1. ANNEX A - CQC Performance, Quarter 3, 2012 Contents Section 1 Section 1 – Scorecard summary Slide 2 Section 2 Section 2 – delivery priority 1: Deliver and Improve our regulatory and other functions Slides 3 - 8 Section 3 Section 3 – delivery priority 3: Manage our organisation, people and resources Slides 9 - 10 Section 4 –Section 4 – Levels of compliance and non-compliance - registered locations Slides 11 - 14 Section 5 – Section 5 – CQC 2012/13 equality objectives tracker Slide 15 Section 6 –Section 6 – Explanatory notes to the scorecard measures Slide 16 1  All measures with a tick are included in our monthly performance dashboard which is published on our website.

2. Q3 and YTD scorecard summary Operating performance - Compliance inspections Resources and audit actions Customer Service Operating performance - Registration, Enforcement and MHA MeasureTargetQ1Q2Q3 Year to Date TrendRAG registrations within 8 weeks 90%88% 83%86%  G variations within 4 weeks 90%70%76%74%73%  A % warning notices - 14 days 90%81%79% 84%  G MHA Commissioner visits 95% 121%106% 82% 101%  G SOAD requests allocated < 4 working days 95%N/R 100% N/AG MeasureTargetQ1Q2Q3 Year to Date TrendRAG CI Vacancy rate <2%13%8%0.4%  G Front line staff mandatory learning 72%42%31%29%34%  R Sickness rate <5%3% 4%  G Revenue variance vs. budget 5%- 8% -6%  A % of outstanding audit actions completed 90%97%94%95%  G MeasureTargetQ1Q2Q3 Year to Date TrendRAG Calls in 30 sec. Safe guarding 90%94% 93%94%  G Calls in 30 sec. Mental Health 90%96% 94%95%  G stage 1 complaints <10% of 2011/12 10596117318  G Stage 1 complaints proceeding stage 2 <20% 20% (21) 27% (26) 12% (13) 19% (60)  G stage 2 completed in < 20 days 95%67%100%77%81%  A MeasureTargetQ1Q2Q3 Year to Date TrendRAG NHS inspections 65% (226) 20% (71) 14% (50) 39% (137) 73% (258)  G ASC inspections 59% (14,847) 14% (3,556) 18% (4,384) 26% (6,562) 58% (14,502)  A IHC inspections 46% (1,279) 7% (196) 7% (186) 20% (565) 34% (947)  R Dental inspections 57% (2,010) 14% (499) 15% (523) 29% (1,023) 58% (2,045)  G Private Ambulance inspections 56% (177) 5% (16) 6% (20) 17% (55) 27% (86)  R 2

3. Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration Compliance Monitoring As at 31 st December we were 75% of the way through the financial year and had completed 55.7%, (17,838) of our inspection delivery plan compared with a year to date profiled plan of 58% (18,539). Against the number of active locations we have met 61.6% of plan over the first 3 quarters, which leaves over 38% of plan to be inspected in Q4. As of 27 th January there were 28,943 active locations (i.e. excluding those that made up the business plan target, but have since deregistered). This leaves 8,020 inspections to be completed in the next 9 weeks. Over the year productivity has improved significantly and additional resources have been made available in support of the programme delivery, however Q4 will be particularly challenging. The graph below illustrates the percentage of the plan by sector that must be delivered in Q4 to meet the overall business plan target. The second table on the left demonstrates the latest position (as at 27 th January 2013 and compares the current weekly run rate and the required weekly run rate.) 1 This is the profiled target to date- annual target is given numerically in the cells to the left 2 Based on including inspections from Q1,Q2 and Q3 that had less than 5 outcomes. CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions 3 Compliance Monitoring Inspections (with 5 outcomes or more) completed RefIndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG C01  NHS - at least 1 service per trust (291 Trusts - 350 locations) 65% (226) 20% (71) 14% (50) 39% (137) 73% (258)  G C02  25,008 ASC provider locations 59% (14,847) 14% (3,556) 18% (4,384) 26% (6,562) 58% (14,502)  A C03  2,764 IHC provider locations 46% (1,279) 7% (196) 7% (186) 20% (565) 34% (947)  R C05  3,545 dental provider locations 57% (2,010) 14% (499) 15% (523) 29% (1,023) 58% (2,045)  G C04  317 private ambulance provider locations 56% (177) 5% (16) 6% (20) 17% (55) 27% (86)  R N/A Overall performance against programme 58% (18,539) 14% (4,338) 16% (5,163) 26% (8,342) 56% (17,838)  A 74 7,303 1,421 1,191 179 Actual number of active locations remaining to be inspected Latest Position of Inspection Activity and run rates (as at 27th January 2013) SectorYTD YTD targetDifference Current weekly Run rate Required weekly run rateVariance NHS 2692618 47-3 ASC 16,97317,633-660 619629-10 IHC 1,2401,784-544 86130-44 Dentist 2,3292,507-178 104109-5 Ambulance 112228-116 917-8 CQC 20,92322,413-1,490 822891-69

4. Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration Scheduled Inspections and compliance RefIndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTD TrendRAG C07Responsive inspections undertaken -4855023931,380  MI C11 The % of our inspections where we used one or more involvement methods or tools -61%81%84%75%  MI C16 The % of draft compliance reports issued within 10 days (of site visit) 90%61%64%73%68%  R C17  The % of final compliance reports issued within 25 days (of site visit) 90%68%65%74%71%  R C30 Total user voice items on QRP -34,35540,95148,703  MI C16 The number of thematic reviews undertaken 31012  G C19 The % of providers and locations in each sector that are meeting essential standards of quality and safety - See Graphs Slide 11-14  MI C24a Inspection Judgements - the % change to non compliant -  MI C24b Inspection Judgements - the % change to compliant -  MI C24c Inspection Judgements - the % no change to compliant -  MI C24d Inspection Judgements - Average time period for change to compliant - 190.1 Days 192.5 Days 198 Days 198 Days N/A MI C24e Inspection Judgements – the % of non compliant for 2 quarters - See Graphs Slide 11-14  MI C24e Inspection Judgements – the % of non compliant for 3 quarters -  MI Commentary: The Regulatory Risk Committee has agreed to 4 thematic reviews this year covering: Dementia NHS data quality Experiences of people waiting for NHS treatment and; Physical health needs of people with a learning disability. The review of dementia started in September and the remaining reviews are on track to report in March 2013. The number of user voice QRP items is 48,703 this is an increase of 42% or 14,348 since Quarter1. Although draft and final report timeliness has improved in comparison to Q2 when it was 64% and 65% respectively performance remains below plan for this year. The graphs below demonstrates that the plan for final reports was met in April, performance declined until September and then started to show improvement. The increase in performance is partly due to release 19 of CRM which provides detailed MI for compliance managers. CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions 4

5. Ref IndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG E12 Locations where enforcement action taken as a % of all locations -0N/R N/AMI E07  Number of warning notices served -177198276651  MI E02  Percentage of warning notices issued within 14 days of identifying one is required 90%81.2%78.9%78.8%83.8%  A E04 Number of Notices of Proposal served to vary / remove / impose a condition. -N/R N/AMI E05 Number of suspensions -0000  MI E09 Non urgent cancellations of registration 0000  MI E11A Number of provides cancelled voluntarily -4024183651185  MI E11B Number of providers de-registered due to CQC intervention -9122041  MI GL13 Prosecutions concluded with a favourable result -1001  MI E13b  Section 31 HSCA 2008 – urgent suspension of registration,or urgent variation or imposition of conditions -0033  MI E13a Section 31 HSCA 2008 – urgent removal of conditions -0000  MI E14 Non urgent variations or imposition of conditions -1348  MI E15 Removal of conditions on non urgent variations or impositions -0000  MI Commentary: The number of warning notices increased by 39% (or 78) in Q3 compared with Q2. Year to date there have been 651 warning notices issued compared to 396 for the same period last year an increase of 64%. The percentage of warning notices that are issued within 14 days of identifying one is required has remained fairly constant between Q2 and Q3 at 78.9% and 78.8% respectively. Year to date the figures is 83.8%. There were almost as many warning notices issued in the first three quarters of 2012/13 (651) than all 4 quarters of 2011/12, when there were 658. So far this year an average of 72 warning notices are issued each month, compared to an average of 55 per month last year. The graph below illustrates the number of warning notices issued on a quarterly basis since Q1, 2011/12. Notable legal action in Q3 included use of Section 30 of our Health and Social Care Act 2008 powers, to cancel the registration of a Nottinghamshire care home owner to stop them from being able to run a residential home to protect the safety and welfare of residents. CQC took this action because it had serious concerns about the service and the risks to the people using it. 3,798 locations that have de-registered since April 2012 of these 41 were due to CQC intervention. Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions 5

