Independent IT review

Published: 26 March 2025 Page last updated: 26 March 2025

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6. Appendices

6.1. Appendix 1: Summary of the meeting with the trade unions

A detailed summary of the meeting with the trade unions, Dec 2024.

1. Painful Implementation:

  • The regulatory platform's implementation has been described as painful for staff, particularly due to unmet expectations and misleading information from senior leadership.

2. Lack of Risk Assessment:

  • There was no risk assessment conducted for the regulatory platform, leading to uncertainty and stress among staff about its impact on their work.

3. Accessibility and Usability Issues:

  • The platform did not meet accessibility standards, causing difficulties for staff, especially those requiring assistive technology.
  • The system was not user-friendly, contradicting initial promises.

4. Health and Well-being Concerns:

  • The stress and uncertainty caused by the platform's implementation have negatively affected staff health and well-being.

5. Governance and Communication Failures:

  • Promised governance processes and communication with trade unions about the platform's introduction and its implications were not followed through.

6. Staff Involvement:

  • Frontline staff were not adequately involved in the development and rollout of the platform, leading to a disconnect between the system's design and its practical use.

6.2. Appendix 2: Business Process Maturity Model (BPMM) levels

The Business Process Maturity Model (BPMM) includes five maturity levels that signify the transformation of an organization based on improvements in its processes and capabilities:

1. Initial:

  • Processes are ad hoc and chaotic. Success depends on individual effort, and there is little to no process discipline.

2. Managed:

  • Basic project management processes are established. Processes are planned and executed in accordance with policy, but they may still be reactive.

3. Standardized:

  • Processes are standardized, documented, and communicated across the organization. There is a focus on process definition and institutionalization.

4. Predictable:

  • Processes are measured and controlled. The organization uses metrics to manage processes and ensure they are stable and predictable.

5. Innovating:

  • Continuous process improvement is enabled by quantitative feedback and innovative ideas. The organization focuses on optimizing processes and adapting to changes proactively

These levels help organizations assess their current process maturity and identify areas for improvement to achieve higher efficiency and effectiveness.

6.3. Appendix 3: Best practice set of risk headings for a large-scale digital transformation programme

Green highlights show where the risk register embedded into the FBC maps to one of the headings

Strategic Risks:

  • Misalignment with business objectives
  • Lack of executive sponsorship
  • Inadequate change management

Operational Risks:

  • Process disruptions
  • Integration challenges with existing systems
  • Insufficient training and user adoption

Technical Risks:

  • Technology selection and compatibility issues
  • Data migration and integrity problems
  • Cybersecurity vulnerabilities

Financial Risks:

  • Budget overruns
  • Unclear ROI and benefits realization
  • Funding and resource allocation issues

Compliance and Regulatory Risks:

  • Non-compliance with industry standards and regulations
  • Data privacy and protection concerns
  • Legal and contractual obligations 

Project Management Risks:

  • Scope creep
  • Missed deadlines and milestones
  • Inadequate risk management planning

Human Resources Risks:

  • Skill gaps and talent shortages
  • Resistance to change
  • High turnover rates

Stakeholder Risks:

  • Miscommunication and lack of stakeholder engagement
  • Conflicting stakeholder interests
  • Unrealistic expectations

6.4. Appendix 4: Tiger Team, Task and Finish Group, Project and Programme

Tiger Teams - is a specialized, cross-functional group of experts assembled to solve critical, high-impact problems or achieve specific, urgent goals. They operate with a high degree of autonomy and flexibility, disbanding once the issue is resolved or the goal is achieved

Task and finish groups are temporary, cross-functional teams established to accomplish a specific objective, such as a review or policy development, within a set timeframe. They operate under the governance of a parent body, which defines their remit and oversees their progress until the task is completed and the final report or recommendations are delivered

formal project is a structured initiative with defined objectives, scope, timeline, and resources, managed through a systematic process to achieve specific goals. It involves detailed planning, execution, monitoring, and completion, governed by established methodologies such as PRINCE2 or Agile.

formal programme is a coordinated set of related projects and activities managed together to achieve strategic objectives and deliver long-term benefits. It involves ongoing governance, resource management, and alignment with organizational goals, using established methodologies such as MSP (Managing Successful Programmes)

6.5. Appendix 5: Ergonomic review

Summary of meeting with users of the new Regulatory Platform (RP) 19th August 2024

Introduction

This report summarizes the findings following a meeting with a selection of CQC users of the newly implemented Regulatory Platform (RP). The users included Inspectors, Assessors, Regulatory Coordinators, and Operations Managers. The feedback and observation of the users undertaking activities on the system highlighted some significant concerns related to the functionality, usability, and impact of the new systems and the subsequent effect on the users mental and physical health.

This review was composed of about two hours discussion away from the system and two hours discussion with access to the system to demonstrate issues raised by users who had expressed concerns. It was not an in-depth structured review.

The following sections outline the key issues raised. 

