CQC Board Meeting 29th November 2023 - Wednesday 29 November 2023, 1:30pm - Care Quality Commission

CQC Board Meeting 29th November 2023
Wednesday, 29th November 2023 at 1:30pm 

Agenda

Slides

Transcript

Map

Resources

Forums

Speakers

Votes

 
Share this agenda point
Share this agenda point
  1. Ian Dilks
  2. Mr Ian Trenholm
  3. Ian Dilks
  4. Mr Ian Trenholm
Share this agenda point
Share this agenda point
Share this agenda point
  1. Tyson Hepple
  2. Kate Terroni
  3. Ian Dilks
  4. Chris Day
  5. Mr Mark Sutton
  6. Ian Dilks
  7. Chris Day
  8. Mr Ian Trenholm
  9. Ian Dilks
  10. Mr Ian Trenholm
  11. Ian Dilks
  12. Mr Ian Trenholm
  13. Ian Dilks
  14. Christine Asbury
  15. Mr Jeremy Boss
  16. James Bullion
  17. Ian Dilks
  18. Christine Asbury
  19. Ian Dilks
  20. Kate Terroni
  21. Ian Dilks
  22. Kate Terroni
  23. Ian Dilks
  24. Mark Chambers
  25. Kate Terroni
  26. Ian Dilks
  27. Mr Ian Trenholm
  28. Mrs Nimali De Silva
  29. Mr Ian Trenholm
  30. Ian Dilks
  31. Mr Ian Trenholm
  32. Mr Mark Sutton
  33. Mr Ian Trenholm
  34. Ian Dilks
  35. Kate Terroni
  36. Ian Dilks
  37. Mr Ian Trenholm
  38. Mark Chakravarty
  39. Mr Ian Trenholm
  40. Ian Dilks
  41. Ian Dilks
  42. Mr Ian Trenholm
  43. Stephen Marston
  44. Ian Dilks
  45. Stephen Marston
  46. Ian Dilks
  47. Kate Terroni
  48. Ian Dilks
  49. Mr Ian Trenholm
  50. Ian Dilks
  51. Tyson Hepple
  52. Ian Dilks
  53. Mr Ian Trenholm
  54. Mrs Nimali De Silva
  55. Mr Ian Trenholm
  56. Ian Dilks
  57. Chris Day
  58. Ian Dilks
  59. Ian Dilks
  60. Mr Ian Trenholm
  61. Mr Ian Trenholm
  62. Mr David Croisdale-Appleby
  63. Ian Dilks
  64. Kate Terroni
  65. Mr Ian Trenholm
  66. Mr David Croisdale-Appleby
  67. Mr Ian Trenholm
  68. Mr David Croisdale-Appleby
  69. Kate Terroni
Share this agenda point
  1. Ian Dilks
  2. Ian Dilks
  3. Mr Ian Trenholm
  4. Mr Ian Trenholm
  5. Ian Dilks
  6. Mr Ian Trenholm
  7. Ian Dilks
Share this agenda point
  1. Kate Terroni
  2. Chris Usher
  3. Ian Dilks
  4. Chris Usher
  5. Ian Dilks
  6. Chris Usher
  7. Tyson Hepple
  8. Ian Dilks
  9. Mrs Nimali De Silva
  10. Mr Ian Trenholm
  11. Ian Dilks
  12. Mr Ian Trenholm
  13. Ian Dilks
  14. Ian Dilks
  15. Ian Dilks
  16. Mark Chakravarty
  17. Ian Dilks
  18. Mr Ian Trenholm
  19. Ian Dilks
  20. Mr Ian Trenholm
  21. Stephen Marston
  22. James Bullion
  23. Ian Dilks
  24. James Bullion
  25. Ali Hasan
  26. Ian Dilks
  27. Ian Dilks
  28. Tyson Hepple
  29. Ian Dilks
  30. Ian Dilks
  31. Ian Dilks
  32. Kate Terroni
  33. Ian Dilks
  34. Ellie Kemp
  35. Ian Dilks
  36. Mark Chambers
  37. Ian Dilks
  38. Mr David Croisdale-Appleby
  39. Ian Dilks
  40. James Bullion
  41. Ian Dilks
  42. Ian Dilks
  43. Ian Dilks
  44. Ian Dilks
Share this agenda point
  1. Ian Dilks
  2. Ian Dilks
  3. Kate Terroni
  4. Ian Dilks
  5. Mr Ian Trenholm
  6. Ian Dilks
  7. Mark Chambers
  8. Ian Dilks
  9. Ali Hasan
  10. Ian Dilks
  11. Mark Chambers
  12. Ian Dilks
Share this agenda point
Share this agenda point
  1. Kate Terroni
  2. Ian Dilks
  3. Mr Ian Trenholm
  4. Ian Dilks
Share this agenda point
Share this agenda point
  1. Joyce Frederick
  2. Ian Dilks
  3. Tyson Hepple
  4. Ian Dilks
  5. Tyson Hepple
  6. Ian Dilks
  7. Webcast Finished

1.0 Opening matters

Mr Ian Dilks - 0:00:00
Mr Ian Trenholm - 0:00:02
Well, good afternoon, everybody and welcome to the public board meeting of the Care Quality Commission. For those watching on record, it’s the 29th of November 2023, 1.30 p.m. Welcome colleagues to the meeting. A few opening observations for me before we get into the main
Mr Ian Dilks - 0:00:26
business. One of our directors is unable to be with us in the room, Belinda Bridge, sorry, Belinda Black, one of our non-executive directors, but is joining us on the screen, so I believe will be visible to those watching virtually, so welcome Belinda. And we
are joined by Ellie Kemp over there, our network representative from the Carers Equality Network, so welcome. The only apology is from Sean Kelly. He remains unwell, so isn’t able to join us today, but (unintelligible), one of his colleagues is joining us, in the corner
there. It is a relatively short agenda, shorter than usual. If you recall last time we started late and I said that wouldn’t repeat, so it hasn’t. We are back to normal times, but it is a fairly short agenda. That is partly because one or
two things we had planned, people aren’t available again through illness, unfortunately, so we will catch up later. But we have taken the opportunity to make a slight change to the agenda and, although not here, we are going to be joined by Sandy Lewis later
on, in about an hour or so’s time. Sandy is the associate director responsible for the new maternity group that has joined us. She can only join for about 10 minutes – it is an opportunity to meet more colleagues and for all colleagues to hear
a little bit more about what she does, or her unit does, ahead of a more substantive discussion at a later time. So, for any of you watching this and interested in timing, it will mean we will run on slightly, hopefully no more than 15
minutes to the allotted time, it may be less than that. What I am proposing to do is to bring her in after the corporate performance update, so that will probably be about 2:30, and then we will take the comfort break at that stage and
cover the Annual Health and Safety Report after the break. So, slight shift, and it means that instead of finishing around about half three, we might be a few minutes later, if that is OK? I believe one of our colleagues around the table may have
to dash slightly before that, quite understand if that is the case. So, thank you everybody. Can I check if there are any new conflicts of interest? None observed, thank you. I haven’t been notified of any other urgent business you would like us to cover
that is not on the agenda, other than Sandy Lewis joining us. So OK, thank you very much. So, Ian, I think I will just hand over to you for
Mr Ian Trenholm - 0:03:10
your report, thank you. Thanks Ian, and good afternoon, everybody. I am going to do what
I normally do and take both this paper and the next paper together, both the organisational matters and the regulatory matters together. I think it would be fair to say it has been a pretty busy time period since we were last together. In terms of
director appointments, I’m really pleased to report the appointment of three new directors: Jackie Jackson as Director of People, Nicola Wise looking after Secondary Care and Rebecca Bauers looking after Learning Disability and Autism. All three of those directors are internal promotees which, I think… I
am really pleased about. I think it makes a really positive statement about the ability to achieve internal promotion and, of course, that will open up opportunities for people to move in their respective areas as well. In terms of the Listening, Learning and Responding to