6. Registration Ref IndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTD Tren d RAG R01  Percentage of new provider and manager registration applications completed within eight weeks 90%87.7%87.6%82.5%85.9%  G R02  Percentage of applications to change a registration completed within four weeks 90%70%75.8%74.3%73.1%  A R04 % of applications rejected (Shared services) <25%21.8%22.9%26.3%23.7%  G R05  Applications validated within 5 days - Shared services 90%98.4%98.8%98.5%98.6%  G R07 Primary medical services providers served with all Notices of Decision by 31 March 2013 (Update as at 11th January 2013). 20% by Q3 N/R 4,784 (59.8%) 4,784 (59.8%) N/A G Tranche 5 Update (Latest Position as at 11 th January 2013) Delivery of tranche 5 continues to progress and remains on track to achieve plan. The first six batches have closed a further two batches remain open; these will close on 4th February and 4th March. Overall, the number of providers that have submitted an application is 7,644.Year to date the figure stands at 1,539 or 20%. All non compliant applications will be subject to additional scrutiny by assessors. Year to date there have been 4,784 (or 62.6%) providers in receipt of their Notices of Decision. Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Compliance, Enforcement and Registration CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions Commentary: New provider and manager applications completed within 8 weeks remains within plan at 85.9% year to date. Meeting the 4 week target for variation applications remains challenging. The graph below illustrates the weekly performance over the period from May 2012 to December 2012, although performance has improved from 65% at the beginning of May to 80% in December it remains below the 90% target. 6 Improvement Line

7. Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model - Other inspections and mental health ‘Other ‘ inspections (controlled drugs, ionising radiation and joint inspections ) RefIndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG OC3 Other inspections on track: pharmacy and controlled drugs - 156231230617  MI OC5 Other inspections on track: ionising radiation (IR(ME)R) - 86519  MI OC6 Joint inspections are on track – Ofsted- 30N/R N/A OC7Joint inspections are on track - HMI prisons - 1118938  MI OC8Joint inspections are on track - HMI Probation - 20N/R N/A MI Mental Health Operations RefIndicator TargetQ1 12-13Q2 12-13Q3 12-13YTD Trend RAG M1MHA Commissioner visits - Hospital visits (Actual vs. Sch.) 95% 121% (277 of 229) 106% (321 of 301) 81% (244 of 300) 101% (842 of 830)  G M2SOADS medicine visits attend within 10 working days of receipt of request Q2 75% N/R 66% (219 of 330) M2 – M4 are reported one quarter in arrears to ensure data accuracy 66% (219 of 330) N/A A M3SOADS ECT visits - those identified as required,attend before second treatment Q2 75% N/R 42% (23 of 55) 42% (23 of 55) N/A R M4SOADS CTO visits- where the opinion is needed before the end of the month Q2 75%N/R 59% (30 of51) 59% (30 of 51) N/A R M5Requests entered within 4 working days of receipt to allocate to SOADS Q2 75%N/R 99.8% (2,132 of 2,136) 99.8% (2,132 of 2,136 N/A G M6MHA Complaints - % and number of complaints triaged within 3 working days 90% 96.4% (81 of 84) 98.6% (209 of 212) 93% (238 of 255) 96% (528 of 551)  G M6AMHA Complaints - % received which are responded to within 25 days 90%N/R 94% (83 of 84 ) 100% (212 of 212) 99% (295 of 296)  G Commentary: Mental Health Act Operations - planned MHA Commissioner visits remain ahead of schedule for the year to date - against a planned programme of 830 inspections in the first 9 months of the year, 842 have been completed. All complaint targets are also on track, year to date of 551 complaints about providers, 528 were triaged within 3 working days. SOAD indicators, M2 to M4, are reported one quarter in arrears to ensure data accuracy. The short- term- type contract relationship the CQC has with SOADs means that they will often complete a visit but not update the report on time. Q2 performance reflects only August and Septembers activity, the online forms that replaced the old manual reporting were delayed in being set up and as a result reporting against these measures (which were new and were not tracked manually) has been delayed. Overall SOAD performance was below plan, recruitment is on going to increase the number of available doctors. During the most recent recruitment process there were 80 SOAD candidates and of these 9 were successful at interview and attended an induction training session. The SOAD leadership will be strengthened to include a Principle SOAD and Operational manager to ensure robust challenge to the quality of second opinions provided. In Q2, 219 out of 330 SOAD medicines visits have been attended within 10 working days of receipt of request. 23 SOAD Electroconvulsive Therapy (ECT) visits out of 55 were attended within plan and, 30 out of 51 Community Treatment Order visits were done before the planed period of one. CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions 7