Summary of Feedback

System Usability and Efficiency
  • Complex and Cumbersome Processes: The RP was reported by users as being overly complex, requiring numerous input clicks and steps to complete tasks that were considered straightforward with the previous CRM system. It was stated that this has led to inefficiencies and a significant increase in the time required to complete assessments. Although it was not possible to compare tasks with the CRM system, it was possible to observe the required number of actions/clicks to undertake some selected tasks. It was observed that a significant number of clicks were required due to the way the tasks had been broken down. This repetitive clicking could in my opinion could lead to both frustration and overuse conditions in the upper limb especially if the lag time (discussed later in the report) is reduced.
  • Navigation and Workflow Issues: Users expressed frustration with the platform's inefficiency, citing that prolonged periods are required to navigate between documents and evidence. Some tasks were demonstrated, and it was observed that the demonstrated process required many actions, and, in some instances, it appeared difficult to ensure the right documents were selected for inclusion within the report. The need for repetitive actions was also reported and observed in the demonstrated activity, which was stated to slow down the workflow and contributing to musculoskeletal discomfort.
Training and Support
  • Inadequate Training: The feedback received indicated that the users felt that there had been a lack of training on the system before implementation and poor ongoing support. The training provided, in the sandbox environment, was specifically criticized for being ineffective; it was requested to view this training, but it appeared to be unavailable during the time of the review.
  • Insufficient Guidance: Insufficient guidance was stated as a concern, with users saying that due to lack of centralised support they relied heavily on peer support and word-of-mouth to navigate the platform. This with the pressure to reduce the backlog of work was reported to have led to ‘work arounds’, inconsistent practices and increased stress among staff.
Impact on Health and Wellbeing
  • Physical Strain: The use of the new RP with the increased number of actions to complete tasks has coincided with increased reports of physical strain, including upper limb disorders, eye strain, and headaches. These issues are reported to have been exacerbated by the platform’s design, which does not appear to adequately accommodate some of the reasonable adjustments put in place to support physical concerns. It was observed that one of the users was using a mouse to complete activities rather than using digital dictation and on discussion they stated that this was due to time pressures and needing to get the tasks completed, they stated that this was causing physical pain. It was reported that during the testing of digital dictation useability with the new system as long as the action could be completed this was deemed as acceptable rather than could the tasks be completed efficiently. During the review repetitive actions to select options were observed as well as the complex time-consuming processes digital dictation users needed to use to complete some tasks e.g. the use of mouse grid to navigate to some screen areas. Using the mouse grid was observed to require many more steps thus slowing the user’s progress. Having observed this process, it was not surprising to be told and see that due to the time pressures users will revert to using a physical input device rather than using digital dictation and the mouse grid undermining the controls put in place to reduce the musculoskeletal risks.
  • Psychological Impact: The platform and the situation created by the concerns appears to have had a significant emotional and psychological impact on employees, with users reporting increased stress, anxiety, and a diminished sense of competence. This appears to have negatively affected job satisfaction and the wellbeing of users. During the interviews, the frustration and concern over the delays the system created was causing was raised frequently and some users stated that they and their colleagues no longer enjoyed their work, had lost confidence and questioned their competence as a result.
Operational Challenges
  • Unreliability and Incomplete Assessments: The users stated that they felt they could not rely on the system due to issues with unsaved work, overwriting (a particular problem reported when more than one colleague was working on a case as instead of inserting additional information the system appeared to overwrite the existing information from the other assessor) and difficulties in managing assessments, has posed significant operational challenges. This has reportedly led to delays in completing assessments.
  • Implementation Concerns: There were concerns raised regarding the rollout of the system, with feedback suggesting that the users feeling that the system was not adequately tested for their needs or that feedback was not acted on before implementation. One user reported that when feedback was provided that they were told that they were ‘Change resistant’.
Specific Application and User Concerns
  • Assessment Application: The assessment application was identified as the part of the system causing the greatest concern, with users highlighting that they found it inefficient and required a large number of actions/clicks to complete tasks. Examples of this were demonstrated during the review and it was observed that to enter information about an issue on the system required on average about five clicks with a lengthy wait before the action from the selection was displayed, this would be frustrating for the user and would be inefficient, increasing time to complete the task. Employees reported that due to the time delays they would try to do several tasks at the same time, this would likely make things more inefficient as usually multitasking is an inefficient strategy and likely to create errors. The reported inability to view cases in overview and the fragmented process were stated as particularly problematic. Delays in parts of the system responding were raised and demonstrated. One identified delay was timed as part of this review and found to be 45 seconds from click to the action being completed, this action was repeated, and the delay demonstrated each time it was tested. This delay (indicated by four dots moving across the screen) was reported to be ‘usual’ and when combined with the number of clicks required to complete the tasks in my opinion would be frustrating and time consuming.
  • Digital Dictation Software: Users of the digital doctation software reported significant frustrations when using parts of the system, noting that while it can achieve tasks, for some tasks it is excessively time-consuming and inefficient compared to using a physically controlled pointing device. I observed that to access parts of the screen required the use of the ‘mouse grid’ so requiring several steps to achieve the required action. The user who demonstrated this reported that due to the increased time using digital dictation takes ‘to get the job done’ they have regularly reverted to using a mouse which has inflamed their musculoskeletal problems.
  • Operations Management: Managers reported that the systems’ current setup complicates the assurance process, requiring time-consuming and ineffective communication with assessors. The inability to review complete documents, and not to be able to use ‘tracked changes’ to provide feedback combined with the lack of a copy-and-paste facility were noted as major frustrations and time-consuming issues. An example of this review process was demonstrated and from experience in reviewing documents it was observed that this process would take longer than reviewing the whole document and using tracked changes. Having to feedback and needing to describe the areas you are commenting on so the feedback makes sense would require more physical and time-consuming inputting for the assessor and would be more difficult for the recipient to understand without the context of the rest of the document to refer to.
Additional Operational Concerns
  • NCSC: There were reports of frustration with the NCSC application, particularly regarding the inability to be made aware of situations where multiple complaints about the same client had been received and the lack of visibility into cases. It was not possible to observe this in action.
  • Factual Accuracy: Concerns were raised about the lack of visibility where changes have been made, leading to challenges in ensuring accuracy and reliability in assessments. Additionally, issues with the integration between the RP and CRM were reported. It was not possible to review this due to the nature of the situation.
Time Requirements and Productivity
  • Increased Time Requirements: It was reported that the time required to complete a typical assessment report has nearly doubled, leading to concerns about increasing backlogs. It was stated that Managers feel that much of their time is now spent managing the wellbeing of their teams rather than focusing on their primary responsibilities.
  • Workarounds and Reduced Productivity: The need for workarounds was reported as commonplace, users were concerned that this could lead to errors or omissions. Use of the platform was reported to have led to reduced productivity, with employees reporting experiencing significant physical and mental strain.
Recommendations and Conclusion