1.1 Chair’s opening remarks, Apologies and Forward View

1.2 Declarations of Conflicts of Interest

1.3 Any urgent business

Concerns Review, this is a very important piece of work and remains an important piece of work. Work continues to respond with two important steps having been achieved this last reporting period. We delivered part one of a two-part course on improving leadership confidence in relation
to race, racism and structural racism, and Board colleagues will be part of the next phase of that. The second thing that we achieved here is that we set up a new Executive Team Subcommittee to help ensure that the actions in the report remain prominent
and are embedded in our wider work. You will remember when we talked about the LLRC Report, we talked about not wanting to create a completely separate set of activities. We wanted, as far as possible, to embed it in those activities which were already running,
but there was a need for coordination and the new Subcommittee helps us with that. I think probably the biggest thing we have achieved though, in the last reporting period, is our go-live, our go-live of our assessment service which is referred to internally as Go-Live
3.0. It has undoubtedly been the main operational focus for this month, but arguably for a number of months now. It means that the Single Assessment Framework that we have been trailing for a while now is now live. That went live a week ago on
the 21st of November in some parts of the South network. We have a plan to go live as a series of relatively small steps over the next over the next four months, and this is a massive milestone for us as an organisation, both organisationally,
methodologically and technically. This is the last phase of replacing a very significant part of our technical architecture. This will enable us to be, I think, much more efficient in the way that we do our work, much more targeted alongside being able to use significantly
more sophisticated data. That will in turn help providers to benchmark their own performance, but it will also ultimately improve the service to the public. I think when we talk about the new Assessment Framework, I think there is an important part of it which is
about efficiency and productivity internally. But I think the thing that I am most excited about is the ability that it is going to give providers to improve the quality of services that they deliver, and in turn delivers a big uptick in quality for the
public. I wanted to just to take this opportunity in public though, to formally record my thanks to all of our colleagues who have worked so hard to get us here. This has truly been a fantastic team effort. I am particularly grateful for the support
and leadership of my Executive Team colleagues who are sitting around this table, as well as the support we have had from a number of non-exec colleagues over a number of years. I think, you know, that colleagues have shown enormous professionalism and resilience to get
us to this point and deliver what is a fundamental evolution in the way that we do our work. I know other colleagues around the table will want to chip in and talk about the experience of the last week and how people are feeling in
a second, but before I do that, I just want to just move on to the regulatory insights component. Alongside the obvious big focus on go-live with the new methodology, we have, of course, been looking to make sure that we are continuing to operate the
old methodology as well. So that is an important part of our plan for the winter. What that has meant is that we are doing a number of things. We are doing a piece of work around responsive assessments in general practice, looking at how they
are coping with demand, looking for examples of good practice. We are completing our maternity inspection programme which we have been talking about for a while now. We expect that to be complete in the very early part of 2024 and we will issue a report
at that point which summarises the good practice as well as some of the challenges. We are refreshing our “patient first” approach which our colleague (unintelligible) Atkin, who is now our Acting Medical Director, helped bring together with Emergency Department practitioners. We will be refreshing that
as part of this winter’s approach as well. Our local authority assessments – we have now published five pilot reports and we are agreeing the next steps with colleagues at the Department of Health and Social Care, ready for wider roll-out next year. And in terms
of our Integrated Care System work, the fieldwork is now complete, and we are now working on the first of two, the first and second reports, but we have had confirmation from the Department of Health and Social Care that they do not want us to
rate this first tranche. So, that is quite an important point about rating this first tranche. We are writing the reports, but not rating. And of course, alongside that, we have also launched our fees consultation for paying fees around ICS work. We have also, I
think importantly, agreed to take on the lead on independent Care and Treatment Reviews for the next two years. You will remember some time ago there was a real concern about people being effectively stuck in inpatient, acute mental health settings and this idea of independent
Care and Treatment Reviews meant that people’s individual cases were reviewed with a view to helping manage their way out of an acute setting. We are discussing… the details of this are being discussed with NHS England and the Department of Health and Social Care, but
we hope to be able to make a real difference to the lives of some incredibly vulnerable people who are currently detained in mental health settings. Finally, our NMSI colleagues have joined us. They are continuing to settle in well and, as Ian was describing at
the top of the meeting, Sandy Lewis will be joining us later on to give us some direct feedback on how she has found the last month or so. So, Ian, I am just going to pause there, and I know one or two other colleagues
are looking to come in and just talk about the experiences of Go-Live 3.0 as well. Yes. I think we probably will record some comments from the Board about what you are doing but, Tyson, do you wish to expand
Mr Tyson Hepple - 0:10:31
on that? Thank you, thank you,
Ian, and can I reinforce Ian’s thanks to colleagues for the way they have approached our Go-Live a couple of weeks ago. I must say I am really proud of the really professional way that they have adapted to the new ways of working in the
south. I am particularly grateful to those colleagues who have been very closely involved in our transformation, helping the Senior Team, helping teams all over all over the CQC. I would like to give a call-out, in particular, to our Super Users and our Change Champions
who, I think, have been really influential in the way that we have been able to do this. I know Ellie sat next to me, has been a Super User. We have run a number of engagement events, launch events all over the country. I think
we have run ten up to now, there are three more to go. There has been an executive team presence at all of those events, and I think that the mood I would describe is really purposeful. People, I think, are now focused on the future,
which is now very close by, and the discussions have been very detailed and exactly the level that you would hope to at this point in time. So, I am glad the launch of the 3.1 has gone well, but I am very grateful to my
colleagues for bringing this to where we are today, but also the purpose they are showing at the moment. OK. Do you want to come in? Thank you. So, I would like to echo Ian and Tyson’s comments. This has been the most epic cross-organisational effort
Ms. Kate Terroni - 0:11:56
from every part of our business to get to where we are now. This is really exciting. This is real and live now - our new Assessment Framework - enabling us to regulate more effectively through the eyes of people who use services. So, this is
a really big day. Last week was a really big day for us. So, I want to thank all the colleagues who have helped get us here, but, also, I want to emphasise Tyson’s point. It is our operational colleagues who have taken this and are
working with this and making this happen. So, from where I sit, I thank all of my people who have been working on this with other colleagues to deliver this new module, but a big thank you to our Operations Teams who are bringing this to
life, and that is where we’re going to see it starting to make a difference for people who use services and providers. Thanks Kate. I mean this is a major change to the way of working where it is enabled,
Mr Ian Dilks - 0:12:41
or underpinned, by some pretty fundamental technology.
So, again, Mark I don’t know if you want to add, Chris, I’ll come to you in a moment. Thank you. Just a few words on the technology side,
Chris Day - 0:12:54
because this is a momentous from a technology perspective. So, we have implemented our new underpinning regulatory
platform. The assessment release that went out last week followed
Mr Mark Sutton - 0:13:06
successful releases on contact and on notifications for providers. And this is the underpinning technology that allows our assessors and inspectors to be able to essentially manage the way in which we record information and evidence
against the new quality statements for our new Single Assessment Framework. That leads to efficiencies in the ways of working, a better, more transparent service for providers, to help providers improve. And it will be the mechanism that enables us to publish our ratings in a
way that allows us to have up to date, more up-to-date ratings and underpins our strategic objective to become a smarter regulator. As colleagues have said already, I wanted to add my thanks to, not just the inspectors and assessors and operational colleagues who have worked
really hard to make this a success, but also all the programme team who have worked incredibly hard. We have had people working ridiculous hours and weekends and evenings and really going above and beyond to get us to the situation where we are now. So,
really thankful for everybody’s huge effort to deliver what we have done. Now, this is obviously the part of a phased rollout, so we have had a number of colleagues in a number of integrated teams across the South network use the new technology. The successful
launch paves the way for us to be able to continue with that rollout, all as we look to roll out in in other regions and extend the rollout in the South. The technology is quite a leap from where we have been before, so this
is going to enable us to have new capabilities about understanding how we work and how we manage our work and the different stages at which we manage our work across that assessment journey; and pulling in that information about contact and information of concern and
notifications as well to enable us with that consistent way of working. The flexibility of the tool enables us to react to the best way in which we can continuously improve our operational way of working. We have got as I said, a number of users
that are live in the last week. We have got another few hundred that are teeing up to get live in the next coming weeks, and that will continue to roll out over the course of the next few months. That also applies to our providers.
So, we have got some 20 odd providers that are now signed up to the portal, and several hundred others in the in the stage of coming on board in the next few weeks. Then, overall, I think it is a great platform to enable us
to move on. It will enable us to move on to develop subsequent capabilities that are in the pipeline around registration and enforcement, and it will get to that position where we have got a complete interim smarter regulation system. Thank you. OK, Thanks Mark. Chris,
Mr Ian Dilks - 0:16:01
you wanted to comment, and then I will open it up to questions from
Chris Day - 0:16:04
people. Just to build on what has already been said, I would also like to thank the provider community who have helped us with the early adoption of this new approach. It
is obviously a change for, as well as colleagues internally - it is a change for them as well - both provider groups, provider organisations and people whose services have been involved in the development of this new approach. In particular, I would like to call
out the group of providers or early adopters in the South region. They have really helped, I think, frame how we are doing this work, to make sure that both, the technology works, but also that it drives the right understanding, the right behaviour. As Mark
said, this isn’t just about the technology, but it does mean that we are more able to gather information from providers more efficiently and effectively and use that information to drive, not just an understanding of how individual providers are performing, but it also gives us
an opportunity to look across local areas and look between providers about how services are working for people. And that is how people experience care, they experience services across a local area, so I’m very grateful for the provider community and people who use services for
their involvement in this work. I very much hope that as we develop the use of this technology, it will help us not only with our assessment of organisations, but our assessment across local areas.
Mr Ian Trenholm - 0:17:31
Mr Ian Dilks - 0:17:32
OK. Thanks for that. I mean a lot of…, good report
of a number of things. Let’s deal with any questions first on the
Mr Ian Trenholm - 0:17:40
transformation, and then we will take any other questions on any other aspects of the reports. But any observations or questions on the
Mr Ian Dilks - 0:17:48
transformation? I mean my colleagues… - I know I’m speaking
on behalf of colleagues as we were chatting earlier - but those of us
Mr Ian Trenholm - 0:18:01
who display grey hair also have also been around long enough to have
Mr Ian Dilks - 0:18:05
the scars on our back when these things go wrong. I know it’s early days and we have still
got lots of stuff to deliver, but I think the collective sigh of relief when it all worked was probably visible, or audible, the other side of London. As everyone has said, and I will just echo it, great thanks to the Executive Team, but also,
I know everyone else – you said, Mark, and referred to the hours that people have been working - we shouldn’t forget how hard a lot of people have worked to get this delivered. So, I think to get us to launch on the… - OK,
the revised timetable, - but on the timetable we set and with things working pretty much is…, congratulations to all of you. So, we should formally note that and thanks to anyone, that is listening. That is the transformation, so, thank you, great to start on
such a high note, but obviously, we will be keeping progress on the rollout under review. Then questions on anything else? So, Christine. Thank you. Yes, it is on regulatory insights, two questions. The first
Ms. Christine Asbury - 0:18:59
one is the local authority assessments. I have had a chance
to dip into them, if not read them in depth, and I just wanted to find out how the issue of fair cost of care has been treated? Because I couldn’t quite see it when I was looking. Then, just to pick up on Ian’s point
about ICS ratings, or not having ratings. You mentioned that it is the first tranche. Is it just the first tranche, or is that going to be something permanent? Thank you, Christine, for the question. On the local authority assessment side of it, so we are
Mr Jeremy Boss - 0:19:38
very pleased to have published the reports. The approach we have taken - obviously, this is using the new SAF and the nine quality statements - the approach we took to these first five reports has been to identify, as it were, the highs and the
lows of what we have found and to support the judgements that we have made around the quality statements and then the overall indicative
Mr James Bullion - 0:19:59
rating. On the question of commissioning and the fair cost of care, so, that is part of the evidence bank that we
collect, so from the authorities we have collected the market position statements and the market sustainability plans and had a discussion, as part of the fieldwork, about commissioning intentions, strategic intentions and the impact of those on sufficiency. It is fair to say that in some
reports it is featured more than others, as a high or a low in the way that we have structured the report. But going forwards, we are looking at both changes to the way that we do the self-assessment for authorities to bring in some more
consistent information, and also that we are looking at the reporting to see whether we might be more explicit to focus on the issue of commissioning. But we have certainly looked at the issue and underpinned that in the ratings eventually…, in the scoring and eventually
in the rating that we have given those authorities. Then on the question of the ICS rating, so that is for the pilot period. So, we have not got a final position from the Department on that, we expect to have that conversation. The reason for
that is mainly because we will be testing the scoring approach in the way that we do the ICSs, and that will then lead us to a conversation about how well does that translate to a rating. An important difference between ICSs and in local authorities,
for the local authority we have the Care Act to test against, for ICSs we don’t have regulations in the same way, and so we are taking, as it were, a step-by-step and cautious approach to that, guided by the policy of the Department. Anything else, Christine? Just
Mr Ian Dilks - 0:21:46
really to say that for the local authority assessments, it seems to be
Ms. Christine Asbury - 0:21:49
the fair cost of care has a major impact on quality-of-care delivery, so it does seem important to me that it is actually covered. Any other
Mr Ian Dilks - 0:22:01
questions or comments from people? I would
just…, OK, so I had one observation and one question. The observation is just to emphasise, we talked about the new Executive Committee that will oversee progressing the LLRC, I think it is important to note that. I just wanted to say James, that committee is
chaired by you, so we do have a member of the Executive Team accountable for delivery which I think is extremely helpful to a point worth noting. My question is really to do with the maternity work. I mean not just because of our work, but
including because of our work, clearly maternity and concerns on the quality is probably one of the biggest issues being debated about the NHS at the moment. I just wondered if some could say a little bit more about the timing of the report and the
extent to which we might be able to comment on, firstly, why would the ratings appear to be going down, but secondly, good practice on what we could do to assist or support improvement where we found very good practice. I mean there have been some
maternity units that are going up, and the media tends to comment only on the ones that are going down, but there have been some going the other way. So, I would just be interested to add a little bit more about timing and likely content
of that report. Thank you, Chair. So, as we talked about in State of
Ms. Kate Terroni - 0:23:21
Care, we are almost at the end of a programme of re-inspecting and re-rating every maternity setting in the country since the pandemic. As we talked about in State of Care, and
the media that followed, showed a notable increase in the number of maternity services that were “requires improvement” or “inadequate”. There are some themes in those inspections that we found as we went to each of the services. There were…, the main theme was people not
listening to women and their families about what their experiences were. There was a theme around a lack of oversight from Boards around the work on the maternity settings and governance. So, we are calling these out in every instance, every time we go to a
maternity setting where we have concerns, we address it immediately with the provider, and in some instances with NHS England. We are on track to publish a kind of thematic piece once we have concluded all the maternity inspections that will draw out in more detail
those themes where we are finding where things aren’t working right. But also, I should say, we have found some examples of good practice and again, we will, as we did with State of Care, we look forward to shining a light on that as well
Mr Ian Dilks - 0:24:33
in our summary report. OK, thanks, Kate. I don’t see any other hands up. OK, well, thank you very much indeed, and your team. Once again, well done on the Transformation Stage 1, it’s been great. Right, shall we move on? We have a quarterly assurance
report on people, so I think Jackie Jackson will be joining us, is that correct? So, I’ll start introing it, if that’s OK as Jackie is
Ms. Kate Terroni - 0:25:14
making her way to her seat. So, colleagues, this is our quarterly report that we provide to Board around our
People insights and our People data. The pack that is attached the paper continues to get fuller, but hopefully provides useful insights to the Board about what is going on in our organisation. You will notice the pack follows a kind of lifecycle of an employer’s
experience, so how we are recruiting and onboarding people and what we know about the make-up of the groups of colleagues we are recruiting, how we are rewarding colleagues, so a bit of information about how we give out our kind of reward and recognition, vouchers
or…, we talk about sickness absence and again things around that, and then we look at people exiting the organisation and their reasons for it. In the summary paper we highlight some of the things we feel quite proud about as a team that we are
doing around diversity and inclusion, and we have talked here before at Board around things like all the inclusive leadership pathway that is a thoroughly enjoyable programme to be part of that I and many other colleagues are as well. So, I will hand over to