8. Commentary: NCSC call handling and quality - there have been almost 150,000 calls to the National Customer Service Centre in the first 9 months of the year, and all call handling targets are on track. The quality of service has been recognised by the ‘UK top 50’ call centres programme. This is the first year the Centre entered the programme and have been ranked 36th. Feedback from has been used to identify improvements to customer service with a view to incorporating benchmarks into the work of the NCSC. Call Volumes increased in Q3, partly due to calls from providers of primary medical services asking for assistance with their registration applications. Call Performance is consistently good across a range of indicators and is on track year to date. Publications, web and communication Year to date there have been almost 4.2m visits to our website of which almost 2.7m were unique visits. The ‘reports’ section of our website has been the most visited area in the first 9 months of the year. The most visited pages were; ‘reports surveys and reviews’ with 133,425 views, ‘contact us’ with 126,775 and the Job page with 107,630 views. The most popular downloads were ‘guidance about compliance’ with 82,639 downloads, the ‘Judgement framework’,15,867 and ‘table of statutory notifications under the Health and Social Care act’,11,412. All key publications have been published on target.Notably, the State of Care report was published during Q3, and received substantial and positive media attention. CQC Performance – Q3, 2012 – section 2, Deliver and Improve our regulatory and other functions Priority 1 – Deliver and improve our regulatory and other functions: Strengthen and improve the effectiveness and consistency of the regulatory model – Information and publication NCSC Call handling indicators RefIndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG NC2  Calls answered within 30 seconds - Safeguarding 90%94%94.4%92.8%93.7%  G NC3  Calls answered within 30 seconds - Mental Health 90%95.9%95.5%93.8%95%  G NC4 Calls answered within 30 seconds - Registration 80%79.9%85.7%81.8%82.5%  G NC1 ‘Other’ calls answered within 30 seconds 80%95.2%95%75.8%78.6%  G NC6 Calls abandoned - Safeguarding 3%1.3%0.7%1.4%1.1%  G NC7 Calls abandoned - Mental Health 3%2.7%0.8%5.1%2.9%  G NC8 Calls abandoned – Registration 5%3.9%1.9%5.3%3.7%  G NC9 Calls abandoned - Other 5%4.6%2.2%4.3%3.7%  G C12 Number of Whistle blowing contacts N/A1,6542,0252,2465,925N/AMI Publications P1 Weekly provider information on the website refreshed timely 100% 92% (12 of 13) 92% (12 of 13) 100% (13 of 13) 94.8% (37 of 39)  A P4 Total visits to the website -1.3m1.4m1.5m4.2m  MI P2 Key publications are on target – State of Care; MHA Monitoring report; etc. Green  G P3 Providers feel informed about CQC and have the information they need to be regulated by us - No data :survey to be run in Q2 95.6% No data: survey run six monthly 95.6% NAMI 8