The feedback from the users and the observations made during the brief review indicates the need for a swift comprehensive review and improvement of usability and accessibility of the Regulatory Platform to address the significant issues identified. The following recommendations are suggested:

  1. System Review and Usability Improvements: A thorough review of the RP appears to be needed to help improve its usability and efficiency particularly for those who use voice activated software. The users appear keen to be involved and user focus groups may be helpful in this review to ensure the highest priority actions are completed first, this should also have a positive impact in the user’s confidence in the system, however frustration was expressed that previous feedback did not appear to have been listened to. Areas of focus should include reducing the number of clicks required for tasks, and enhancing navigation, accessibility options being able to be used effectively, reducing data retrieval lag times and improving workflows.
  2. Targeted Training and Support: A more robust training program appears to be important, with targeted and effective training tailored to different user roles. Support mechanisms should also be enhanced to provide ongoing assistance to users before systems go live.
  3. Health and Wellbeing Initiatives: Immediate action appears to be needed to address the physical and psychological impact of the new RP on employees. A road map to improvement and effective snagging and feedback systems would help the users to feel that they were being listened to and involved in improvements, this is likely to be a significant help in improving their mental health. Consideration should be given to the possibility of returning to the old system while changes are made to ensure the back log does not increase and accessibility solutions are able to be used whilst adjustments and improvements are made.
  4. Review of digital dictation software Integration: The use of this software with the RP must be ensured, the ability to use it effectively must be checked for all tasks, with a focus on optimizing its performance and reducing users feeling that they need to revert to physical input methods that may exacerbate their musculoskeletal conditions.
  5. Streamlining Processes for Managers: The platform should be adjusted to allow for more efficient management of assurance processes, including the ability to review documents holistically and make annotations directly on the documents.

Addressing these issues appears crucial for restoring confidence among staff, improving efficiency, and safeguarding the health and wellbeing of the workforce. The current situation appears to have had a significant negative impact on the effectiveness of the process and its employees.

29.08.2024

6.6. Appendix 6: Studies into Home Working, collaboration and communication

  1. Increased Siloing: A study involving over 61,000 Microsoft employees found that remote work led to more siloed communication. Employees engaged in fewer real-time conversations and spent less time in meetings, which could hinder collaboration and the sharing of new information[1][2].
  2. Less Dynamic Networks: Research from MIT indicated that remote work made workers' collaboration networks less dynamic over time. This ossification of networks can reduce the flow of information and innovation[3].
  3. Challenges in Communication: The same studies highlighted that while remote work offers flexibility, it can also create challenges in maintaining effective communication and collaboration, especially for complex tasks that benefit from spontaneous interactions[1][2].

Overall, while remote work provides many benefits, it can also pose challenges for collaboration.

References

  1. When everyone works remotely, communication and collaboration suffer ...
  2. How Remote Work Affects Our Communication and Collaboration - Greater Good
  3. THE EFFECTS OF REMOTE WORK ON COLLABORATION AMONG INFORMATION WORKERS
    There have been studies examining the impact of remote work on building social capital. Here are some key findings:
    1. Shrinking Networks: Research from Microsoft found that remote work led to a significant reduction in employees' internal networks. Connections with colleagues outside of immediate teams decreased, which can hinder the development of social capital[1].
    2. Challenges in Visibility: A study highlighted in the Harvard Business Review noted that remote workers often become less visible within their organizations. This invisibility can make it harder to build and maintain social capital, which is crucial for career advancement and effective collaboration[2].
    3. Intentional Efforts Needed: To counteract these challenges, experts recommend that remote workers be proactive in building relationships. Strategies include being generous with time, communicating strategically, and making intentional efforts to connect with colleagues[2].

Overall, while remote work offers many benefits, it can pose challenges for building social capital.