Jackie just to draw out any highlights, so then between Jackie and I, we are happy to take any comments or questions from colleagues. Jackie, welcome. The red, yes? Thank you. OK, there is a couple of points I just want to add into the paper, which
I am particularly proud of. We often get questions around recruitment and how attractive we are as an employer. The latest round of the local authority assurance and integrated care recruitment yielded circa, across all the roles that are currently being advertised, was around 900 applications.
So, it was 502 lots of 200, so a lot of shortlisting for somebody, but what was really impressive around the numbers was the quality and that made it quite a challenging longlisting and shortlisting process because of the volume and the quality, which was really
encouraging from a recruitment perspective. So, now, also we are thinking about actually, whilst that addressed that campaign, but actually the numbers there, what is the art of the possible in terms of any other roles that we will have, in terms of inspectors and assessors
across ops. So, I think that was you know, worth sharing as hot off the press. We will continue to look at the data that is contained and collected in ASR, have feedback around (unintelligible) job share, and we’ve had the functionality to start and do
that. As we rebuild the structures in the organisation in ASR, which will be a significant task, we will look to any improvements we can make on the data collection. So, you know, hopefully, that we will see that come to fruition in terms of how
we can report and quickly access data that we need to. We touched on Staff Survey. So, the next full survey is being prepared now in terms of the question bank and socialising the proposals through our internal governance. Then after we have that full survey
which will start, commence at the start of 2024, it will come out of Christmas leave. We will think about what the next planned surveys are following that. We are looking at how we provide that data, provide the survey, and that will be an ongoing
conversation early 2024, But the full staff survey is being planned now and we will keep you abreast of how that goes, and we are looking at a quicker turnaround with suppliers in terms of the data that that provides. I think really, they were the
three things I just wanted to add in to the detail that I have already provided, but happy to take any questions on anything that is already there, or other things that might be on colleagues’ minds. OK, thanks very much indeed, Jackie. You have given
us a lot more information. I think this pack has got progressively
Mr Ian Dilks - 0:30:00
more insightful over the last year or so I have been here, so thank you very much for that. If any of my colleagues have observations on that, or things they would like to
see, can I invite them to give them to Jackie, but we will take that offline rather than now. I had nothing to add majorly, although I do have one or two questions on the data if we have time, but anyway, let me hand over
to my colleagues any comments, observations, questions? Mark. Thanks, and thanks very much Jackie. It is really good to see such a
Mr Mark Chambers - 0:30:35
comprehensive report. I was drawn to the recognition page just because it is something that many organisations don’t spend time and effort on and
it is tremendously important and much more impactful than people think. I think we introduced this a couple of years ago as I understand it, but what are we doing to try and get the criteria right? Because we have still got, sort of half of
them just down as, categorised as other? And what are we doing to push the shape of that curve further to the right, because it is still quite top-heavy in terms of the recipients? Yes, so I think you are right, it has been in place
for two years and, you know, it has been successful, and it has been well received, but there is much more we can do with that. So, it is part of the reward work, the recognition and reward work that we have commissioned, recognition is part
of that. Basically, looking at technology solutions, what other public and private sectors or companies are using in terms of recognition, not all have monetary value, but a combination of both. So, at the moment we are doing a benchmark piece looking across many industries to
see basically what will be our value add. You know, we already have our Edenred Platform which we probably need to advertise more in terms of a lot of the benefits and discounts, and are part of the civil service as well, in terms of their
discount programme. So, it is all up for review at the moment, including this, and also working with finance colleagues in terms of what the art of the possible is. May I just add? So, just to flag, so
Ms. Kate Terroni - 0:32:34
it shows the largest percentage of these
recognitions go to B grades and just a reminder for colleagues, so those are our inspectors, so actually our largest number of our workforce is in that B grade column. So, where the rewards are being dished out broadly is in line with where you would
see the volumes of our people in the organisation. So, yes, just want just wanted to make that point, thank you. Ian, if you just want… Just
Mr Ian Dilks - 0:32:58
Mr Ian Trenholm - 0:32:59
to build on that, I think the other thing we do it at an individual
Mrs Nimali De Silva - 0:33:00
directorate level is look at this at a
Mr Ian Trenholm - 0:33:04
much lower level as well. So, as Kate said, this sort of broadly reflects the shape of the workforce on one level, but I think one of the things we were interested in doing is looking at impact. Because, obviously, a voucher for some colleagues will
have more of an impact than other, so again, looking at that as well.
Mr Ian Dilks - 0:33:20
Mr Ian Trenholm - 0:33:22
Mark. Another point, if I may? I just want to say particular
Mr Mark Sutton - 0:33:23
congratulations Jackie, to you and the team, on the Inclusive Leadership Pathway as that draws to a close. In the
pack you have listed out the number of people that have successfully got promotion during that period, so 11 out of 39 people on the Inclusive Leadership Programme which is made up of colleagues from an ethnic minority or colleagues from a disabled background, that promotion
which is, I think, actually incredible. And I would also… you are moving on to extend the Reverse Mentoring Programme to that cohort of colleagues in the organisation which I think is to be applauded, thank
Mr Ian Trenholm - 0:34:03
Mr Ian Dilks - 0:34:04
you. Can I just ask about the reverse mentoring? I
mean maybe we can take this offline, but certainly since I arrived, as of the date I arrived, the Board hasn’t been, the non-executive part of the Board hasn’t been involved on that. I wonder if we might reconsider… I don’t want to commit my colleagues
to things, but I think it would be worth a discussion, see what we might do. I think it used to happen didn’t it, but not in my time
Ms. Kate Terroni - 0:34:27
here. So very briefly, we have only run this once and we ran it and then we
also wanted to evaluate it, to understand colleagues’ experiences of being on it. Then, that evaluation has informed our plan for this… so it is only the second phase we are talking about, but the intention - absolutely Jackie, isn’t it - is to offer it
to colleagues around this table as well. As someone who has been on the programme before myself and I have had a mentor, I would highly
Mr Ian Dilks - 0:34:53
Mr Ian Trenholm - 0:34:55
recommend it to others also. Kate, thanks. Mark. Thank you. So, great
Mark Chakravarty - 0:34:58
to see the report, it is a good
format and I like the sort of chronological story it tells of a person’s journey. One thing I am just sort of aware of is there’s lots of valuable current activity, whether that is leaders to lead change, whether it is a talent programme with the
introduction of the nine-box grid, whether it is coaching and mentoring frameworks. I am also aware you have got, obviously, we have got a larger piece of cultural work going on in parallel, so what are the thoughts about making sure that, yes, we keep going,
but then we can also point and course correct as the culture work matures, so that we don’t have a generation that have been through a
Mr Ian Trenholm - 0:35:38
Mr Ian Dilks - 0:35:43
programme, but it feels a little bit out of date? Yes, that is exactly…, we have had the conversation actually
just this morning around the talent programme and where that fits in with culture. Because, actually, when you look at a lot of our activity, if you are looking at culture as being the foundation, a lot of the activity that will have built on that
and there is an interdependency as well, talent being one of them. So actually, you know, we have had two or three rounds of talent conversations, talent plotting, but actually as for me now, it is what is next and where does that fit in, and
how can we refine, improve and value add to talent amongst a whole myriad of other things that basically give a much stronger People proposition? So, I think you know, I absolutely recognise the point that there is relationships and interdependencies with so many of the
Mr Ian Dilks - 0:36:47
work and activities that we undertake. Stephen, sorry, the sun is shining right behind you, and you are almost invisible from… Jackie,
Mr Ian Trenholm - 0:36:54
thank you, really helpful report and I think it shows that you and
Mr Stephen Marston - 0:36:57
colleagues are making a lot of progress in some really important
areas, so thank you. I welcome, like others, the mentoring scheme. You call it reverse, in my previous job we had a reciprocal mentoring scheme and there may be something worth thinking about, about kind of how does this relationship work to the benefit of both
parties, but I would just kind of leave that with you. I would certainly welcome being involved in the scheme. The questions I had, Page 29 of the all papers pack, as Mark commented, you have made some really, really good progress in recruitment and promotion
of ethnic minority colleagues, but if I am reading the figures rise, the turnover rate is much higher. Is there an issue there? Are we recruiting people, and they then leave rather quickly, or what is happening there? No, there isn’t an issue. With this specific,
with this particular data pack, it encapsulates a number of fixed-term contractors where they were specifically recruited because of their technology skills, to support the transformation. Those contracts are now rolling off, has come to an end, the work is concluded, and also it captures the
timescale where there would have been some voluntary severance, and also there was a number of colleagues who took retirement in there as
Mr Ian Dilks - 0:38:39
well. Did that answer your question, Stephen? I think so… So, in terms of the contractors (inaudible). So, the colleagues I am specifically talking about were here for
a time-bound period only, and there was 2.5, the ratio was 2.5 extra in the technology arena, and those contracts have now come to an end. So, you would expect to see it increased slightly because of the fact that there was a bigger number of
colleagues in that cohort who will leave at the same time. OK, thanks. (inaudible), the other question if I may? It is a link through actually to the Health and Safety Report which may sound a bit
Mr Stephen Marston - 0:39:29
counterintuitive, but that report says 95% of the workforce are homeworking on a contractual basis. I
just thought, wow, that must have quite interesting consequences for the work that you and your colleagues are doing in HR, including in relation to culture. Is there work ongoing about whether this is now a stable position in the right position, or are there consequences
for colleagues? Just interested in that sort of read across to your actual patterns of working in the organisation. . I think there’s one thing, one thing I would like to… so I don’t think we should forget, is, I think our organisation pre-COVID had a higher number of homeworking contracts because of the nature of the inspectors anyway. So, I think that was our starting
point. I think in terms of the homeworking, I have to say I haven’t really noticed a significant detriment in terms of the People work. You know, I think, and I do think, as we have moved further away from COVID, I think we are seeing
more people coming to offices for meetings, more people wanting to meet up, but I haven’t really, I haven’t really had anything across my desk that would cause me great concern, in terms of this is a burning platform. Kate, do you want to…? Yes, thank you, if I may?
Mr Ian Dilks - 0:41:06
Ms. Kate Terroni - 0:41:07
Yes, I think about 65% of our workforce were homeworkers prior to COVID. So, I know other organisations went on a massive transformation when it came to homeworking, ours was less so. I think for all of us, except colleagues who have been on away days
recently, been on Tyson’s launch events, what you hear time and time again from colleagues is how is so lovely to get together in person. So I think what’s important when we do the cultural work - I don’t think this is about anyone saying, you
know, mandating how they should look - but I think inviting our teams as they will be doing now, to think about what sort of set-up, what sort of form does it add value to come together in person, be it a monthly team meeting, be
it a strategy session, et cetera, because we know it really matters to our people to get together. I think it is just really important that we create the culture where those teams set out for themselves what good looks like and that they are kind
of supported rather than anything being mandated. And as you say, Stephen, 95% per cent of our workforce now have a homeworker contract, so we also need to be really sensitive that they manage their time correctly between being in the office and being at home
Mr Ian Dilks - 0:42:11
Mr Ian Trenholm - 0:42:12
Mr Ian Dilks - 0:42:13
as well. Tyson, do you want to add? Thank you. I completely agree with
Mr Tyson Hepple - 0:42:16
Kate about the value of bringing people together occasionally, and I have really enjoyed the launch events we have had. But the other point I was going to make is that part of our design for our
new integrated teams was that people were as close to where they worked as possible, so that it would be much more efficient in future if people didn’t have to travel large distances to inspect, for example. So, we have almost designed ourselves into that homeworking
way, but I think bringing people together from time to time for team meetings or conferences or whatever is also a bit of the blend that we
Mr Ian Dilks - 0:42:52
Mr Ian Trenholm - 0:42:53
need to have going forward. Thanks. Ian, do you want to say…? Yes,
Mrs Nimali De Silva - 0:42:54
just to finally pick up on that point, I mean Tyson’s point,
we have built an organisational design with the new transformation
Mr Ian Trenholm - 0:42:59
programme that enables assessors and inspectors to work collaboratively together. That has been designed in, in a way that it wasn’t designed in before. We have now got the technology that enables us to collaborate, to
collaborate and for everybody to know everyone’s doing, which again is important, and all of the managerial development activities, all of our creating a culture in a workforce which is largely a field force. So, all of those things together, I think what we are trying
to do is say we are not doing a generic culture change programme, what we are saying is, we need to build a culture for this organisation in 2023 with the work patterns and the technology stack, and so forth. So, I think it is a
really good challenge, I think, but it is something that we have debated long and hard and feel that the different components when glued together will be OK, but it’s something where we are very much
Mr Ian Dilks - 0:43:51
alive to. Thank you. Just in terms of the data
you presented, Jackie, I mean I do like that sort of overall People summary with the arrows, I mean it is easy to absorb and read. So, it is encouraging to see that vast majority are on the green and going the right way, so… I
had a couple of really detailed questions in one way or the other on the data that follows. On, it is Page 27 on my Board pack, I don’t know if for you, but the diversity declarations, I just want to make sure I have understood
what this says. So, if I look at the column called ethnic origin, 92.7%, does that mean that 92.7% of our people agreed to declare an ethnic origin? OK, so when we look at overall, what does that 90.5%, what does that mean? That is the overall diversity. So, 92.7%
of people declared ethnic origin, 93.7% disability, but 90.5% of, what people responded in any of the above categories? OK, so it’s a bit of an average, but it doesn’t actually? OK. More specifically, just interested if they said they…, the good thing about this is
that most things are moving in the right direction and there was little that sort of stood out for you as a major problem, but I just wanted to pick up on the leavers’ diversity. Because the overall turnover rate is 12.1%, but then if we
look at the categories LGBT+ 13.7, same for disabled and ethnicity as 20.5, so that must mean if you are not in those categories where the average is 12.1, the average must be quite a lot lower. So, there is a big difference between people who
don’t fit into those categories and people who do, but, in particular, ethnicity at 20% seems quite high. I just wondered if we had any insights on what’s driving that. (inaudible) I mean, it is partly a statistical question, but I think, you know, the more
substantive one is we appear to have a much higher turnover rate with people from an ethnic minority. I think we ought to try and get behind
Chris Day - 0:46:11
that. So, the only reason I know about this is we looked at it for exactly the same reason that you did. So related to Jackie’s earlier
point, there are a number of people that are on the transformation programme in fixed-terms roles, particularly in technology, who come from a BME community. Because that work has finished, their work, their contract is finished, and it is reflected in these figures. So, their work
has come to a natural end because that part of the transformation has come to an end. There is a higher degree of people from a BME community in that community, there are a lot of the people working on the technology solutions. So, in a
sense that particular part of it, which is what Jackie was describing earlier, there’s a group of people that we had expected to move off as we come to the end of the transformation programme. They have indeed moved off. That cohort of people are overrepresented
by people from the BME community, which is why the leavers’ figures look…, they are distorted by that that move off as fixed-term contract people leave. OK, that is really helpful. So, basically, we are saying
Mr Ian Dilks - 0:47:08
there is not a systemic problem for the organisation, it
is a statistical anomaly because of the ethnic mix of a particular cohort of people who are leaving. So, we would expect to see that
Mr Ian Trenholm - 0:47:21
Mr Ian Dilks - 0:47:21
Mr Ian Trenholm - 0:47:22
Mr David Croisdale-Appleby - 0:47:29
change next time round. OK. David. What I have found from a lot of organisations is that the attitude to, and
the methods of managing people in the post-COVID time with homeworking is quite starkly different from the experience when they were forced to work at home through the COVID situation. Bearing in mind that this is a very fertile area of research at the moment, a
lot of papers produced, etc., I just wondered where you got your…, where you were looking for your evidence about the best way of managing this situation because of this point of difference between successful management styles during COVID and post-COVID? Because the attitude of people
to homeworking has changed very significantly.
Mr Ian Dilks - 0:48:32
I think perhaps, Kate, have a first go at this. Yeah, so as I said, so
Ms. Kate Terroni - 0:48:33
95% of people prior to the pandemic were used to be line-managed by someone remotely and not in the office. It has been a change of about 30% of our line managers needing
to adapt to different ways of working. I think when we look at where this works well, so where we have had a kind of historical track record about this, it is really critical for managers to manage kind of outcomes and outputs from their employees,
rather than hours and minutes spent at the desk. So, I think, having the clarity of expectations between an individual and their line manager about how they’ll meet business need, how they will deliver X amount of outputs and during their working week, but one of
the benefits of working for us - Jackie talked about, you know, how delighted we were with the number of people who have applied to come and work with us. a) people are drawn to us for our purpose, which is the most important reason why
we would want people to come and work for us, but also, we do offer that degree of flexibility as well. So, I think, as the rest of the organisation adapted to what 65% of the organisation was doing anyway, I think that emphasis on clarity
about outputs, rather than measuring the amount of minutes someone sat at the desk is absolutely critical. And that is the kind of autonomy that we, you know, that is the kind of culture we want in our organisation. People shouldn’t be micromanaged. We should judge
someone’s success on their ability to deliver the outcomes rather than
Mr Ian Trenholm - 0:49:54
Mr David Croisdale-Appleby - 0:50:01
Mr Ian Trenholm - 0:50:01
Mr David Croisdale-Appleby - 0:50:02
minutes… (inaudible) outside to other organisations, for their experience at all. It is just an open question, or are we relying on our own information? So, I am not aware that we have particularly done
Ms. Kate Terroni - 0:50:16
that, but certainly as we start down this cultural work, that would be something we would maybe want to do, but I (unintelligible) I think there’s another dynamic to this as well, and this is this is post-COVID. Whilst we talk about homeworking, we also had

