning our evidence base and improving our skills for assessment of providers and local systems

Milestones:

• We will establish an appropriate structure for enhanced internal and external working.
• We will use published evidence, data and the 42 ICS Health Inequalities reduction plans to assess equity in access quality statement and report nationally. (Q1)
• Obtain health inequalities reduction plans, identify appropriate data and insight, and align our findings to national measures that exist on health inequalities. (Q2)
• We will build evidence to enable us to assess equity in access, experience and outcomes in providers in Q3.

Core ambition: Accessing local systems

Objective 15: We will examine and understand how quality of care is experienced in local systems and use our findings to share best practice, challenge unwarranted variances and drive improvement.

Milestones:

• We will publish analysis of CQC and public evidence to start to understand the quality of care in a local area or integrated care system. (Q3).
• Engagement activities with integrated care systems, providers and other regulators. (Q2)
• Pilot assessment of Integrated care systems (ICS) completed and learning shared in 23/24.
• Pilot local authority assessment to be completed and learning shared, and volume of local authority assessments to be published according to baselining plan in 23/24.

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Appendix A – Risks

Strategy risks

• Our strategy does not match the current needs of the sector.
• We do not have effective governance and risk management frameworks in place.
• We do not deliver our organisation transformation effectively.
• We do not obtain enough feedback from people to ensure that user voice is central to our regulatory activity.
• We are unable to obtain the right data from external stakeholders to accurately assess the risk in services we regulate.
• We do not have enough quality data to be an intelligence-based regulator that shares information with others so they can act.
• We are unable to drive improvement and therefore do not add value to the health and social care sector.

Operational risks

• Our operational workforce is not as productive as it should be.
• We do not make an accurate and timely assessment on the quality of care or risk for people using services.
• Our operational workforce does not comply with policies and procedures.
• Our operational processes and controls are not flexible enough to respond to changing demands and priorities.
• There is the risk that business/continuity/IT disaster recovery arrangements do not meet business needs.
• If risk within the sector significantly increases, there is a risk that we do not have operational resources to respond in a timely manner.

Reputational risks

• We do not have a productive relationship with key stakeholders.
• The current legislation is inappropriate to cope with innovations.

People risks

• We cannot attract and retain our workforce.
• Our colleagues don’t have the appropriate skills (including clinical skills).
• Our colleagues are insufficiently engaged in our culture change and ways of working.
• We have not delegated roles and responsibilities appropriately, clearly and/or effectively.

Security risks

• Interruption to our technology systems due to ransomware or other malign attacks.
• Unauthorised access to our systems and misuse of information we hold.

Financial risks

• The fees we charge are considered to be excessive by those we regulate.
• We do not get appropriate funding to deliver our commitments.
• We do not have appropriate departmental controls and financial oversight.

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Appendix B – Budget

Budget 2023-24

Expenditure	£ million
Pay	190
Non-pay	44
Expenditure	234
Depreciation	11
Total net expenditure	245

Funding	£ million
Fee income	-212
Funded Activity	-2
Grant in Aid	-20
Non-cash	-11
Total funding	-245

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Appendix C – Detailed objectives and key results

Strategic theme: People and communities

Objective 1: We will respond to information we receive and incorporate it into our regulation

1.1 Desired impact: Review and improve how we utilize and respond to safeguarding and whistleblowing information in order to demonstrate we are an organisation that listens and utilizes people’s views on regulated services.

• Key result: Ninety-five per cent of safeguarding alerts and priority 1 whistleblowing will have action recorded within 1 day, priority 2 whistleblowing will have action recorded with 3 days and safeguarding concerns and priority 3 and 4 whistleblowing concerns have action within 5 days.
• Milestone: Review our triage and categorisation of Safeguarding and Whistleblowing and define meaningful measures for this information in future, in line with the timing of the regulatory transformation connect. (November 2023)
• Owner: Directors of Operations

1.2 Desired impact: As we transition through regulatory methodology it is important that we monitor and ensure that people’s voice and feedback are key to our regulatory assessment.

• Key result: Monitor the percentage of assessment triggered by people’s experience and feedback.
• Owner: Directors of Operations

1.3 Desired impact: To ensure we capture key regulatory information and provide an effective service, calls to our National Customer Service Centre (NCSC) will be responded to quickly, processed promptly and information captured to a high standard to inform our regulation.