9. Priority 3 – Manage our organisation, people and resources Human Resources RefIndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG HR1Establishment Total-2,2922,2962,392  N/A HR1a Establishment and vacancy rate ( establishment less permanent staff ) 5% by Dec. 2012 14.8%9%3.1%  G HR2Compliance inspector vacancy rate<2%12.5%7.8%0.4%  G HR3a New compliance inspectors complete full induction programme within 12 weeks of start date 100%  G HR4a Staff Complete mandatory e-learning per annum and refresh it annually 72% by Dec 2012 N/R 65%  G HR5a Frontline staff complete role specific mandatory learning per annum and refresh it annually 72%42%31%29%  R HR6 Number of permanent staff (FTE) -1,8492,0152,188  MI HR7 No of Vacancies -339 73  MI HR7a New staff pipeline (Staff with an offer of employment) -11174 N/AMI HR8 Temporary staff in established posts -445053  MI HR10 Turnover 2 <1.125 % per month 2%1.8%0.3%1.4%  G HR11 Sickness Rate (based on calendar days) 2 <5%3.6%3.2%4%3.6%  G HR12 Health and Safety - no. of workplace accidents -411 26  MI Commentary: Vacancies and establishment - establishment increased in Q3 to 2,392 compared to 2,292 in Q1 reflecting the significant programme of recruitment of additional compliance inspectors. The Compliance inspector vacancy rate has improved significantly from 12.5% in Q1 to 0.4% in Q3 against a target of 2%. There is now a pipeline of candidates in place to fill future Compliance Inspector vacancies in all regions. The establishment and vacancy rate reflects the increase in staff, having improved from 14.8% in Q1 to 3.1% in Q3. overall vacancies have reduced from 339 in Q1 to 73 in Q3 a reduction of 78%. Compliance Inspector and Registration Assessor mandatory learning remains below target. HR is investigating this and a comprehensive skills audit will seek to understand the organisational mandatory training requirements and make recommendations for delivering improvements. Turnover and sickness rate Turnover improved significantly in Q3 to 0.3% compared to 1.8% in Q2 and year to date it stands at 0.3%. The sickness rate has increased marginally from 3.6% in Q1 to 4% in Q3, although performance remains within the 5% target. 1 Actual performance is the most recent fortnight reported, therefore not an average 2 The rolling year average ( Sept 2011- Sept 2012) for Turnover is 7.2% and 4% for the sickness rate 3 The annual target is 96%, the monthly target is cumulative and 8% per month CQC Performance – Q3, 2012– section 3, Manage our organisation, people and resources 9

10. Priority 3 – Manage our organisation, people and resources and governance Corporate governance (complaints and statutory requests for information) and Finance Ref IndicatorTarget Q1 12-13 Q2 12-13 Q3 12-13 YTDTrendRAG GL01  Number of stage 1 corporate complaints received across the organisation 10% less than 2011/12 10596117318  G GL02  Stage 1 Corporate complaints upheld - 7 (7%) 8 (8%) 3 (3%) 18 (3%) N/A MI GL03  Of the initial stage 1 complaints received the number proceeding stage 2 <20% 20% (21) 27% (26) 12% (13) 19% (60)  G GL05  Of those closed, the number of stage 2 reviews completed in 20 working days 95%67%100%77%81%  A GL04  No of stage 2 complaints upheld -5207 N/A MI GL07 Information access requests closed within deadline 95% 95.9% (304) 97.3% (268) 92.6% (263) 96.1% (835)  G GL08 Parliamentary Ombudsman enquiries -1231126  MI GL09 Of closed requests proportion closed within deadline - Freedom of Information 95% 95.8% (236) 97.1% (189) 97.5% (175) 97% (600)  G GL10 Of closed requests proportion closed within deadline - Data Protection 95% 92.9% (28) 100% (37) 84% (34) 92% (99)  G GL11 Of closed requests proportion closed within deadline - Info Sharing 95% 98% (40) 94.7% (42) 93.1% (54) 95.3% (136)  G GL14  Urgent cancellations of registration (under section 30 of the HSCA 2008) -0011  MI GL12Percentage of outstanding critical and important audit actions completed 90%97%94% 1 95%  G F01Revenue expenditure plus depreciation variance vs. Budget (excluding fee income) 5% £36M v £39.1M (8%) £81.3M v £74.9M (8%) £123.8M v 116.9M (6%) £123.8 Mv 116.9M (6%)  A Commentary: Complaint handling - Year to date there have been 318 stage one complaints, this is a decrease of 15% or 55 compared to the same period last year, when there were 373 stage one complaints received. The majority of complaints were from members of the public and service users. The number of stage 1 complaints proceeding to stage 2 decreased in Q3 to 13. 77% of stage 2 complaints in Q3 were closed within 20 working days compared with 100% in Q2. Year to date 81% of these complaints were closed against a target of 95%. There have been a number of complex stage 2 complaints considered by the Corporate Complaints team. Due to a small number of complaints received the percentage fall in Q3 only equates to 1 complaint. Statutory requests for information There have been almost 869 requests for statutory information in the first 9 months of the year. 835 or 96.1% were completed within the statutory deadlines. The majority, 619, were freedom of information requests. There were 143 information sharing request and 108 data protection Act requests. All measures are on track to achieve their 2012/13 business plan targets. Audit actions In the first 9 months of the year 95% of audit actions raised, were due to be completed by the end of December against a target of 90%. Revenue expenditure Year to date revenue expenditure shows an under spend of £6.9m (excluding fee income or 6%) consisting of staff costs of £5.4m, depreciation of £1.9m and an overspend on Non staff costs of £0.4M. CQC Performance – Q3, 2012– section 3, Manage our organisation, people and resources 1 This figure is correct as of the last reported update in respect of year to date performance to August 10