2.0 Strategic Discussions

quite a significant percentage of colleagues that may have been office-based but didn’t have their teams in that office. So, for a number of years – I am based in the North and I have never had really big a direct reports in the north. All
my team have been always spread across the country, not necessarily homeworkers, but in offices, and I am not unique in that situation. So, I think I’m not sure we’ve got a problem to solve here. I think you’re right in terms of if there is
a different way of thinking about things, but I am not sure as an organisation that we have a problem to solve. I think we can continue to evaluate, and we can continue to think about leadership and management, and the benefits of coming together and
the use of technology. But I would also counter that, actually, spending several hours on a train whereas you can pick up technology, is a worthwhile consideration too. So, I think, you know, I think it is an ongoing conversation, but I’m not sure that we
have got a problem to solve at the moment. I mean I don’t want to…,
Mr Ian Dilks - 0:51:44
maybe David is making a different point, but I was going to say something similar. It doesn’t mean to say we necessarily have got a problem, but we are different because
of the number of people who were working from home before, but the fact is that this transition from workplace working to homeworking is an issue everyone is facing. People are trying to deal with it, so there will be people out there who are suffering
things that maybe we are not suffering yet, but we might do. Or they have got good solutions to potential issues that we haven’t thought of, so I think it is worth finding a way, whether it is through other ALB networks or other HR directors
or whatever…, just keeping an eye on it. I mean there are screeds of papers written by consultants at the moment about the impact on mental health and skeletal problems, and you name it. We may not have any of those, but I would encourage you
to look outside and just see what others are finding, and then conclude, if necessary, we haven’t got them as opposed to saying we haven’t noticed it yet, but we should just be careful, someone else might have seen it. I think that’s probably what you
were saying, David. More clearly put than I did. I didn’t mean that,
Mr Ian Trenholm - 0:52:50
Mr Ian Dilks - 0:52:50
Mr Ian Trenholm - 0:52:52
Mr Ian Dilks - 0:52:53
sorry. Any other questions or comments? OK, well, look Jackie, thanks very much. Again thanks, first for the clarity of the report and the improvements you made on reporting, and also you may
not be solely responsible for the better results, but that looks better as well. But I think there’s probably a couple of things there
Mr Ian Trenholm - 0:53:18
Mr Ian Dilks - 0:53:19
to think about. OK, thank you. Right, we are on to the quarterly performance report. I think this is again, probably Kate