• Milestone: Create and test quality measures for NCSC by July 2023.
• Key result: Achieve a 60-80% response rate on NCSC call lines (60% general enquiries, 70% registration, 80% concerns and 80% mental health).
• Key result: Process time from receipt to transferred to Operations (where required).
• Owner: Director of Operations Hub

1.4 Desired impact: Ensure people detained under the Mental Health Act have access to a complaints process where they feel listened to and to increase public knowledge of the experience of people detained.

• Key result: We will monitor and improve the timeliness of Mental Health Act reviews.
• Owner: Director of National Operations

Objective 2. Through our regulation we will work in partnership and collaboration with other sectors and regulators

2.1 Desired impact: Through partnership working we will inspect and assess specialist services to ensure safe and effective care. We will use our findings to drive improvement in these areas. Partnership assessments includes Health and Justice, Children’s service, Mental Health Act reviews and Ionising Radiation (Medical Exposure) Regulations work.

• Key result: Deliver volume of commitments on partnership assessments per quarter.
• Owner: Director of National Operations

Strategic theme: Smarter regulation

Objective 3: We will manage our organisation well, determining and measuring this through appropriate assurance

3.1 Desired impact: Defining what good quality regulation is and implementing quality measures locally and centrally, we will provide data on our current status and a governance pathway from strategy to quality improvement informed by quality assurance.

• Milestone: Develop, test and then implement a new quality framework by September 2023.
• Owner: Director of Finance, Commercial, Workplace & Performance

3.2 Desired impact: Our Internal Audit programme will provide independent assurance of our risk management, governance and control measures that are in place. Where recommendations are made, we will ensure timely action is taken.

• Milestone: Deliver the internal audit programme within the financial year.
• Key result: 90% of audit recommendations are complete within agreed timescales.
• Owner: Director of Finance, Commercial, Workplace & Performance

3.3 Desired impact: Alongside the roll-out of our new methodology and processes we will develop metrics to understand and monitor our operational productivity.

• Milestone: Design and develop productivity metrics.
• Owner: Director of Finance, Commercial, Workplace & Performance

Objective 4: We will use insight to measure risk at service and national level and use the insight to prioritise our activities

4.1 Desired impact: We will embed National and Service level profiles in our regulatory approach to ensure all data and information is utilised in our understanding of the risk of services.

• Milestone: Launch national and service level profiles by October 2023.
• Owner: Director of Data and Insight

4.2 Desired impact: We will explore sector and regional variation in the outcomes of our assessment, specifically in relation to those with the most inherent risk, to ensure continuous learning and improvement in our insight approach.

• Key result: Increase the percentage of inspections triggered by risk.
• Key result: Monitor and analyse trends around the percentage of risk inspections resulting in a rating less than good.
• Owner: Directors of Operations

Objective 5: We will have an always on regulation and ensure only services assessed as able to provide appropriate safe care are registered.

5.1 Desired impact: We will reduce the time between a service being rated and their next assessment to reduce the time between assessments, especially in poorly rated services. This will reduce the potential impact on people receiving poor care, as well as improve the accuracy of service ratings.

• Key result: Reduce the average time between assessments.
• Owner: Directors of Operations

5.2 Desired impact: Out of hours activity is key to our regulation. We will be clear on our definition of out of hours and expectations. Whilst this work is ongoing, we will increase the number of out of hours site visits for services where people live to ensure to ensure we have a wider experience of the service, and the care people receive.

• Milestone: Further explore and clarify on definition of ‘out of hours’ assessment and what future targets should look like (Q3).
• Owner: Director of Operations Hub

• Key result: Increase the percentage of site visits out of hours by 10% by September 2023.
• Owner: Director of Operations

5.3 Desired impact: We will increase the proportion of time that people who use services or are experts in providing services, are involved in assessing service quality.

• Key result: Monitor and improve days per quarter that Experts by Experience and Specialist advisors are used as part of assessment.
• Owner: Directors of Operations

5.4 Desired impact: We will develop our understanding of the quality of our registration service through a new process to measure it.