References

  1. What a Year of WFH Has Done to Our Relationships at Work
  2. Building Social Capital When You Work Remotely - Harvard Business Review

6.7. Appendix 7: ITIL V4 Principles

ITIL (Information Technology Infrastructure Library) v4 focuses on aligning IT services with the needs of businesses. It introduces key principles that help organizations deliver value through effective and efficient IT services. Here are the core ITIL v4 principles:

  1. Focus on Value: Understand and prioritize what the customer values. Every action should contribute to delivering value to customers.
  2. Start Where You Are: Assess the current situation to make use of existing resources and avoid reinventing the wheel.
  3. Progress Iteratively with Feedback: Implement changes in small, manageable steps with feedback at each stage to ensure alignment with goals.
  4. Collaborate and Promote Visibility: Encourage collaboration across departments and promote transparency to improve decision-making and outcomes.
  5. Think and Work Holistically: Consider the complete picture rather than isolated components. Systems thinking helps in understanding interdependencies and impacts.
  6. Keep it Simple and Practical: Simplify processes to focus on what adds value. Avoid over-complication to enhance efficiency and clarity.
  7. Optimize and Automate: Optimize processes before automating them to ensure efficiency. Leverage technology to reduce manual work and increase consistency.

6.8. Appendix 8: Stakeholder Engagement and Communications Plan

According to the Managing Successful Programmes (MSP) framework, the purpose of the Stakeholder Engagement and Communications Plan is to ensure that stakeholders are effectively engaged and informed throughout the program. This involves:

  1. Identifying and Analysing Stakeholders: Understanding who the stakeholders are, their interests, and how they might impact or be impacted by the program.
  2. Engaging Stakeholders: Developing strategies to involve stakeholders in the decision-making process, ensuring their needs and expectations are considered.
  3. Communicating Effectively: Establishing clear and consistent communication channels to keep stakeholders informed about the program's progress, goals, and any changes.
  4. Managing Expectations: Helping stakeholders understand the program's objectives, timelines, and potential challenges to align their expectations with the program's outcomes.
  5. Facilitating Feedback: Creating opportunities for stakeholders to provide feedback and suggestions, which can be used to improve the program.
  6. Building Trust and Support: Fostering a collaborative environment where stakeholders feel valued and supported, leading to better cooperation and program success.

6.9. Appendix 9:  ITIL knowledge management process

ITIL Knowledge Management is a process within the ITIL framework that focuses on capturing, sharing, and utilizing knowledge within an organization to improve IT service management. Here's a breakdown of its key components:

  1. Definition: ITIL Knowledge Management involves creating, sharing, using, and managing knowledge and information to achieve organizational goals.
  2. Objective: The primary goal is to collect, analyse, store, and share knowledge and information to improve service efficiency and reduce the need for rediscovering knowledge.
  3. Core Activities:
  • Knowledge Creation: Gathering knowledge from various sources, including incidents, problems, and solutions.
  • Knowledge Sharing: Distributing knowledge to relevant stakeholders through appropriate channels.
  • Knowledge Utilization: Applying knowledge to resolve issues and improve processes.
  • Knowledge Maintenance: Keeping knowledge up-to-date and relevant.
  1. Service Knowledge Management System (SKMS): This is a suite of tools and databases that support the knowledge management process by storing and managing knowledge.
  2. DIKW Hierarchy: This hierarchy stands for Data, Information, Knowledge, and Wisdom, and it helps in converting raw data into actionable insights.

By implementing effective knowledge management practices, organizations can enhance decision-making, improve service delivery, and foster continuous improvement

6.10. Appendix 10: Contents of a Target Operating Model

According to Managing Successful Programmes (MSP), the elements of a Target Operating Model (TOM) include:

1. Processes:

  • Defines the key business processes required to deliver the organization's services and achieve its strategic objectives.

2. Technology:

  • Outlines the technological infrastructure and systems needed to support the business processes and operations.

3. Organization:

  • Describes the organizational structure, roles, and responsibilities necessary to operate effectively.

4. Information:

  • Specifies the data and information requirements, including how information is managed and utilized.

5. People:

  • Focuses on the skills, competencies, and culture needed within the organization to support the TOM.

6. Governance:

  • Establishes the governance framework, including decision-making processes, policies, and controls.

These elements collectively define how an organization will operate to achieve its strategic goals and deliver value

6.11. Appendix 11: Monolithic vs. Microservices Architecture Monolithic Architecture:

  • Structure: Built as a single, unified unit with one code base.
  • Deployment: Entire application is deployed at once.
  • Development: Easier to start with, as it requires less upfront planning.
  • Scalability: Scaling requires duplicating the entire application.
  • Maintenance: Can become complex and challenging to update over time.
  • Examples: Traditional enterprise applications. 
    Microservices Architecture:
  • Structure: Composed of smaller, independently deployable services.
  • Deployment: Each service can be deployed independently.
  • Development: Requires more planning and design initially.
  • Scalability: Individual services can be scaled independently.
  • Maintenance: Easier to maintain, update, and debug.
  • Examples: Modern cloud-based applications like Netflix 
    Key Differences:

1. Modularity:

  • Monolithic: Single code base.
  • Microservices: Multiple independent services.

2. Flexibility:

  • Monolithic: Less flexible, changes affect the entire application.
  • Microservices: More flexible, changes can be made to individual services.

3. Deployment:

  • Monolithic: Single deployment unit.
  • Microservices: Multiple deployment units.

4. Scalability:

  • Monolithic: Scale the entire application.
  • Microservices: Scale individual services.

5. Fault Isolation:

  • Monolithic: Failure in one part can affect the whole system.
  • Microservices: Failures are isolated to individual services.

These differences highlight the advantages and trade-offs of each architecture, helping organizations choose the best approach based on their specific needs and goals.