2.2 Quarterly Assurance on People and Culture

for you to introduce and Chris, and no doubt Tyson will have comments to make. So, perhaps I could hand over to you to introduce it, Kate. And this wasn’t on my list but Steph, welcome, thank you for coming along. Thank you. So, this report
Ms. Kate Terroni - 0:53:47
is providing an overview of performance up to the end of Quarter 2, up to September of this year. You will note, as you look at the report, there are some areas where good progress has been made and performance has been met. There are other
areas where we continue to keep a really close eye as we see performance needing to…, we need to see some moves in regards to performance hitting the expected standards, but without further ado, I will hand over to Steph our Head of Performance, to bring
you through the highlights unless Chris wants to say anything first. I’ll do it, Steph can take all of the questions. As you said, this is
Chris Usher - 0:54:21
our performance report to the end of September. Just one thing to flag in the report, we have taken on
board and tried to address the amount of monitor trends we had previously. There are about four, I think, that are still monitored where it is hard to set a target, but we have tried to incorporate whether things are improving or declining to add a
bit more light to the trend there. Just to run through some of the key results to pull out, and then I will hand over to Tyson. Safeguarding alerts and whistleblowing- we have currently got this down as not met, which is primarily due to a
temporary issue we had following the Go-Live of our new contact service in in July. You can see in the graphs performance is recovering, but we just need to monitor this closely. Areas such as safeguarding alerts – the first graph - has particularly low volumes,
therefore can be volatile, so performance is heading in the right direction after that dip, but we monitor that closely. In Key Result 3, NCSC response times also not met, again continuing to see challenges with response times to some call lines and NCSC not all…
This is partly due to adjusting to the transition to a new contact service as well, but it is also, I think, resourcing challenges within the centre that Tyson and the team are reviewing. Under Smarter Regulation, our Key Result 2, which is to increase the
amount of inspections triggered by risk, so we set ourselves a target of increasing that volume. Last year we had 86%, and this year up to 91% of inspections triggered by risks. That is either inherent risk where things we are aware of such as inadequate
services, or new and emerging risks such as whistleblowing information we have had. Key Result 5, out-of-hours, again another area where we have increased, last year we had 9.2% of activity included out-of-hours site visits, we are now up to 10.7. Although, as I’m sure we’ll
come on to, we are still looking to redefine what we mean by out-of-hours and make sure we have got a clear definition and looking at pilots and work in that area. In terms of registration, another area to pull out, Key Result 7, we’ve got
35% of registration applications are over 10 weeks old which is an increase on last financial year. The volume of applications continues to increase in this area seriously, so we are seeing demand really, really soar at the same time as I think we saw some
challenges in registration. So, we have been doing a bit of work to look at how we can address that, and how we can look at the resources in registration which Tyson may want to touch on. A couple of final bits, risk – we have
got nine risks that exceed our tolerance. However, what we don’t have in the plan is what we are doing about those. There is a plan against each with a path to green, so we’re closely monitoring those to get them back into a tolerated space.
In terms of finance, at the end of September, we had a 0.9 million deficit on our revenue expenditure which is forecast to increase to 4.7 million by the end of the year. That is largely down to our Grant in Aid position which is due
to pressures such as the COVID inquiry, which is something we are trying to accommodate into our funding allocation, as well as the impact of pay agreements. On our capital position, we have got 3.2 million overspend year to date, that is forecast to increase to
7.1 million by the end of the year, so it’s an increasing deficit. We are trying to minimise that as much as possible, but also in conversations with the Department about how we can address that
Mr Ian Dilks - 0:58:24
position. So, I think I will hand over to Tyson,
Chris Usher - 0:58:28
Mr Ian Dilks - 0:58:28
Chris Usher - 0:58:29
if you want to come in. Thank you, and thank you, Chris. I was just going to expand slightly on a couple of the measures Chris talked
Mr Tyson Hepple - 0:58:35
about. Firstly, on safeguarding alerts. I mean Chris has explained why the performance was as it was in July,
and that we are now working hard to recover the position and we keep a regular watch, including weekly, at our ET meetings on the position. I think it is worth reminding the Board that in July, even though we weren’t able to process the alerts
digitally, we were still contacting local authorities, I think over the phone, to let them know about the material we were receiving. Also, colleagues in regulatory leadership did a piece of assurance work to help us reassure ourselves that during that time we were still able
to keep people safe. On registration, I think when you are faced with a situation where demand, which has gone up by 40% over the last three years, is outstripping capacity, I think there are probably three things you can do. One is to do with
People, and you need more people and we are busily recruiting, and Chris and his investment committee are being very helpful in that regard and we are working hard to recruit up to our full complement by the end of the financial year. I think the
second one is to do with processes, and I would pay tribute to the team in registration and the senior leaders in particular, who have worked very hard to lean out the processes. I had a long session with them a couple of weeks ago where
I thought I could come up with some bright ideas about how we can make things more efficient, but all the ideas I had had already been done. But we are coming to ET in a week or so to have a similar session and just
to see if some slightly fresher pairs of eyes will also have a look at the at the processes and make sure we have leaned them out as much as we can. And in the final one, the final P is productivity and a tribute to
the teams in registration who have been working under a lot of pressure, but the productivity remains very high. Last month we managed to…, the output was 3,200 applications which is returning us to where we were before the summer, and given that there are fewer
numbers of people working in registration at the moment that sort of output is really impressive. So, I think probably the immediate thing we need to do is to keep bringing people in. We roll out the enforcement part of the transformation programme in February and
that will start to help, and they’ll be further development. But I realise that having 40% over the 10 weeks target is not what we are aiming for, so we are keeping it under constant review and pulling
Mr Ian Dilks - 1:00:56
whatever levers we can. OK, thanks Tyson. Questions or comments
from our colleagues? Sorry, yes, sorry, (unintelligible) Just to add
Mrs Nimali De Silva - 1:01:11
to what Tyson has just said, we also have a fast-track process as well for those applications were an application is going to add additional
Mr Ian Trenholm - 1:01:19
capacity to, particularly to NHS or local authority-funded care in order
to make sure that we can we can act quickly. So, we can move quickly
Mr Ian Dilks - 1:01:32
if we need to. Belinda, I’ll come to you, and then Mark. Thank you.
Mr Ian Trenholm - 1:01:35
So, in the performance report, there is a couple of items that are classed as “on hold”
about monitoring the timing of the Mental Health Act Reviews and reducing the average time between assessments. I just wondered if you could explain why they are “on hold” and when you think they will be coming on track again. Just in terms of that, so
Mr Ian Dilks - 1:01:58
the Mental Health Act, it is just in terms of accessing that data, to be honest, Belinda. So, we have access at it in terms of at a level whereby we can go in and explore it, but not at a level where we can report
it at scale. So, that is on hold at the moment for that purpose and that is part of our digital transformation. What was the second one
Mr Ian Dilks - 1:02:23
you said, sorry, I couldn’t capture it? Sorry, it was in the Smarter Regulation, Key Result 4, reduce the
average time between assessments. I wasn’t even quite sure what that meant, actually. So, I think this one is a bit of a nature of, we are in a business plan, yes, where we are talking old methodology and new methodology, and that is probably why
that may not always make sense, so that is to set us up for the future in that we want to look at the average time between us assessing a service. What we were looking at previously is the average time between an inspection, but now
we are in a hybrid state where we are looking at inspections and assessments. With our new regulatory model, the aspiration is that we will actually be going into services a lot more often, and that’s what that metric is designed to look at that. We
are just working out a way to combine those two methodologies together to be able to report on that more accurately. Mark. So, thank you for
Mr Ian Dilks - 1:03:24
Mark Chakravarty - 1:03:26
the report. Again, so set in the context of the comments I going to make, one is, you know, we
have just seen the outstanding work that has been done to do the Go-Live 3.1. The update has given a lot of narrative to the assurance of the progress we’re making. I am still relatively new to the Board, so I’m going to give maybe some
fresh eyes to this. If you think about what the score, what this sort of KPI scorecard does for us, which is to give us assurance, help us focus on the right topics to discuss, make sure we’re making decisions and driving action, I still think
we have got a little bit of way to go. Because if you take a step back, we have only very few percentage of these that we actually say are met. Does that mean that we have been too ambitious and we set the scorecard too
high on some of these other measures? There is quite a lot that we are just sort of tracking which doesn’t necessarily lead to action, so I think we have got to ask ourselves, are we looking at this in the right way? Also reading it,
I would have a question and then maybe four pages later, I would get the answer and maybe there is a way of visually presenting the answer closer to the question, so that we are actually helping drive the conversation earlier. Just to give - I
realise this is also in the context that all of us are owning that journey from going from looking at inputs to outputs to really focusing on the outcomes that we are driving. As one example, Key Result 19 under Smarter Regulation, which is increasing the
positive sentiment for recommendation as CQC as a place to work. we have as met, which would then take our focus off that and say we should not be looking at that. But when we dig one click deeper, it’s 40%, and that is a data
point from May 23 up from 37 in September 22. I don’t think anyone here says that’s where we want to be and it doesn’t feel like met, and I know the culture work as a result of that. So, it is just more taking the
opportunity to say I don’t think we are quite there yet in terms of having this support, the intent or reflect the great work that is
Mr Ian Dilks - 1:05:28
Mr Ian Trenholm - 1:05:32
being done under some of these topics. Sorry Stephen, you wanted to
Mr Ian Dilks - 1:05:33
comment, but it was really more of an
observation, but I was going to make the same point about actions. I think I have touched on that at another meeting recently, but I think if performance reporting tells us how a particular metric is compared to original expectation, which we define (unintelligible) budget ambition,
whatever, maybe you want to stretch target in there and prior periods. But I think if it is not where you want it to be, then there’s two things, one is why - can we interpret it? And then b) what are we going to do
about it? So, I think, I quite take your point on the action. Well, the point of putting it all in the one place - I mean, Chris, you may want to add, - but I shared with Chris the other day what I had come
across before, which I thought was quite a helpful template which kind of put on one page, the metrics around area and then a block with some other measurements, and then what are we doing about it. I think if we could move to that, it
would be helpful. I also have a question but, Stephen, let me come to
Mr Ian Trenholm - 1:06:33
you first. It was firstly to agree with Mark, it would be really
Mr Stephen Marston - 1:06:36
helpful going forward if all of these key results could have a target, so that we could track whether
or not we were pursuing that. It may be the same point as Ian was just making, could they - underneath this - always explain why we think indicators are not met or not improving where they’re not. Some of them, just to take an example
Key Result 6, the days per quarter where we are involving experts by experience has declined as there’s a narrative about what that figure decline is, but it tells us nothing about why, let alone what are we doing about it. So, it would be really
helpful where, you know, wherever we are not meeting what we said we will try to do, could we have a bit of explanation why? Anything to
Mr James Bullion - 1:07:34
say, Steph? Just thank you both for your comments, I guess. I absolutely recognise what you are saying. I
think, Mark, your point about have we been too ambitious? I don’t know if it is necessarily we have been too ambitious in the individual metrics, but I think there is a point of reflection in terms of the sheer scale of what we have got
in our business plan, both the metrics that we have and the milestones we have. I think that is, I guess, in part why, visually, I think it over complicates it. We recognise that as we move into the next year. We need that kind of
high level, six to ten metrics that give that indication and when you don’t have them, you drill down into it. I think that, in part, makes this a complex report to read because we wanted to show in our business plan and to ensure public
and providers that we know we have all of these aspirations in our strategy and we’re holding ourselves to them. But, actually, in doing so and having that sheer complexity in the business plan, I think that has made it exceptionally complex to report on and
made it difficult to be able to truly see the narrative. So, I just thank you for your comments and I think we need to visually try to
Mr Ian Dilks - 1:08:54
represent this better. Thanks. Ali. Thank you very much for the
Mr James Bullion - 1:08:59
update. When I was going through the paper,
I did notice, as it has been called out and highlighted, the
Mr Ali Hasan - 1:09:06
challenges around safeguarding whistleblowing, concerns and responding to them, and I appreciate the commentary that has been given about this too. A couple of follow-on questions from this, firstly, if we look at the
speed of recovery of the metrics for whistleblowing, they are somewhat slower than safeguarding and I wonder whether there is any specific reason that is underpinning that. Secondly, just recognising that we are reporting to the end of September, we are now nearly at the end
of November, I wonder if we would be able to confidently say at this stage, we think we are broadly on track, or if there is more work to
Mr Ian Dilks - 1:09:39
be done? So, Kate, sorry, Steph, you go first. I just wanted to give a bit of context in terms of the whistleblowing
metric because in seeing a rolling 12 months that may add some confusion to that. So, last year our metric was around five days for a whistleblowing, and we did change that on the 1st of April and we changed our aspirations as to how we
would respond to whistleblowings. So, from the 1st of April we looked at a Priority 1 where we are the only people that know about that concern or potential neglect would be one day, Priority 2, which is where other parties be aware, but there is
still a risk of harm to an individual would be three days, and the remainder of those whistleblowings is 5 days. So, I think there is something to recognise in that chart that, actually, the previous years’ visuals were based upon a five-day metric and we
have really aspired to be more timely in how we respond this year. So, I think actually having that in one visual causes some confusion because you can’t compare last year’s delivery to this year’s because we are aspiring to do it in a much more
timely way, which is the right thing to do, but it has taken us time between both transformation and that shift to be able to get to where
Mr Ian Dilks - 1:11:01
we want to be. Answer your question, Ali? Tyson, do you want to add? I
Mr Tyson Hepple - 1:11:07
was just going to pick up on the sort of consistency
point and I was trying to pull up the latest data - Steph may have it to hand while I talk. I think it is fair to say it has continued to recover. Some weeks it has been higher than other weeks, but we haven’t got
anywhere near the levels we reached in July and we do keep it under constant observation. As I said, it is part of the pack that we consider as an Executive Team every Friday, and my directors and I get quizzed on performance on both of
those indicators. So, it’s something we keep under close review and the performance has been higher than it was, but I think the most recent data was quite encouraging, but I don’t know if you know,