• Milestone: Create and test process for understanding quality of registration service across Q1 and Q2.
• Owner: Director of National Operations

5.5 Desired impact: We will ensure we offer a timely registration service for providers.

• Key result: We will reduce the volume of applications pending completion that are over 10 weeks old.
• Owner: Director of National Operations

Objective 6: We will protect people who use services from risk of harm, by using systematic findings from assessment and enforcement powers where there is poor practice.

6.1 Desired impact: We will analyse and monitor services that require enforcement following assessment to review for any trends or patterns. We will ensure where we need to take civil enforcement it is undertaken in a timely manner to minimise the risk of people receiving poor care and to ensure the services have the information necessary to take action.

• Key result: Percentage of services that require enforcement action following regulatory activity.
• Key result: Improving the timeliness in taking civil enforcement action.
• Owner: Director of National Operations

6.2 Desired impact: We will monitor where we receive representations to civil enforcement to ensure we can learn from any themes in both the challenges and the outcomes.

• Key result: Monitor percentage of civil enforcement which receive representations.
• Owner: Director of National Operations

6.3 Desired impact: Ensure we take timely criminal enforcement action that is successful in holding services to account and protecting people and monitor the outcomes of criminal activity to consider any learning.

• Key results: Baseline (and then improve) timeliness in criminal enforcement and monitor percentage of successful prosecutions and guilty pleas.
• Owner: Director of National Operations

6.4 Desired impact: Through learning and engagement with the sector we will see a reduction in prosecution of common incidents (such as falls from windows, ligature risks and sexual abuse).

• Key result: Reduction in prosecution of common incidents.
• Owner: Director of National Operations

Objective 7: We will train and develop our people, so they have appropriate capabilities and personal and career development; respond to their well-being needs and reinforce our equalities ambitions; whilst ensuring the key results for our people are supportive of cultural expectations

7.1 Desired impact: Ensure our people have the appropriate capabilities for their role we will monitor completion of induction requirements and passing probation.

• Key result: Monitor the percentage of colleagues passing probation (equivalent for internal candidates).
• Owner: Director of People

7.2 Desired impact: We will support our people with career progression through personal developments and participation in development.

• Milestone: We will monitor the volume of internal recruitment and promotion and undertake a quarterly review.
• Key result: Percentage of colleagues with career development plan.
• Key result: Increase in completion of development opportunities.
• Owner: Director of People

7.3 Desired impact: We will reinforce and deliver our equalities ambitions as an organisation.

• Milestone: Widening the People/Pulse Survey and ESR protected characteristics data capture (for example, trans and non-binary, disability and neurodivergence breakdown), and going further than the Equality Act characteristics, for example, menopause, social mobility.
• Key result: Increase of percentage of colleagues with protected characteristics at all grades.
• Key result: Increasing reporting of protected characteristics to 95%.
• Owner: Director of People

7.4 Desired impact: Through our people survey we will see an increase in the volume of colleagues who provide a positive response to the question ‘recommend CQC as a place to work’, whilst continuing to drive improvement in this area.

• Key result: Increase positive sentiment on ‘Recommend CQC as a place to work’.
• Owner: Director of People

7.5 Desired impact: We will understand our colleague’s sentiment in relation to the support and line management they receive through our people pulse survey.

• Key result: Baseline (then increase) positive sentiment, ‘I feel empowered by my line manager.’
• Owner: Director of People

Objective 8: We will manage within our financial resources and measure that we are delivering effectively, efficiently and economically

8.1 Desired impact: To ensure we are making sound financial decisions we will ensure we manage our budget within our available fee funded envelope.

• Key result: Within 1% of our available fee funded envelope.
• Owner: Director of Finance, Commercial, Workplace & Performance

8.2 Desired impact: Ensure we are making sound financial decisions; we will ensure we manage our budget within our available grant-in-aid funded envelope.

• Key result: Within our available grant-in-aid funded envelope.
• Owner: Director of Finance, Commercial, Workplace & Performance

Objective 9: We will deliver reliable, flexible processes and technology and measure that that they are responding to our needs and priorities

9.1 Desired impact: All CQC will be using a new single assessment framework across all sectors and across the full breadth of our regulation, including registration, assessment, reporting and enforcement.

