CQC:  First  Inspec/on:  A Survival Guide

“Raising  the  bar  on  regulatory  standards”    

•  Regulator under increasing pressure from cases of cruelty and neglect in adult

social care and scandals such as Mid Staffordshire NHS Foundation Trust

•  High profile cases fuel public outrage at regulatory failure and increase the

political stakes

•  The regulator has come under increasing pressure to improve its performance

including a tougher approach to inspections

How to pass your first

inspection and all the others

that come afterwards.

“Surviving  your  first  CQC  Inspec/on”      

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Registra/ons  Versus  

Inspec/on  •  Registrations means you self-certify by making a declaration that

you are compliant

•  Inspection means you have to stand up under scrutiny of the CQC

•  Identify areas of non compliance using Provider Compliance

Assessment (PCA) Self Assessment Tool

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The  Burden  of  Proof    •  It is for a service provider to

demonstrate that it is in compliance

•  CQC does not have to “prove”

compliance - practice may be complaint

but any absence of required

documentation is compliance failure

•  It’s not quite “guilty until proven

innocent” but it is for service providers

to show that they are “innocent” of

compliance failure

Data  Triangula/on    •  Inspection appears to be about demonstrating

compliance by providing an audit trail of the

documentation that is required by the CQC

•  WRONG!! It is a false assumption to believe that

presenting a flawless set of records, reports and a

PCA, will ensure an inspection pass.

•  The inspection process requires CQC inspectors and

assessors to cross-reference or “triangulate” the date

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Methods for gathering information include:

Source  of  Triangulated  Informa/on  

•  Talking to people who use the service

•  Surveys

•  Making direct observations of care

The  QCS  Framework  for  

Achieving  Compliance  

 

•  The QCS Compliance Management System

is a comprehensive library of compliance

policies and procedures

•  System documentation enables all health

and social care providers to adhere to

processes that have compliance interwoven

•  A “Compliance Blueprint” enabling every

activity to be managed so that service

providers achieve the required CQC

regulatory standard

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Blueprint  for  Compliance   •  Emphasis on service users is

embedded throughout the entire

QCS policy set.

•  Direct employees towards the

goal of achieving compliance

•  The HR Policy set is consistent

with the care culture embedded

within the QCS care policy set

Leading  by  Example  

•  Care workers take their cue for interacting with

service users from the management culture

which is forested by this approach to HR

•  When assessed and triangulated data methods a

consistent view of compliance is obtained

•  This is also true in areas like maintenance,

catering and housekeeping policies

Providing  Proof  -­‐    Integrated  Records  and  Repor/ng    •  QCS integrates the process of collecting all the

required information with a ‘pack approach’ which

provides templates to record data

•  Enables all necessary recording, minimising the

risk of a critical process going undocumented

•  Users are easily guided through such processes

as recruitment, care planning and employee

performance management

Providing  Proof  -­‐  Ac/on  Planning    

•  Action planning and management control enables

compliance shortfalls

•  Action plan attached whenever a PDCA

•  (Plan, Do, Check, Act) cycle approach is required

•  The effective use of policies can be audited and

the QCS approach is further supported by the

Quality Assurance Policy www.123rf.com/photo_11066582  

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9411833   Providing  Proof  -­‐    

Management  Control    •  The Management Meeting Policy promotes PDCA and embeds the process

of ensuring that Action Plans are monitored

•  Recommends a weekly Management Meeting to review all Action Plans,

audits, complaints, external quality reports and statutory inspection reports

•  A simple Management Meeting Policy template produces an integrated Action

Plan which drives the whole organisation along the PDCA pathway

 

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Summary  -­‐  Surviving  First  

Inspec/on    

•  QCS compliance management enables

health and social care service providers

survive first and subsequent inspections

by providing:

•  Policies and procedures to ensure

processes are compliant

•  Recording and reporting systems to

document practice

•  Consistency when scrutinised using

data triangulation methods

•  QCS compliance management also provides

compelling benefits such as:

•  Raising compliance standards and

improving care quality standards

•  Confidence for care workers in critical areas

like infection control, care planning and

medication

•  Structured approach reduces risks to

service users and service providers

Summary  -­‐  Driving  BeNer  Care    

Find out more on our website and register for a free trial at: www.ukqcs.co.uk      T:  020  7138  3078  

For  more  informa?on  download  our  free  white  paper:  hCp://www.ukqcs.co.uk/useful-­‐guides/cqc-­‐first-­‐inspec?on-­‐a-­‐survival-­‐guide/