Mr Ian Dilks - 1:11:49
Steph. I am happy to answer that. So, looking at
the data that we have today, so this report is updated on a daily basis, so the year-to-date figure is at 78% for protected disclosures, so we are seeing a slight increase in the figure that is proposed from
Mr Ian Dilks - 1:12:11
September. So, another question. Steph, a request and a question,
both fairly detailed. On (unintelligible), you’ve responded I think to previous comments about giving us a better field, it is not just “met” or “not met”, so we’ve got gradations and colours, that’s all very helpful, but I wonder if you could go a step further
and give us some definitions of what it means to be close. But also there’s some inconsistency. So, if you look on Page 24, one thing is “met” or “almost met”, and another one is “close to target” and I struggle to understand the difference between
the two. That is not a question for now, but if you could define, you know within 10% or something and then be consistent, that would be really helpful. The question - it may just be a typo - but on Page, if I can find
it, there is a point about, sorry, the number of people with development plans. Sorry about this, my machine has frozen. I’ll be with you in a moment. Yes, on Page, it’s 58, beg your pardon, 50 of Diligence, Page 16 of the pack, Key Result
15, it says that in the second quarter 0.5% of our colleagues have a career development plan. I thought the ambition was pretty much everyone had one, but we are saying that 99.5% don’t. So, I guess this is…, we have an aspiration to do this,
but we haven’t made this mandatory in the organisation. So, when we put the pack together, we obviously wanted to be transparent in terms of the data that we had, but what we have also done is add additional context of the learning and development that
is existing across the organisation. So, we haven’t made a development plan mandatory, but what we can see is the sheer volume of activity that is undertaken across the organisation in terms of development and the opportunities that are available for colleagues. I think that is
something that I can work on with Jackie in terms of ensuring that we get the right balance between our people and culture, and our performance work, to ensure that what we are aspiring to do is something we can measure and that those two line
Mr Ian Dilks - 1:14:38
up in the future If I could ask you to beef up with Jackie because we were discussing the (unintelligible) yesterday and I had the statistic in the back of my mind, but she hadn’t got these papers and I could not remember. But she basically
said, most of our people have career development plans, so there’s a disconnect between what we were being told there looking at development of our people, and the statistic here, so if it is half a percent I think that is a real problem. I mean,
I understand if it is not mandatory, it won’t be 100%, but I would expect not mandatory to mean 80 or 90%, not half a percent, so OK. Just to link this to another conversation that we have had around
Ms. Kate Terroni - 1:15:12
talent management. So, you will remember that during the period of
COVID we kind of stood down our formal, having a clear conversation, plotting where colleagues are in terms of readiness for the next step and the next promotion. That has all restarted now, so it started with the Exec grades, we have now done it with
our directors and we have done it with our heads of, our kind of deputy director level. We now plan for that to be rolled out to the organisation and then that goes hand in glove with the conversation about your future, what you need to
get there and what sort of support should be on offer to you to do that. So, I think, having the formal structure of a talent conversation with a set format would go hand in glove with also having a conversation about what a career development
Mr Ian Dilks - 1:15:54
plan could look like as well. So that now will be very, very much bigger next time we meet. Thank you very much, Kate. If there are no… sorry, one last question, do go ahead. Hello there, yes, just to add
Ellie Kemp - 1:16:04
on to that as well, the networks
can get involved, especially around the cultural element of this, and we would happily support wherever we are needed to as well, to roll this out and encourage and promote it. Sorry, thanks for the
Mr Ian Dilks - 1:16:18
observation. OK, we are running a bit behind now, but Mark
and then David and then let’s move on. Just one quick encouragement
Mr Mark Chambers - 1:16:27
really to continue to develop and progress this. I think the notes are very helpful. I think there is a fair number of things in here where it is the best measure that we
can easily get to, but it’s not really necessarily telling us what is going on. So, good to hear that 98% of colleagues pass probation, but until we know actually whether probation - an assessment at the end of probation is really being used or not
– that is probably a more meaningful measure. We know that we have done quite a lot of work and we looked in RGC at out-of-hours and making sure that it is a genuine measure, and not just inspections that start earlier and finish late. You
know audit recommendations, we have discussed in Audit Committee, you know, the impact of extended deadlines. So, you know, sometimes you are going to need some underpinning measures to make sure that your lead metric is telling us the whole story, but for the moment, if
you could make sure that, continue to make sure that the narrative
Mr Ian Dilks - 1:17:42
unpacks it for us, that’s really helpful. Thanks Mark. David Thank you Chair. Really interested, if it was possible, to see an anonymised example of a career development plan because I’m kind of not
Mr David Croisdale-Appleby - 1:17:58
quite sure what it looks like. I don’t want any personal details in that, but I would very much like to see the framework, and I guess some of my non-executive colleagues would too because of their experience in other organisations and in doing that and
we might be able to shed some helpful suggestions on that, if that’s
Mr Ian Dilks - 1:18:19
acceptable? Well, if it is OK, we will share an outline or a template at our future meeting. If it is OK, I should draw (unintelligible) on that, we are running quite a bit behind, and
I did say we have got Sandy sitting outside. So, let’s get Sandy in and we will take a couple of minutes. Steph, thanks very much indeed. Welcome Sandy, so we invite you along and then we keep you waiting for a quarter of an hour,
but anyway. So welcome, you may have met some people, I know you were here a little bit earlier, so a chance to meet them over a sandwich, but if not, we have got name cards so we won’t introduce one another. It would be helpful,
by the way before you speak you will need to press the red button so that you make the microphone work, but just introduce yourself, what the organisation does and then some early observations about working with us. I think before that though, James, you were
just going to give a couple of introductory remarks. Well in the interests of timing, I think I will just hand straight over to Sandy.
Mr James Bullion - 1:19:34
She is a very welcome new member of the Regulatory Leadership Team. She is in the Health part of that team,
Sean Kelly’s team, and we have begun in the short time that Sandy has been with us, to sort of build our mutual understanding of the issues
Mr Ian Dilks - 1:19:49
Mr Ian Dilks - 1:19:56
that run right across health and care. Thank you. Thank you, thank you for inviting me this afternoon. So,
a little bit about us and the programme and what we do. So, the Maternity and Newborn Safety Investigation Programme was transitioned across into the CQC from the 1st of October with a team of about 170ish members, and that constitutes investigators, clinical advisory team, all
with a variety of backgrounds from both clinical and non-clinical. The ambition of our work is to undertake safety investigations within NHS-funded care relating to maternity. We have a defined criteria of work that we undertake and that is instructed by directions, and some of it
is undertaken under some of the CCC legislation now we have transitioned across. So, the work we do is about ensuring that we’re looking at safety, we are looking at the systems and the processes that impact on safety, and it is also just thinking about
sort of where we can make recommendations to trusts in relation to improving their processes, et cetera. The programme does not look at portioning blame to individuals and is very focused on ensuring that where we are making those recommendations, they are recommendations that trusts can
implement across the system. So, we have 14 teams across four regions and they all work with defined groups of trusts, and they all have very close working relationships across all of those trusts and the work that they do. So, we have been in place
for the last nearly five years as HSIB, now coming across to MNSI. We have had over, we have progressed over three and a half thousand investigations in relation to our criteria, and that is around babies and mothers and that is really thinking about, sort
of, babies from intrapartum stillbirth, neonatal deaths and those with severe brain injury. We also look at maternal deaths as well as part of our work going forwards. So, so from that work we have completed nearly three and a half thousand investigations that has told
us an awful lot about, sort of, what is going on in the maternity services across the whole of England. So, we do identify a selection of themes, et cetera, in the work we do. We are in quite an exceptionally privileged position, so we work
really closely with families and we have a very strong family engagement model, so they really become quite central to the work that we do, and we really do a lot of work to ensure that they can engage with the work. We have specialist communication
plans with them and really think about, actually, the importance of their involvement and accessibility to the work that we do as well. So, from those sort of additional elements, we, sort of, also think about where are some thematic areas of learning, and we have
published a number of articles in relation to how we learn. The sort of rule we have in the team is around thinking about how do we share information that you hear in Newcastle down to Penzance? How do we make sure that information is valid,
important and is relevant to the sort of healthcare providers trying to provide that work? Our teams work across multiple providers and I think this is quite a unique position for the work we do. Whereas a lot of safety investigations are very bespoke to one
area of one organisation, we work with GP surgeries, ambulance services, we work across primary, secondary providers, etc depending on where our investigation takes us. I think that gives us a really good understanding over a nine-month period of actually what happened to a mother, her
baby and their families in relation to the care that they received, so it really gives us a really good understanding of that. So, we do have, so the transition across to CCC has been, I think, relatively smooth. I can safely say I think we
have, the teams, you know, we had a really tight timeframe to bring the transition across and the teams have really done an amazing job to ensure it worked. I think that’s, you know, a recognition of collaboration from both our team and across to the
wider CCC. Everyone has made us feel very welcome and ensured that we are really in a position to support the work we do going forwards, but also think about the opportunities going forwards. So, as a team, there are many resources and opportunities within CQC,
I think, that are quite exciting opportunities. Our team, you know, we know a lot about doing safety investigations and actually, how can we share some of that, but likewise, what is there we can learn from the CQC in relation to resources. A couple of
sort of key areas really for our team are around data analytics. We have an awful lot of information. We work, you know, we work in and out of trusts on a daily basis, and therefore we are in a very unique position to really think
about, actually, are the changes that we are suggesting being made and being implemented? And this enables the sort of team to sort of think about how we work with them, and, sort of, where a trust says that changes are being made, actually, we can
see some of those changes being made. We see some really positive experiences across maternity, whereas we also see opportunities that need a little bit more further development in the work that they are doing. So, I think sort of another area of risk for us
in relation to our team, so our team worked really closely with families and they can work with families for six to nine months up to a year and beyond. and in doing that work they are repetitively exposed to some of the traumas these families
live through, and you know we are meeting families who are experienced in some of the worst events of their life and the teamwork really closely with them to try and ensure they understand what their concerns are, what the questions are, but that does take
its toll on our team. So we’ve been doing quite a lot of work, we’ve already had a trauma programmes in place for a number of years, but we’re now implementing a much more bespoke trauma programme that really thinks about the individual’s psychological wellbeing. Quiets,
our team another area of concern in relation to the work we do so our work is shared quite widely across the system, so we’re really involved. We once we’ve completed investigation or investigations, are shared with corners. They also shed quite widely and Israel litigation
processes. So, while the initial, the intention of our work is about systems and processes, I think we have to be very aware, but actually that may not always be what those are. Reports are useful and we see some of that playthrough in relation to
request for information across our team, and actually what does that mean to ensure that we’re supporting staff to tell us and share with us what their concerns, though, and really think about how we sort of keep that information to ensure that we’re making the
best of that information to improve services around us, and I think those are probably the top areas of work that we do, we hold a bespoke budget, we have 60 million pound budget that is ring fenced under Grant-in-Aid, and we really start thinking about
how we utilise that to the best of our ability across the teams going forwards. but I think there’s certainly some areas of opportunity around collaboration, data analytics and thinking about thematic learning across the system, so thank you.
Mr Ian Dilks - 1:27:09
Sandy, thank you very much. So succinct, no slides, no PowerPoints, well done. We will have Sandy back for
a longer session at a future date, yet to be determined. So, by then she will have settled in and we will probably have a more detailed discussion, but just for now, this opportunity, (unintelligible) just to ask her any burning questions or any other questions
you may have. Looking particularly at my non-executive colleagues, since the executive have sort of met her. OK. Sandy, can I just ask you to just say a little bit more about the views of your team, I mean, how are they settling in to the
switchover? Sorry, press the button. I think change is always challenging across any team, and the transition understandably created quite a lot of anxiety across our team. What would it mean coming across? You know the team were…, I suppose some of their anxiety sat around
what our role is. So, we are safety investigators, that is our role. We don’t have a regulatory function and it’s trying to ensure that we maintain that viewpoint, sort of reputationally around the work we’ve done. We have developed a really positive reputation across trusts
and they really trust in the work that we do, that we will not be talking about blame and liability, et cetera. So, some of the anxieties have been actually, what does that mean moving across into the CQC, and really thinking about, actually, where the
positives are. I think, overall, I think the team have settled across really well. I think we have been able to address their anxieties, their concerns, and I think they feel you know, predominantly, sort of fairly forearmed and able to answer the questions and really
be responsive to trusts. I think that the system, the sort of healthcare system has really shifted in the last five years in that actually we need to be transparent, we need to understand there needs to be a very open discussion. We are all here
for the same reason, and I think that understanding around the ambition is the same, and we need to do that very openly. So, I think we were probably two thirds of the way there at the point of transition and where those questions about what
information do you share with the CQC, I think we have been able to be really clear about what we do and what we don’t share information-wise with our wider CQC colleagues. But I think we have moved across in the system to really think about,
actually, we need to be more transparent and we need to think about the families that we are caring for ultimately in relation to their
Mr Ian Dilks - 1:29:44
safety. Thank you. Any other questions or comments? Well, look, Sandy, thank you very much indeed for coming along. We are
delighted to have you onboard. I am glad to hear that you personally are settling into the Regulatory Leadership Team and sorry to keep you waiting. But we do appreciate you coming along today, look forward to meeting you in future in other circumstances. Thank you.
I suggest we give ourselves a ten-minute break. If we try to keep it to ten minutes. We are behind, but I did say I would try to keep the overrun to about a quarter of an hour which was the fifteen minutes we spent with