• Milestone: All staff and providers are using the new single assessment framework, regulatory framework and Regulatory Platform by 31 March 2024.
• Owner: Director of Transformation

9.2 Desired impact: We will have defined structures, ways of working, capabilities, roles and responsibilities for our corporate functions and modernised CQC finance systems, to ensure future resilience, address current deficiencies and deliver a direct benefit to a wide range of stakeholders by upgrading the service offering available to support the business.

• Milestone: All staff in corporate functions will be working in a new organisational structure and using the latest cloud-based technology by 31 March 2024.
• Owner: Director of Transformation

9.3 Desired impact: We want to ensure our colleagues and providers who use our systems, have access to reliable consistent technology systems to support our work.

• Key result: Availability of systems – target 99.9%.
• Owner: Director of Technology

9.4 Desired impact: We will track customer satisfaction with our systems to understand the digital service we provide and inform improvement.

• Key result: Public and Provider Customer Satisfaction on our systems – target 90%
• Owner: Director of Technology

9.5 Desired impact: We want to ensure our people have a positive experience with their equipment and technology, that makes it possible to do their work.

• Key result: Increase in positive feedback during people survey, for question ‘I have the equipment / technology to carry out my role’.
• Owner: Director of Technology

Objective 10: We will regulate for stronger safety cultures across health and social care

10.1 Desired impact: We will regulate for stronger safety cultures across health and social care.

• Milestone: Complete research on safety cultures in 2023.
• Milestone: Establish a language and definition of safety culture 23/24.
• Milestone: Develop training to increase internal expertise on safety 23/24.
• Owner: Director of Policy and Strategy

Objective 11. We will listen, learn and respond to people’s concerns about our organisation

11.1 Desired impact: Ensure we have a culture in place to listen, learn and respond as an organisation.

• Milestone: Create and test quality metrics on culture by December 2023.
• Owner: Director of People

11.2 Desired impact: We will respond to complaints about CQC, and Freedom of Information requests in a timely manner to ensure we are transparent and providing information / supportive of those who contact us.

• Key result: Baseline the timeliness in our complaint’s responses.
• Key result: Baseline the timeliness and volumes of Freedom of Information requests we receive and respond to.
• Owner: Director of Governance and Legal Services

11.3 Desired impact: We will respond to requests to review the ratings reviews that we have received and evaluate the reviews for any themes, trends or learning.

• Milestone: Quarterly analysis of ratings review
• Owner: Director of Governance and Legal Services

11.4 Desired impact: As an organisation we will support the learning process from the COVID-19 pandemic, including providing information, documentation and supporting the COVID-19 inquiry.

• Milestone: Support the Covid-19 inquiry.
• Owner: Director of Governance and Legal Services

11.5 Desired impact: CQC colleagues trust and feel able to use our Speak up processes.

• Key result: Improve the sentiment scores for the Pulse survey question ‘I feel it is safe to challenge the way things are done here’ – from 29% to 51% over the 3 years of the business plan.
• Owner: Director of People

11.6 Desired impact: To ensure visibility in our delivery we will monitor the recommendations made to CQC from stakeholders and the commitments we make through our publications and track the delivery and progress quarterly.

• Key result: Monitor the percentage of recommendations with progress and on track.
• Owner: Director of Finance, Commercial, Workplace & Performance

Strategic theme: Accelerating improvement

Objective 12. Using our independent voice, we will communicate our findings on the sectors and poor practice and develop our knowledge of what good looks like

12.1 Desired impact: Our independent voice gives unique perspective on people’s experience and shines a light on inequalities in the sector. Throughout the year we will publish a number of major reports and evaluate and monitor the reach they have.

• Milestone: Publication of our major reports across the financial year.
• Key result: Monitor and improve the number of people who access our major reports and publications through our website.
• Owner: Director of Engagement

12.2 Desired impact: Through quarterly analysis we will demonstrate that we have chosen the most important areas to focus on, based on our evidence and insights, and ensure that, in our publications, inequalities have been addressed.

• Key result: Output of quarterly analysis (To include quarterly qual analysis on decision making for independent voice prioritisation)
• Owner: Director of Data and insight

12.3 Desired impact: Our independent voice will have a strong focus on people’s experiences and seek to reduce inequalities. Independent Voice draws on findings from our people’s experience framework and inequalities outreach.