11. Number of locations in each sector that meet essential standards of quality and safety CQC Performance – April - June, Q1, 2012 – compliance outcomes By sector – location level The graph to the left illustrates levels of compliance across all sectors. This graph should be viewed as a ‘snapshot’ at a given point across a range of variables, for example, which outcomes are reviewed and when, therefore it is not possible to make a perfect and direct comparison quarter on quarter. However by means of an overview, a comparison with other quarterly snapshots demonstrates that - at the end of Q3 there were 20,133 compliant locations compared with 17,292 in Q2. 16,156 locations have not yet had an inspection (compared with 23,306 in Q1) and 4,795 were non compliant with at least one outcome. Year to date there have been 651 warning notices served to 422 providers, 41 locations have de-registered following intervention by the CQC (compared to 21 in Q2) and there have been 3 urgent suspensions of registration, or urgent variation or imposition of conditions using Section 31 powers. CQC Performance – Q3, 2012 – section 4, levels of compliance and non compliance at registered locations 11

12. CQC Performance – Q3, 2012 – section 4, compliance outcomes NHS locations non-compliant with one or more outcomes, by age Non compliance is broken down by sector and period. On the table on the left, the column ‘Q4 2011/12’ demonstrates the number that were non compliant by age at the end of that quarter. The row ‘less than one quarter’ shows that there were 34 non compliant NHS locations at the end of Q4, tracking this group by following the arrow shows that the number of these that were non compliant fell in Q1 2012/13 to 29 and then again to 14 in Q2 2012/13 and 11 in Q3 2012/13. The graph illustrates the total number of locations that were non compliant in each quarter. There was a decrease in total non compliant locations in Q1 and Q2 and then an increase in Q3, this may or may not be related to the increase in inspections in Q3. This data includes locations consistently non-compliant with a single outcome and locations that were non-compliant at the beginning of several quarters but with different outcomes. Some of the latter group may have returned to compliance during a quarter, only to become non-compliant again by the time the data is captured at the beginning of the next quarter. Further analysis is being undertaken to review the movements in compliance, evaluate the effectiveness of actions, non compliance across outcomes and the variation across sectors. The following two slides are in the same layout as this slide and illustrate the levels of compliance at ASC (slide 13) and IHC, Ambulance and dentist locations (slide 14) Levels of compliance and non-compliance - registered locations 12 Location been non compliant for: Q4Q1Q2Q3 2011/122012/13 Over one year 13251629 10%22%14%22% More than three quarters but less than one year 26 19511 20%16%5%8% More than two quarters but less than three quarters 24221411 19% 13%8% More than one quarter but less than two quarters 31292826 24%25% 20% Less than one quarter 34214954 27%18%44%41% Total non compliant in period 128116112131 Note that these slides must be viewed in the context of time lags between inspection and final publication of the report and also the lag to re-inspection following identification of non-compliance

13. ASC locations non-compliant with one or more outcomes, by age Levels of compliance and non-compliance - registered locations 13 1 The increase in ASC Q4 to Q1 is due to a small difference in the time range between the two sets of data used for the report. CQC Performance – Q3, 2012 – section 4, compliance outcomes Location been non compliant for: Q4Q1Q2Q3 2011/122012/13 2012/14 Over one year 178432460953 5%12% 23% More than three quarters but less than one year 372500489501 11%13% 11% More than two quarters but less than three quarters 656783663501 20%21%17%12% More than one quarter but less than two quarters 1,0781,070 1 1,039710 32%29%27%17% Less than one quarter 1,0659561,2551529 32%26%32%37% Total non compliant in period 3,3493,7413,9064,194 Note that these slides must be viewed in the context of time lags between inspection and final publication of the report and also the lag to re-inspection following identification of non-compliance

14. IHC, Primary Dental Care and Independent Ambulance, locations non-compliant with one or more outcomes, by age Levels of compliance and non-compliance - registered locations 14 CQC Performance – Q3, 2012 – section 4, compliance outcomes Location been non compliant for: Q4Q1Q2Q3 2011/122012/13 Over one year 182045 <1%2%5%10% More than three quarters but less than one year 13233873 5%6%10%16% More than two quarters but less than three quarters 315311483 12%14%30%18% More than one quarter but less than two quarters 6813711663 26%35%30%14% Less than one quarter 14516698205 56%43%25%44% Total non compliant in period258387386469 Note that these slides must be viewed in the context of time lags between inspection and final publication of the report and also the lag to re-inspection following identification of non-compliance