6.12. Appendix 12: definition of CRM and ERP

Customer Relationship Management (CRM) System: A CRM system is a platform designed to help businesses manage and improve relationships with customers and potential customers. It collects and stores customer information, activities, and communications in a centralized and accessible database, facilitating better customer service, sales management, and marketing efforts.

Enterprise Resource Planning (ERP) System: An ERP system is a business management software that integrates and automates core business processes, such as finance, HR, manufacturing, supply chain, sales, and procurement, or in the CQC’s case Contact, Notifications, Registration, Assessment, Inspection and Enforcement. It provides a unified view of business operations and a single source of truth, helping organizations streamline workflows and improve efficiency.

6.13. Appendix 13: Independent Reviews of MS Dynamics 365 Insights from independent reviews of Microsoft Dynamics 365:

1. Third Stage Consulting:

  • Strengths: Microsoft Dynamics 365 is praised for its flexibility, scalability, and integration with other Microsoft products like Office 365, SharePoint, and Power BI. It is suitable for both large enterprises and mid-sized organizations[1].
  • Challenges: The flexibility of Dynamics 365 can also be a drawback, as it may lead to over-customization and complexity. The reseller network is noted as a potential weak point[1].

2. ElevatIQ:

  • Strengths: Dynamics 365 Finance & Operations (F&O) is highlighted for its comprehensive features and ability to handle complex business processes. It is considered one of the top ERP systems for 2024[2].
  • Challenges: Implementation can be challenging, and there may be a steep learning curve for users[2].

3. Forbes Advisor:

  • Strengths: Dynamics 365 is recognized as a comprehensive platform that meets various business management needs. It is noted for its range of functionalities and integration capabilities[3].
  • Challenges: The review mentions that while it is a powerful tool, it requires careful planning and execution to fully leverage its capabilities[3].

Overall, Microsoft Dynamics 365 is seen as a robust and versatile platform, but it requires careful implementation and management to avoid potential pitfalls.

References

  1. Independent Review of Microsoft Dynamics 365 - Third Stage Consulting
  2. Microsoft Dynamics 365 F&O ERP Independent Review 2024 - ElevatIQ
  3. Microsoft Dynamics 365 ERP Review (2024) – Forbes Advisor

Gartner provides detailed reviews and ratings for various modules of Microsoft Dynamics 365. Here are some key insights:

1. Microsoft Dynamics 365 Sales:

  • Overall Rating: 4.3 out of 5 based on 529 ratings[1].
  • Strengths: Streamlines and automates sales processes, providing a centralized view of leads from prospects to closures.
  • Challenges: Some users face configuration challenges to meet specific business needs.

2. Microsoft Dynamics 365 Customer Service:

  • Overall Rating: 4.2 out of 5 based on 113 ratings[2].
  • Strengths: Effective for ticket management and integration with data warehouses.
  • Challenges: Over-customization can lead to performance issues and user frustration.

3. Microsoft Dynamics 365 Business Central:

  • Overall Rating: 4.2 out of 5 based on 125 ratings[3].
  • Strengths: Suitable for small to medium-sized enterprises, offering robust ERP capabilities.
  • Challenges: Some users report difficulties with customization and integration.

Overall, Gartner's reviews highlight Microsoft Dynamics 365 as a powerful and versatile platform, though customization and configuration can present challenges for some users.

References

  1. Microsoft Dynamics 365 Sales Reviews - Gartner
  2. Microsoft Dynamics 365 Customer Service Reviews - Gartner
  3. Microsoft Dynamics 365 Business Central Reviews - Gartner

6.14. Appendix 14: the RACI matrix

The RACI matrix is a project management tool used to clarify roles and responsibilities in a project or process. The acronym RACI stands for:

  • Responsible: The person or people who are responsible for doing the work to complete the task. They are the ones who actually perform the task or activity.
  • Accountable: The person who is ultimately accountable for the task's completion and the outcome. This person delegates the work and ensures it is done correctly. There should be only one accountable person per task.
  • Consulted: The people who provide input, advice, or expertise necessary for completing the task. They are typically subject matter experts or stakeholders whose opinions are sought.
  • Informed: The people who need to be kept informed about the progress and outcomes of the task. They are not directly involved in the task but need to be aware of its status.

How to Create a RACI Matrix

  1. List Tasks: Identify all the tasks or activities involved in the project or process.
  2. Identify Roles: Determine all the roles or individuals involved in the project.
  3. Assign RACI: For each task, assign the appropriate RACI roles to the individuals or groups involved.
  4. Review and Validate: Ensure that each task has one and only one accountable person, and that the roles are clearly understood and agreed upon by all stakeholders.

Benefits of Using a RACI Matrix

  • Clarifies Roles and Responsibilities: Helps avoid confusion by clearly defining who is responsible, accountable, consulted, and informed for each task.
  • Improves Communication: Ensures that all stakeholders are aware of their roles and the roles of others, facilitating better communication and collaboration.
  • Enhances Accountability: By assigning accountability, it ensures that there is a clear point of ownership for each task.
  • Streamlines Decision-Making: Helps identify who needs to be consulted and

The RACI matrix is a simple yet powerful tool to ensure that everyone involved in a project understands their roles and responsibilities, leading to more effective project management and successful outcomes.