• Milestone: Using our people’s experience framework and piloting inequalities local outreach plans (Q3)
• Owner: Director of Engagement

Objective 13. We will spotlight priority areas that need to improve, enable access to support where it’s needed most and where relevant encourage innovation and research

13.1 Desired impact: We will undertake a series of improvement campaigns throughout the year, and for each undertake an evaluation of the impact of the work, the results of which will inform our improvement campaigns and overall improvement approach across CQC for the following years.

• Milestone: Launch of improvement campaigns.
• Milestone: Evaluate the impact of improvement campaigns.
• Owner: Director of Policy and Strategy

13.2 Desired impact: We will commission and publish research on evidence-based practice, improvement cultures and innovation in services to inform our improvement approach across regulation.

• Milestone: Publish research on evidence-based practice, improvement cultures and innovation in services to inform our improvement approach across regulation.
• Owner: Director of Policy and Strategy

13.3 Desired impact: We will produce a plan on activities we will drive improvement internally, and in the health and care system, whilst delivering our strategic commitments. Our plan will incorporate our work on our quality improvement strategy.

• Milestone: Produce strategic improvement plan by end of Q2.
• Owner: Director of Integrated Care, Inequalities and Improvement

Objective 14. We will develop our approach to health and care inequality reduction through work with our partners, aligning our evidence base and improving our skills for assessment of providers and local systems

14.1 Desired impact: In order to ensure appropriate skills, approach and tactical response to drive health inequalities we will establish an appropriate structure to enhance both internal and external working.

• Milestone: Establish an appropriate structure for both enhanced internal and external working (Q1
• Owner: Director of Integrated Care, Inequalities and Improvement

14.2 Desired impact: We will use published evidence, data and the 42 ICS Health Inequalities reduction plans to assess equity in access quality statement and report nationally. (Q1)

• Milestone: We will use published evidence, data and the 42 ICS Health Inequalities reduction plans to assess equity in access quality statement and report nationally. (Q1)
• Owner: Director of Integrated Care, Inequalities and Improvement

14.3 Desired impact: We will obtain health inequalities reduction plans for 22-23 to identify health inequalities by footprint area, and this with key stakeholders, appropriate data and insight, and align our findings to national measures of health inequalities. We will use the conclusions throughout our regulation.

• Milestone: Obtain health inequalities reduction plans, identify appropriate data and insight, and align our findings to national measures that exist on health inequalities. (Q2)
• Owner: Director of Integrated Care, Inequalities and Improvement

14.4 Desired impact: We will build evidence to enable us to assess equity in access, experience, and outcomes in providers in our Single Assessment Framework

• Milestone: Build evidence to enable us to assess equity in access, experience, and outcomes in providers (Q3)
• Owner: Director of Integrated Care, Inequalities and Improvement

Core ambition: Assessing local systems

Objective 15. We will examine and understand how quality of care is experienced in local systems and use our findings to share best practice, challenge unwarranted variances and drive improvement

15.1 Desired impact: We will review data, ratings and published documentary evidence across all local authorities, the analysis will enable us to start to understand the quality of care in a local area or integrated care system and provide independent assurance to the public of the quality of care in their area.

• Milestone: Publish analysis of CQC and public evidence to start to understand the quality of care in a local area or integrated care system. (Q3)
• Owner: Director of Data and Insight

15.2 Desired impact: Use our Integrated Care System insights, to engage, influence and drive improvement across sectors.

• Milestone: Engagement activities with integrated care systems, providers and other regulators. (Q2)
• Owner: Director of Engagement

15.3 Desired impact: We will launch our work to review and assess how Integrated Care Systems are delivering their responsibilities under the Health and Care Act 2022. Pilot integrated care system methodology in 23/24.

• Milestone: Pilot assessment of Integrated care systems (ICS) completed and learning shared in 23/24.
• Owner: Director of Integrated Care, Inequalities and Improvement

15.4 Desired impact: We will launch our work to review and assess how Local Authorities are delivering their Care Act functions. Up to five pilots and up to 20 baseline assessments in 23/24.

• Milestone: Pilot local authority assessment to be completed and learning shared, and volume of local authority assessments to be published according to baselining plan in 23/24.
• Owner: Director of Adult Social Care