2.2 Quarterly Assurance on People and Culture

Sandy. So, see you back here in about five minutes, if that’s
Mr Ian Dilks - 1:30:30
possible, thanks. We have one reporting update and then a number of Board governance matters to complete and then, after the conclusion of the meeting, we have, as usual, one or two questions that
Mr Ian Dilks - 1:30:46
have been posed that I will ask the Executive to answer. So, we will welcome Max Hood over there. Kate, I don’t know if you want to introduce this, but we need to consider the Annual Health and Safety Report. Thank you. So, this report is
for noting. It is a report for the last financial year and, as I just
Ms. Kate Terroni - 1:31:06
mentioned to Max, I know we have had a long conversation already in this Board about homeworking, so we quite possibly won’t major on that as we hand over to Max
to do highlights. I also said it might be useful for Board as we are already in November, knocking on December, maybe to just give a flavour of how these scenes have or haven’t changed through this year as well, as a bit of a kind
of hot-off-the-press what we need to know. But without further ado, I will hand to Max. Thank you, Kate, thank you. I think the report sets out, relatively speaking, we are a low-risk low-incident organisation when it comes to health and safety, but we are not
a no-risk organisation. So, the primary things that we are seeing are threats and verbal abuse, which is mainly our colleagues in NCSC, but not exclusively. So, we see that sometimes from providers, people on inspections, on-site DSE-related risks continue to be sort of quite a
big issue for us. We have got pretty high compliance with DSEs assessment, but we are seeing, and coming back to Kate’s point just now, certainly in this year we’re seeing an increasing trend of more assistance and more help being asked of us for reasonable
adjustment equipment for people working in offices or in homes. Then work-related stress, still certainly in the reporting year was an issue. There is a lot of work going on with colleagues and the People directorate to make sure that managers have got the right training
and support in place to support people, and individual risk assessments are carried out to support people in those situations. But, overall, I think, we are not seeing an increase in reporting, but there is still sufficient reporting to cause concern and make sure we have
got the right measures in place and keep a close eye on things. Thanks very much Max. Admirably brief, thank you for the report. Do any of the other executives wish to add anything and, if not, I will go to questions? that? No? Yes? Yes. The one area
Mr Ian Dilks - 1:33:27
that we discussed as an Exec Team that I was particularly concerned
Mr Ian Trenholm - 1:33:29
about was this idea of colleagues being abused. I was particularly concerned about colleagues who were in our inspection and it is something that we need to keep a close eye on. I think
there is an understandable natural reluctance sometimes for colleagues to report these sorts of things, but I know it is something we are working with Tyson’s group on, on encouraging people to report this so that we can decide what action we might take. Because I
just think it is totally unacceptable for providers to be to be abusing inspection colleagues and, you know, there may very well be regulatory consequences to those providers that do that. It feels completely, instinctively wrong that if you can’t have a sensible conversation with an
inspector that calls into question your ability to deliver a caring service, in my view. So, it is something that I am very keen our inspection colleagues do report, and then we will take strong action. Thank you. Yes, can I just add, I mean I
Mr Ian Dilks - 1:34:27
speak for everyone on the Board to be absolutely clear, I mean ill treatment of our people is utterly unacceptable. So, for anyone that are members of our people listening or Ali, I will ask you to pass it back, the message is we do expect
any adverse incidents to be reported and we will take them seriously. So, Mark. I strongly agree with that and another important area where
Mr Mark Chambers - 1:34:51
we want people to report is near misses because you quite often learn as much from a near miss as an incident.
Are you happy with the level of reporting there? Is there more that we can do? Have we got some benchmarking that tells us whether we are tracking enough of that? I think there is more we can do. We previously had near miss campaigns to try and encourage colleagues
to report, but that has been a little while ago. I think this came up when we presented the paper to ET that I think an awareness campaign would be good, and particularly drawing, sharing this information wider with colleagues about what we are seeing, but
also encouraging more near miss reporting. There is a very strong correlation, as you say, between good safety cultures and high levels of near miss reporting. So that is, and I think we are still on the low side. I suppose we should emphasise as well,
given events in other parts of the world, there are many other examples of tensions rising on this, and we do need to make sure that
Mr Ian Dilks - 1:35:59
the message we talked about is emphasised. Ali. Thank you very much for the clear report. I had a question
about the slide with the number of incidents, 188 between April 22 in
Mr Ali Hasan - 1:36:13
March 23. I am keen to explore a bit more about how we think about severity of incidents in our response proportionate to the levels of severity of those incidents. I wondered if
you could share a bit more? Thank you. Each incident is investigated, so we’ve got a small, but a very active Health and Safety Team. So, each of these is investigated with the individual and the line manager of the individual. I think we have identified
some areas where we would like to improve on our reporting, like giving a bit more granular detail, and I think severity is one of the things that is probably missing from this, because it is just numbers, isn’t it? It doesn’t give a real understanding,
so I think we have got a few other things, and from our meeting earlier in the year with ET on this as well, we have got some suggestions just to give that a little bit more detail. So, I am happy to take that away
for future reporting. In terms of some of the things that we see, there are some - in a very small number, - but there are some quite serious incidents, mixed in with quite a lot of low-level incidents as well. So, I think if we
can draw those out, it will provide a sort of better picture for us, but what I would say when all of these instances take place, the support that we give colleagues, I think, is pretty good and particularly when they are of a more serious
nature. We get fantastic support from colleagues, both in the line management chain and also from our People directorate. Thanks Max. Any other questions or comments from colleagues? No. So, Max, I think a clear report. Comforting, but still work to do and some messages to
Mr Ian Dilks - 1:38:13
get out about our intolerance of any abuse of our people. Sorry, was there any… oh, I thought someone else was speaking. OK. So, thank you very much indeed. We have now got a number of Board and Committee matters, so we have got a couple
of oral reports. Mark, I just wonder if you could give us a brief oral report on the last RGC meeting? Thank you very much, Chair. As a
Mr Mark Chambers - 1:38:42
reminder, RGC is the committee that looks at the design, delivery and effectiveness of our regulatory model. We
had a meeting at the end of October. As part of our, sort of, there’s two parts to it. First part is a regular look at some of the component elements to design and delivery, and then the second part is a deep dive on a
particular area. As part of that first part, we, you know, we looked at progress of the rollout of the Single Assessment Framework, internal and external feedback so far, and how that interrelated with our plans for winter. Because, of course, it is tremendously important that
we continue to deliver our programme of inspections at the same time as rolling out our new approach. The, as we looked at, the deep dive this time was on silent services. Our new approach to regulation, obviously a key, core part of it is triangulation
and triangulating a lot of information to get an assessment of risk. So, we draw in information from providers, feedback from service users and their families who give us feedback on care, third-party information and insights from those who are brave enough to speak up as
part of whistleblowing. You know, of course, one of the limitations to that triangulation exercise is if the data is not there and there are services where, despite our best efforts, we are not getting a lot of feedback. So, we looked at that in the
context of an understanding of the operation of the Single Assessment Framework, where we do have access to all the information that we would like, and how we are assessing the risk in those services where we don’t hear quite so much. The data that we
see at the committee continues to improve. We are, as a couple of examples, we raised the concern at the last meeting about an apparent tale of unpublished reports, and the need to better understand that. As we drilled into that, actually a lot of it
was, it was a data wreck, it was a data problem rather than a substantive backlog of unpublished reports, so that is encouraging. We have also tried to make sure that we are clear on how that is going to be assessed going forward. We saw
in one of the earlier papers here about the significant number of recommendations that we have had from third parties in terms of how we could improve, and there were about 200 listed at the last RGC. I think we are getting a reasonable oversight now
as to how those are being progressed and actioned, but what we want to see at the next meeting is more unpacking of some of the themes and learnings and insights that we have had from that and how those are being addressed. Our next meeting,
the topic at our next meeting is going to be whistleblowing. That is a really important challenge for us. We are aware of how much courage and conviction is required for people to speak up about services that they are part of. We will do, we
will spend more time going through it than we would have been able to enlist in this forum and we will also be concentrating on what we are doing to support and protect people who do raise their concerns with us. So, that next meeting will