15. All priorities – corporate equality objectives Ref IndicatorTargetQ1 12-13 Q2 12-13 Q3 12-13 YTD Trend RAG EQ1 Embed equality across all our regulatory and corporate activities Green rating Green  G EQ2 Ensure that, we identify and respond appropriately when providers do not meet the equality aspects of the essential standards of quality and safety Green rating N/A EQ3 Improve information and intelligence that we hold about health and social care providers in order to better identify risks to equality Green rating Green  G EQ4 Involve a diverse range of people who use services in our work Green rating Green  G EQ5 Increase the uptake of accessible information for easy to read. Large print and 6 community language downloads. Green rating 17,64416,14315,75949,566  G EQ6 Monitor whether people detained under the Mental Health Act have their rights to equality under the Act and Code of Practice protected through our monitoring functions, and actively seek improvements where we uncover shortcomings Green rating Green N/AG EQ7 Improve the diversity profile of CQC's workforce so it is representative of the communities we serve Green rating 1 st report Q2 AmberGreen N/AA EQ8 Improve the percentage of staff who say that they feel safe from harassment and are treated equally at work Green rating 1 st report Q2 Amber N/AA EQ9Improve the percentage of staff who have the knowledge, skills and tools to embed equality and human rights in their work. Green rating GreenAmber N/AA This is the third update against the equality objectives. Notable progress compared to the objectives has been included below as well as risks and issues to delivery. Objective 1: The ET and Board received quarterly updates covering our equality objectives as part of the overall performance governance of CQC. Objective 2: A plan from the evaluation of equality and human rights in compliance reviews was carried out in Q3 and will be implemented from Q4. Objective 3: A p roject plan, governance group and monitoring have been established to deliver this priority - identified work streams are currently on course. A reference group was set up and analytical resources allocated to deliver pilot of quantative indicators for the NHS. The report on availability of equality information on priorities and actions for next stage of work has been completed. Work is ongoing on the new mental health minimum dataset and on the multi-agency design of learning disability data collection set. Objective 4: Work is underway to monitor diversity of CQC involvement mechanisms and address gaps including: monitoring Speak Out network areas of interest in line with protected characteristics (Speak Out includes many of the seldom heard equality groups such as refugees, transgender people and gypsies and travellers) eQuality Voices recent recruitment of 10 new members to fill identified gaps including transgender people, carers of older people and refugees, Acting Together - Support organisations carry out equality monitoring and we are investigating best ways to bring this together and identify gaps for future expert by experience recruitment Objective 7: An analysis of staff profile has recently been completed for our annual equality information report (including for the first time analysis by pay grade). Work is underway with staff equality networks on the equality action plan arising from the staff survey may identify action we need to take in relation to making the profile more representative. Learning and development and the Race Equality Network are working together to develop opportunities for career development for Black and Minority ethnic staff. Objective 8: This objective is rated as amber overall to reflect the significant work required in this area following the 2012 staff survey. To assess work to date a proposed ‘pulse check’ for 500 staff of 20 questions is being prepared and will be presented to ET in late February. Work is underway to identify specific action required to take around bullying and harassment for particular staff groups, such as disabled staff, through the Staff Survey Equality Action Plan development. In Q3 HR appointed named officers for staff to talk to, during bullying and harassment week and they are planning other actions to improve support to staff who feel that they have been bullied or harassed. Objectives 9: Staff undertake equality training at the induction, this takes the form of an interactive session called equally yours, which includes updates to focus upon inclusion and using external networks. There is further work to improve the guidance that was identified following feedback, this means that some of the work will be delivered slightly later than planned. CQC Performance – Q3, 2012, – section 4, equality outcomes 15