6.15. Appendix 15: Issues with the regulatory platform and specifically the assessment app

  1. It is extremely slow. It can take up to 3 days to score a fully comprehensive report in order to move it on to the part where you can start inputting, he actual report.
  2. They have sped up the uploading of evidence but now want us to create and link a case to upload the evidence into the case. This seems an unnecessary step when we will still have to upload a word doc to all areas of assessment and make a comment in order to the process on to the scoring and assessment.
  3. Assessments are getting ‘stuck’ at various points in the process. So, either you can’t move it on to the next step or it jumps to publishing when not ready and there is no way to just go back one step, you have to roll back to draft report stage.
  4. When rolling back to draft report stage, often you have to copy paste the entire report back into the system and re-send to the provider in order generate the next stage again.
  5. Because there are now so many quality statements to cover which are very specific in what they want us to report on, the list of questions/points to raise when speaking with people, relatives, staff and professionals to ensure we have something to report on in these sections is extremely difficult. It ends up making what should be a conversation that leads into covering many areas naturally, into an interview like scenario that people back away from instead of opening up to us.
  6. When setting up an assessment, we have to click ‘yes’ to have we set up all resources in another system, before we are actually able to do that.
  7. If you forget to go into the location and change the provider check date before the operations manager clicks the approve button of a draft report, it can just sit in the system for up to 1 month before it is able to be sent to the provider to start the factual accuracy process.
  8. Links sent to the provider for factual accuracy process etc often do not work for them.
  9. We also need to consider staffs physical health. I have developed a muscle injury that is probably not connected but I can really feel it when I am in the reg platform doing the repetitive clicking and scrolling as it requires so much of this. I fear that in time we will start to develop repetitive strain injury or carpal tunnel syndrome. The constant running dots across the screen also causes my eyes to blur sometimes and I have to keep looking away and re­focusing. The risk assessment/HR solution to this is to look away as much as possible. However, when in the system uploading/scoring/inputting the report etc you actually cannot look away for long as you have to keep checking back to see if the system is now ready to move onto the next step (this can sometimes take up to 3 mins per step). Also, the dots rarely actually stop so it’s not that you can look away until they stop and then move on otherwise it would take hours per step to wait for the dots to stop moving. I fear this will in time cause actual damage to people’s sight.
  10. The system asks us to choose a review date when setting up a plan, but the function is actually not currently working.
  11. It loses our work on a regular basis, and we have to re-do everything.
  12. We are unable to see what it sends to the provider at draft report stage. For some, this has meant it has sent to the incorrect registered person, breaching GDPR but we have no idea that has happened.
  13. There are far too many quality statements, they are long drawn out, overlap in multi areas causing unnecessary repetition. They could easily be reduced to just 2-3 per key question, with the right wording and then just do a good summary of each key question rather than at quality statement level.
  14. There is no way to see the whole factual accuracy comments and the whole draft report in one go.
  15. Why do we need to have overall, people and key question summaries as well as the actual evidence in the quality statements? Can we not just have one or the other?
  16. I haven’t yet used the new hybrid approach but am concerned that the time we save by dropping the evidence categories will be replaced with the decision review records, risk calculator spreadsheet and peer review reports so end up not really saving much time at all.
  17. You can’t have evidence open and comments at the same time.
  18. You are constantly having to click back and forth and each time it takes sometimes up to 3 minutes to get back to where you were. When having to repeatedly do this for (currently up to 113 sections) it can take days.
  19. You often cannot just go back a stage or undo an error when someone has pressed the wrong button, you either have to go back a long way or just cancel and start again.
  20. Things in the timeline disappear and you have to keep refreshing to see older emails, they are not always in chronological order either, another aspect of time wasting.
  21. We still cannot find things like provider certificates of registration or statement of purpose; we have to use CRM.
  22. There is so much clicking that has to be done for the simplest of tasks.
  23. You can’t just drag and drop documents.
  24. We have no helpful training on the systems. They ran some eLearning modules, but we have never been able to actually follow those instructions as the functionality in the RP doesn’t work. So, we have just been having to constantly try to search in the handbook or FAQs or ask others if they have come across it. Superusers have been great for this but that is not a solution to skills development. I spend a portion of almost every workday, helping colleagues figure out something in the RP.
  1. It no longer automatically generates action plan request like CRM used to. We have to remember to generate them by creating a decision review record and then remember to email them to the provider once the final report has gone out.
  2. When trying to add additional quality statements, it is impossible to find the right wording to search for a specific area of assessment, so we have to just put everything under ‘additional evidence’ in order for it to come up to choose.
  3. With cases, you can’t just search the list of them for key words or phrases, you have to individually open each one up to see what it is.
  4. Now that providers submit most of their notifications via the provider portal, when it comes through to us in the RP, you sometimes still do not get sufficient information or even contact details.
  5. In SSC is these LAPs (Location assessment plans). We get the theory, but (a) they've been blanketed over all SSC providers, even if they're not appropriate (1 location, or 1 ASG for example). And (b) we have been told today (2 December 2024), that until they've worked out the specific hybrid method for these LAPs, we still have to report all the way down to EC level. This could take a few months. I understand that this may be already on their list, but I think Julian needs to bear this extra workload per assessment in mind, when he's considering what we can and can't deliver in this interim period.
  6. Boxes appear greyed out for no reason so you cannot choose the right thing to progress reports.
  7. The writing in the report and scoring stage sometimes overlaps, when it does this you cannot get to the button underneath the overlap to press it and progress the report.
  8. When setting up an assessment you can’t just allocate all to yourself, you have to do them one at a time, this too is time consuming when you have a fully comp and around 100 evidence categories (or it will now be up to 34) to do.
  9. The word limit is too small for our responses and reports in places.
  10. The scoring allows for a service with one or more breaches of regulation even with warning notices to come out as good.
  11. Standard statements in the new reports produced int eh reg platform are unclear such as the only difference between and RI or good stamen being the word ‘generally’. The layers are just unnecessarily complex now and I feel we just need to get back to basics and have systems and reports that very clearly, simply and briefly state the outcomes of our findings against the regulations.
  12. We feel that there should either be just scoring or just rating but either way using judgement and common sense and based against clear characteristics of the regs but not both.
  13. When trying to set up an assessment, we have been told not to click the comprehensive as it doesn’t work so we have to set up individually by key question.
  14. The assessment plans are now accessed via the reg platform linked through to power BI. The data though is often incorrect in terms of the correct RM/NI/Conditions etc. It is missing prompts to check the legal status in Companies House.
  15. The way we now set up providers factual accuracy comments with no limit and to each EC/QS makes the process so much longer. It is also really difficult sometimes depending on how they have uploaded evidence to see what document refers to which point. Sometimes it has come through as a big pdf where they refer to appendix 1, 1a etc but the assessment app does not allow does appendices in that way. This risk us missing something and opening up the risk for ratings review.
  16. There is a huge risk in terms of judicial reviews and rating reviews due to not being able to follow clear and consistent methodology as each region seems to be doing different things, guidance changes constantly, new workarounds are being used constantly that contradict the guidance we have, legacy guidance is still available so leads to confusion.
  17. From another inspector colleague:

-     The scoring of just QS is going to help somewhat, but it is still going to take longer than it did before. I am currently writing a full comp report, and there is so much crossover it is unbelievable, and adds on to inspectors thinking time as to where the evidence is best placed. If they dropped/or we were able to combine QS evidence as we did in our old ways of working it will be ideal, but the system is so rigid I cannot see us being able to do that. Getting feedback on 30+ quality statements is a mean task, I read some reports yesterday that literally said, 'we did not gain any feedback from people for this QS as part of this assessment, which probably means we didn't have the time to do it. From an external point of view, probably doesn't look great, why didn't we gather feedback, would be interesting for someone above to literally have a go at what we do. Each time I open up my assessment an error message is appearing, I raised a ticket and was asked to do a speed test, which I have sent to the IT team, waiting to hear. But I spent absolutely ages, adding 2 documents to this assessment, some of the records had my internal comments, others didn't, I spend ages making it look tickety boo, all fine and dandy, and then this week I go in and it has all been jumbled up again. Its demoralising to say the least. Waiting to hear back.... The problem is the system was most probably designed by someone who hasn't the experience of completing and assessment and knowing all the stages that we have to go through, including the inspector judgement processes.

  1. The ‘training’ for the reg platform is often really confusing as it is not clear training it is various internal colleagues just talking about their experiences and demonstrating the change. It is often long winded, too much chat and too many workarounds, it makes it so hard to follow and understand. It would be so much better (even if slower) to arrange proper trainers (or give internal colleagues these skills if needed) in face-to-face sessions at a venue where we can use our laptops and actually have a go at it in practice ourselves. A lot of people learn much better this way.
  2. Often by the time we go to do the new ways or working, the ‘training’ we got has changed due to updates and learning. Nothing ever feels complete and finished and definitive. We all feel like we are constantly floating in a world of change where no one is clear about what we should do. We often get conflicting advice from colleagues and managers and just adds to the already high levels of frustration and stress.
  3. When working in notifications, in order to make a simple referral request for a safeguarding, we have to create a case and complete a lot of information already in the notification in order to move the process along to make the safeguarding request. This can sometimes take around 20 mins every time.
  4. When we are wanting to send an email to the registered manager or nominated individual in a notification, we cannot trust the RP to give the correct information of the current registered person, so we have to click into the location, copy the location ID< open up CRM and go into CRM to search the registered manager and their contact details then go back into the RP to send the email. Again, all very time consuming.
  5. From an assessor perspective shared by a colleague:

-     Whilst the priority is to improve the assessment process on the reg platform, there are frustrations and inefficiencies with how the platform works when dealing with cases etc. There is a lot of clicking, a lot of screens / multiple views, which creates a risk of us missing cases / notifications etc, and repetition e.g. when we receive LA safeguarding feedback it is often saved in a case and recorded as information of concern. However, this opens up further buttons / processes that are not required - such as do we need to raise a safeguarding? No, we don’t because the information has come from the LA safeguarding team. There needs to be a way of recording information of concern that does not require this level of follow up activity so we can log the information and close it down more easily.

-     Building a full picture of risk in a service is impossible. The current reg platform data & insight risk ratings do not always reflect what we know on the ground e.g. services with high levels of concerns from recent cases or services may be rated medium, whilst services that have recently been assessed and their rating improved can be rated high / very high. We are still reliant upon maintaining manual spreadsheets at team level to record our combined local information & reg platform case info; to try to work out the priority order for assessing services. Despite our best attempts to ensure information is up to date on the team spreadsheets, there is a risk that as the information is not live, that risk could be missed.