4.2 Remuneration Committee Assurance Report - 28 November 2023

be in the middle of January. Thank you very much Mark. Any questions
Mr Ian Dilks - 1:43:33
for Mark? OK, I should - thank you very much Mark - I should comment on the remuneration committee, so that’s a committee I chair comprising only the non-executives. The nature of the
agenda means that it is pretty much all sensitive, but as a point of principle we do have obligations. So I think it is right that the Board is made aware that we do meet and consider things. We actually had a meeting yesterday afternoon, so
hot-off-the-press and broadly we covered four things. One was to look at the results of a, what we call a talent review, the management have carried out and the implications of that for succession, both immediate should it become necessary but also longer-term. Secondly, we do
have an explicit responsibility to look at the pay, pay position or approvals for ESMs, senior managers. Many of the things we ought to do have to be approved by - some is delegated to the executives, some for our committee, some is for the DHSC
Committee, some have to go through more than one of those stages. The DHSC rules haven’t changed necessarily, but I think we formalised our approach to ensure that we do comply with them and that we consider the right things at the right time. So, I
think it was just a little tightening-up internally, but it was helpful to have that agreed, but there’s no major change to anything. We did consider, or were asked to consider approving a number of business cases for recruitment, predominantly replacement of existing places, although one
was for a potential new position, which we did and were supportive of all of them, although one or two require a little bit of modification, so it is approval subject to tweaking. And last but no means least, we are a unitary Board and we
did spend some time looking at the current and future membership of the Board and what proposals we ought to come up with. So, I think those are the four main areas. Many people around this table were in the room, so this is partly an
update for the Executive Team and partly an update for anybody listening to show that we do take these matters very seriously, but I am happy to answer any questions if there are any, or indeed if any of my colleagues wish to add anything. It
looks like not, OK, thank you very much. So we have some minutes of the previous meeting in the pack. They were circulated some time ago to members of the Committee and so members of the Board. Any comments on them, or can we take them

4.3 Minutes of the previous Public Board meeting held on 27 September 2023

as a true and fair view of what was agreed? Approved. Thank you very much indeed. We have as good practice an action log, which shows status, including highlighted blue matters, that we propose to close as being dealt with. I just want to pick up
on a couple of these things. Item 1 was the question on job sharing. It has got the date completed as 29/11, but actually the question was can we analyse this and the answer is we don’t have all the data, but there will be a
commitment that we will have it in the future. So, it is not true to say we have it today, but I would suggest that colleagues agree we regard it as closed on the grounds that actions are being taken so that we can capture that
and it will be included in future reports. On the corporate performance reporting, there was a request that the future reporting should not use terms like “monitoring” and “on hold”. I think a number of changes have been made, Chris, thank you for that, but on
the other hand we did, when we discussed it earlier, point out there are still some terms that could be better explained. So again, if colleagues don’t mind, I would regard it as closed, but we got the message, but I think this meeting will capture
in the minutes a few further things that are required. Then Item 5, the Pulse Survey results, it was said we would agree, the Board, we said with the opportunity to comment on the values refresh, and that would be today. We haven’t really discussed the
values refresh in any great detail, but we have talked about some of the programmes, but, Kate, I don’t know if you wish to add anything. Just very briefly, we talked earlier this afternoon in the People
Ms. Kate Terroni - 1:48:01
update about our intention to do more work around
culture and to bring together the various activities that’s been happening in the organisation with a kind of coherent plan around our values and the behaviours associated with that. I think maybe this action is just a little premature. I think the conversations we started with
our NEDs and Exec team will carry on in the next couple of months as will the conversations into the organisation. So this agenda item isn’t going away and we will work with Secretariat to plot a time, probably in spring, where we will come back
and give an update to Board on that. OK. Thank you, Kate. Ian. It is
Mr Ian Dilks - 1:48:37
just a minor point in Action 1, I think that should read the Interim
Mr Ian Trenholm - 1:48:38
Deputy Chief Executive, not Chief Executive, thank you. Noted, thank
Mr Ian Dilks - 1:48:48
you, Ian. I think that deals with the formal Board agenda,
but I should just ask, is there any other business that people wanted to raise? OK. Well look, thank you very much indeed colleagues, that closes the formal meeting and concludes - the minutes will stop there. But as often happens, we do invite by questions

4.4 Review of the matters arising and the action log

5.0 Any Other Business

from the public and we do have three this time. And I believe, Joyce, you are expecting (unintelligible) and I was going to ask you to deal with a couple. So, the first question was how is CQC reviewing their use of the term safe, effective,
caring, responsive and well-led in inspections? So, can I ask you to speak first? I don’t know if any colleagues wish to then add. OK. Thank you Ian. Those are our five key questions and they describe the
Ms. Joyce Frederick - 1:49:37
quality which is a key element of our
strategy. When we engaged in our strategy, we had high support from providers, stakeholders, people who use services and the public that we should keep the five key questions and they are a common language of definition for quality across health and social care services. But
in the rollout of the Single Assessment Framework and we talked earlier about it is going live without early adopters this month, we have looked at the five key questions and I’ll just go through where, perhaps, there may be some changes. They have remained, but
we did a lot of work with people who use services as to what lies beneath them in our quality statements. So, under safe there was a stronger emphasis on learning, lots of best practice, lots of research, lots of our assessment demonstrates that there is
yes, an element of compliance with safety, but learning through safety and learning is one of the things that can promote higher safety standards. Under effective, there is a stronger emphasis around how teams work together to produce better outcomes for people and under caring, we
are describing more about compassionate care in the moment for people and also revised and make clearer links with our human rights and healthcare principles, especially fairness, dignity, respect, autonomy and equality. Under responsive, we want a stronger emphasis on how services and systems are built
around people, including equity of access and equity of experience and outcomes. And under well-led, there is a stronger emphasis on the role of leadership, Freedom to Speak Up, innovation and improvement, and workforce equality. We engaged on the framework as well, and we had strong
support across health and social care services in that development of the framework and, as I said, we are going to be using the five key questions and the quality statements in the rollout of our Single Assessment Framework. The Framework is also applied to Local
Authority and ICS assessments where we use a subset of quality statements, and this does mean for the first time that the five key questions covers the whole health and social care system in terms of our assessment. Thank you. OK. Thanks, Joyce, (unintelligible) a couple of good points
Mr Ian Dilks - 1:51:57
to emphasise to the question of how reviewing is a combination of our own experiences of expertise, but importantly, working with providers as well, so thank you for that. The other question is about the availability of how we assess things, so, Tyson, I am going
to ask you to pick this up if I could? The question was how does CQC assess the availability of hospital consultants to respond to emergencies out of hours? Thank you. Thank you for the question.
Mr Tyson Hepple - 1:52:27
During on-site inspections, we assess medical staffing under the safe
key line of inquiry, subheading medical staffing. This includes evaluating whether there are consultant grade staff with the appropriate specialism on-call and available to reach the appropriate department within 30 minutes. In addition to assessing the availability of consultant grade staff, we also evaluate the wider
team mix - this is to assess whether trusts are deploying safe levels of staff cover more broadly. Outside of the inspection process, we monitor any potential concerns received such as information shared via Give Feedback on Care. This would be triangulated with other information and
followed up with organisations by the operational teams. Thank you very much, Tyson. And then a third question, and I think probably it
Mr Ian Dilks - 1:53:15
is also best for you to pick up. It is probably in two parts, so the question was, how do we CQC regulate
the way in which NHS bodies, so that would include hospitals and GP surgeries, change their IT systems to ensure that patients and staff can use their systems with confidence? And as I say, you may want to answer it separately for hospitals and GPs. Thank
Mr Tyson Hepple - 1:53:39
you. I will roll them together if that’s OK? It is probably, it’s probably worth saying at the top that we don’t regulate the procurement of change of IT systems. What we want to know is if an IT system supports and improves the standard of
care in an organisation, and also whether the organisation undertake the assurance and audit they need to do to ensure that the IT systems are safe. In terms of hospitals, we assess this under the well-led key question, particularly the prompt, are information technology systems used
effectively to monitor and improve the quality of care? And that assessment takes place both of the service and at a corporate level, as well as interviewing senior leaders such as a senior IT lead for the trust, and during interviews with the executive team, we
will also want to discuss the digital strategy. In terms of general practice, there are two relevant questions where we would cover the IT strategy under responsive, for example, we would want to know how technology is used to support timely access to care and treatment?
And under well-led, for example, we would ask our people’s views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups? Thank you. OK Tyson, thanks very much. Unless I missed something,
I think it was only three questions, so thanks to my Executive
Mr Ian Dilks - 1:55:00
colleagues for that. So, that does bring us to the end, so for those of you listening or watching us, thank you very much indeed. We will see you again in two months’ time.
Thank you to my colleagues and cheerio. Thanks