16. A document with public to technical definitions of our corporate measures has been completed and is available on the intranet. This section is intended as an accessible guide to the overall performance areas in this report. Compliance A key part of our regulatory work is carrying out inspections to determine whether services are meeting the government standards. Our inspections focus on the outcomes that we expect people to experience when they use a service and assess the care, treatment and support they receive. Inspections include information from a range of sources including service users, the public, commissioners and other regulators. The measures in this section monitor the commitments we made to inspect services this year. Our inspections of NHS Trusts include inspecting acute hospitals. The term 'acute' is used when referring to active care or treatment (usually in secondary care) to adults, children, or both, that requires urgent or emergency care, usually within 48 hours of admission or referral from other specialties, and includes recovery time from surgery. Our publication ‘How CQC regulates’ was published alongside our business plan and explains the types of inspection we undertake: Scheduled inspections are planned by CQC in advance and can be carried out at any time. Follow up inspections are made when we want to check whether the provider has made improvements we are requiring them to make Responsive inspections are where inspectors inspect because of a specific and immediate concern. Themed inspections are where we look at a particular type of care or issue across one or more care sectors, for example dignity and nutrition in NHS hospitals, or care for people with a learning disability in both care homes and hospitals. Complaints The CQC welcomes comments and suggestions about performance and the conduct of staff, including complaints about the CQC. Every complaint is investigated, and the feedback used to develop and improve the Commissions services. These measures demonstrate the volume, efficiency and overall effectiveness of how complaints are handled. CQC Performance – section 6, understanding the scorecard Enforcement We have a variety of enforcement powers available to us where we find a service is not meeting one or more of the standards. When we exercise these powers we do so in a proportionate way, considering the effect on the public and those who use services. This suite of powers enables us to take swift, targeted action where services are failing the people who use them. We report in our scorecard on the enforcement actions we have taken. A detailed description of our enforcement actions is available on our website. One of the most often used of our enforcement powers is a Warning notice. A warning notice tells a 'registered person' that they are not complying with a condition of registration, requirement in the Act or a regulation or any other legal requirement we think is relevant. They can be published if the provider has been given the opportunity to make representations and where those representations if made are not upheld. Our enforcement powers also include suspending or cancelling the service’s registration, or prosecution. Equality Setting equality objectives is a requirement for public sector bodies under the Equality Act 2010 specific duties regulations. The objectives that we have set for the CQC are stretching and they focus on the biggest equality challenges that we face. The objectives are listed here and are reported quarterly, they will track delivery of supporting work against each objective. Finance Our finance measures cover high level expenditure against budget and how effective the Commission is at collecting fees due. Human Resources The indicators in this area demonstrate the overall key human resources performance areas and cover, vacancy rate, staff turnover, the sickness rate and the Commission's establishment Publication The Commission publishes information about the services it regulates on the CQC website. It also produces a number of publications each year covering reports, surveys, themed inspections, reviews and studies. These measures indicates how well the Commission is in getting information to people in a timely way. Mental Health We protect the rights of people being treated under the Mental Health Act. Our aim is to improve the outcome for every person who uses care services commissioned under the Act. Indicators in this area cover, Commissioner visits, second opinion appointed doctor service and complaints from service users about providers. Commissioner's visit wards that detain people under the Mental Health Act. They meet patients and ensure staff use their powers appropriately. These measures track the Commission's performance against the number of visits planned. The SOAD service safeguards the rights of patients detained under the Mental Health Act who refuse the treatment prescribed to them or are deemed incapable of consenting. The role of the SOAD is to decide whether the treatment recommended is clinically defensible and if consideration has been given to the views and rights of the patient. National Customer Service Centre The National Customer Service Centre (NCSC) is the first point of contact for members of the public, service users and providers. These measures demonstrate the level of efficiency of the NCSC in terms of the speed at which we respond to the calls we receive and how they are prioritised, as well as the volume of calls we respond to. Other Inspections The Commission has the power to inspect a range of other specific areas, all of the measures in this area track our delivery of inspection activity against our plan. IR(ME)R - the Ionising Radiation (Medical Exposure) Regulations, our inspections monitor the use of ionising radiation for medical exposure. Controlled drugs covers a range of areas including assessing and overseeing how health and social care providers manage controlled drugs. The Pharmacy team supports Compliance function in specific activities relating to controlled drugs. There are also a number of joint inspections were the CQC work with other regulators, for example a 3 year programme of inspections covering all local authority areas in terms of their provisions for child safeguarding and looked after children with Ofsted, and joint inspections with HM Inspectorate of Prisons and HM Inspectorate of Probation. Registration To be registered with the CQC, providers must meet the essential standards of quality and safety for each regulated activity they provide at each location. Providers will not be registered if they cannot declare full compliance. These measures capture the efficiency of the Commission in processing these applications. 16