-     In order to get a full picture of services we need to include all information -

such as registration applications and enforcement activity. This information is stored in different places – some on CRM and some in a different App on the reg platform. There is no way to pull everything together in one place at the current time. The reg platform risk indicators only pull through information that has been dealt with and stored on the reg platform, so information from CRM is not included. As we cannot currently pull everything together in the one place, we could miss risk.

-     It is also very difficult to access information about enforcement activity that has been carried out by other inspectors, as it is buried in the reg platform. We need to be able to find / monitor enforcement and breach content to work out when we should carry out follow up assessment activity.

-     The information we have access to still cannot be relied on, such as the risk ratings (see above) and registered manager / nominated individual contact details.

- We also cannot be assured those functions, such as emails being sent on

the reg platform, is happening as planned. We are constantly discovering new or ongoing issues. And, when registered managers / providers do respond to emails we do not always know they have replied – so their responses may sit in a view / queue for a while without acknowledgement.

  1. The biggest problems with the reg platform are that it has clearly been designed by people who do not understand the role of an inspector/registration colleague or what and how we regulate. Those not using the system on a daily basis for assessments, registration and NCSC calls etc are the ones who are designing and making tweaks and changes. This has just made it worse. Even when we were ‘included’ it was just tokenistic and they never listened and clearly had already decided exactly what would happen and what it would look like, all of our thoughts were simply dismissed and then we were accused of being against change. This was not at all the case; we simply want change that works. The next change and long-term plans need to come from those who actually use it to do their jobs. Myself and a number of colleagues all feel completely overwhelmed by the sheer amount of information we have to keep digesting and learning what the current guidance and processes are in order to work in-line with the latest changes and workarounds. It is exhausting and before long will simply be untenable. Everything is such a blur, we struggle to be clear on what the latest processes are, meaning things take at least twice as long as they should while we have to keep looking up where to find the guidance (often this will be a dead link or the incorrect guidance or templates posted) and then reading through again to understand what we need to now do. This causes a huge amount of unnecessary stress and frustration on us.

6.16. Appendix 16: The Theory of Constraints (TOC)

The Theory of Constraints (TOC) is a management philosophy developed by Dr. Eliyahu M. Goldratt, which focuses on identifying and addressing the most significant limiting factor (constraint) that hinders an organization's ability to achieve its goals. Here’s a brief summary:

Key Concepts

1. Constraint:

  • A constraint is any factor that limits the performance of a system and prevents it from achieving higher levels of output or efficiency.
  • Constraints can be physical (e.g., equipment, materials, person) or non­physical (e.g., policies, procedures, mindsets).

2. Five Focusing Steps:

  • Identify the Constraint: Determine the single most critical constraint that limits the system's performance.
  • Exploit the Constraint: Make the most of the constraint's capacity by ensuring it is not wasted. This may involve optimizing processes or reallocating resources.
  • Subordinate Everything Else: Align all other processes and resources to support the constraint, ensuring that the entire system works to maximize the constraint's efficiency.
  • Elevate the Constraint: Take actions to increase the capacity of the constraint, such as investing in new equipment, hiring additional staff, or changing policies.
  • Repeat the Process: Once the constraint is resolved, identify the next constraint and repeat the process to achieve continuous improvement.

3. Throughput, Inventory, and Operating Expense:

  • Throughput: The rate at which the system generates money through sales.
  • Inventory: All the money invested in purchasing things the system intends to sell.
  • Operating Expense: All the money the system spends to turn inventory into throughput.

4. Applications

  • Manufacturing: TOC is often applied in manufacturing to identify bottlenecks in production processes and improve overall efficiency.
  • Project Management: The Critical Chain Project Management (CCPM) methodology, derived from TOC, focuses on managing project constraints to ensure timely completion.
  • Supply Chain Management: TOC helps optimize supply chain processes by addressing constraints that affect the flow of goods and materials.

5. Benefits

  • Improved Efficiency: By focusing on the most critical constraint, organizations can achieve significant improvements in efficiency and productivity.
  • Continuous Improvement: The iterative nature of TOC encourages ongoing identification and resolution of constraints, leading to continuous improvement.
  • Holistic Approach: TOC emphasizes the interdependence of different parts of a system, promoting a holistic approach to problem-solving and decision-making.

6. Example

In a manufacturing plant, if a particular machine is the bottleneck that limits production capacity, TOC would focus on optimizing the use of that machine (exploiting the constraint), ensuring other processes support it (subordinating everything else), and eventually increasing its capacity (elevating the constraint).

Overall, the Theory of Constraints provides a structured approach to identifying and addressing the most significant limiting factors in any system, leading to improved performance and efficiency.

6.17. Appendix 17: The best practice principles of Risk Allocation

  1. Optimal Allocation: Risks should be allocated to the party best able to manage them. This means that risks are assigned to the party that can handle them most efficiently and cost-effectively
  2. Value for Money (VfM): Proper risk allocation is crucial for achieving value for money in public projects. By transferring risks to the private sector where appropriate, public agencies can ensure that projects are delivered on time and within budget
  3. Risk Transfer: Not all risks should be transferred to the private sector. Some risks, such as those related to policy changes or force majeure events, are better managed by the public sector
  4. Clear Documentation: All risk allocation decisions should be clearly documented in the business case. This includes the rationale for the allocation and the expected impact on project outcomes
  5. Continuous Monitoring: Risks should be continuously monitored and managed throughout the project lifecycle. This ensures that any changes in risk profiles are promptly addressed