Title Page
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Site/Service
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Address
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Inspection Team Lead
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Conducted on
CQC Compliance Checklist
Outcome 1 (Regulation 17)
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Provide evidence to demonstrate that people who use services are involved in and receive care, treatment and support that respects their right to make or influence decisions.
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Provide evidence to demonstrate that people who use services have their care, treatment and support needs met.
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Provide evidence to demonstrate that people who use services receive care, treatment and support where clear procedures are followed in practice, monitored and reviewed.
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Provide evidence to demonstrate that people who use services benefit from a service that takes into account relevant guidance.
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Provide evidence to demonstrate that people who use services, or others acting on their behalf, are supported to make informed choices about their care, treatment and support.
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Provide evidence to demonstrate that people who use services receive care, treatment and support that is provided in a way that ensures their independence is promoted.
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Provide evidence to demonstrate that people who use services receive care, treatment and support that is provided in a way that ensures their human rights and diversity are respected.
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Provide evidence that demonstrates that people who use services, can influence how the service is run as they are given opportunities to take part in decision making.
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Provide evidence that demonstrates that people who use services can be confident that the outcome of diagnostic tests and assessments will be explained and discussed with them in a way which they are able to understand and which enables them to make informed choices about their care, treatment and support, where this is the role or responsibility of the service undertaking the test.
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Provide evidence that demonstrates that people who use services are enabled to participate in the activities of the local community so that they can exercise their right to be a citizen as independently as they are able to.
Outcome 2 (Regulation 18)
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Provide evidence that where they are able, people who use services receive the examination, care, treatment and support they agree to. This is because clear procedures to get valid consent are followed in practice, monitored and reviewed.
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Provide evidence that demonstrates that the service has clear procedures that are followed in practice, monitored and reviewed about decision making for people who are unable to give, or choose to withhold, consent for each individual care, treatment and support activity.
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Provide evidence that demonstrates that people who use services benefit from a service that takes into account relevant guidance, including that from the Care Quality Commission’s Schedule of Applicable Publications.
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Provide evidence that demonstrates that people are able to make a decision about whether or not to give consent because they have information about the alternative options for their care, treatment and support and the risks and benefits of each.
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Provide evidence that demonstrates that people who use services give valid consent because arrangements are followed to ensure that cosmetic surgery does not take place on the same day as the consultation.
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Provide evidence that demonstrates that people who use services are supported to make a decision about whether or not to give consent when this is not in conflict with any restrictions set by the courts, Mental Health Act 1983, Mental Capacity Act 2005 or criminal justice system.
Outcome 4 (Regulation 9)
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Provide evidence that demonstrates that people who use services have safe and appropriate care, treatment and support because their individual needs are established from when they are referred or begin to use the service.
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Provide evidence that demonstrates that people who use services can be confident that staff will quickly recognise and immediately respond to their needs when their condition deteriorates or they become seriously ill, transferring them to another service as quickly and as safely as possible, if this is deemed to be necessary.
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Provide evidence that demonstrates that people who use services know that they will receive care, treatment and support in single sex accommodation wherever it is available.
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Provide evidence that demonstrates that people who use services know that their length of stay will be as short as possible in order to meet their needs, or as required by legal restrictions and that their accommodation will not limit their freedom any further than is agreed in their plan of care.
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Provide evidence that demonstrates that people who use services, who are thought to present a risk of suicide and homicide or harm to themselves or others have an ongoing, multi-disciplinary assessment and plan of care made to determine whether they have a history of harm to themselves or others, including environmental risks, and how these can be minimised.
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Provide evidence that demonstrates that people who use services benefit from a service that ensures that patient safety alerts, rapid response reports and patient safety recommendations issued by National Patient Safety Agency (NPSA) and which require action are acted upon within required time-scales.
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Provide evidence that demonstrates that people who use rehabilitation or treatment services for substance misuse have their care, treatment, and support options explained before they start to use the service. These include any restrictions identified, and the alternatives, risks and benefits. In addition a risk assessment is completed that includes the risk of drug related death.
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Provide evidence that demonstrates that people using rehabilitation or treatment services for substance misuse benefit from clear procedures followed in practice, monitored and reviewed, for when they leave the service, in a planned or unplanned way.
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Provide evidence that demonstrates that people with a learning disability who use services are supported to have a Health Action Plan developed by their primary care trust.
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Provide evidence that demonstrates that people who use services have their needs met through the Care Programme Approach if they meet the criteria set out in ‘Refocusing the Care Programme Approach: policy and positive practice guidance 2008’.
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Provide evidence that demonstrates that people who use services, receive care, treatment and support that is developed carefully and systematically where protocols or processes require rapid development in response to an unexpected public health event.
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Provide evidence that demonstrates that people who use services can be confident that blood, blood products and human tissue donated for transplantation are only taken from donors who do not present an unacceptable risk to the person.
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Provide evidence that demonstrates that people who use services are able to visit the service, where it is practical or appropriate to do so, prior to using it so that they can decide whether or not they wish to use it, or to allow them to become familiar with it in order to allay anxiety or fear.
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Provide evidence that demonstrates that people who use services can be confident that searches are conducted in line with nationally recommended practice and that the service will prevent and rapidly respond to incidents of illicit drug use and supply on or near the premises.
Outcome 5 (Regulation 14)
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Provide evidence that demonstrates that where the service provides food and drink, people who use services have their care, treatment and support needs met.
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Provide evidence that demonstrates that where the service provides food and drink (but not when this is in the person’s own home or shared lives arrangement), people have their care, treatment and support needs met.
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Provide evidence that demonstrates that where the service provides food and drink, people who use services can make decisions about their food and drink.
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Provide evidence that demonstrates people who use services who are requested to fast, benefit from clear procedures followed in practice, monitored and reviewed.
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Provide evidence that demonstrates that people who use services have access to facilities for infant feeding, including facilities to support breastfeeding.
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Provide evidence that demonstrates that people using rehabilitation or treatment services for substance misuse which provides them with food and drink, will have some limited choice about: • When to eat. • Where to eat. • Whether to eat alone, or with company
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Provide evidence that demonstrates that people who use services are actively supported to plan and prepare their own meals, where this is safe and they are able to do so.
Outcome 6 (Regulation 24)
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Provide evidence that demonstrates that people who use services can be confident that when their care, treatment or support is provided by more than one service, team, individual or agency, or is transferred from one service, team, individual or agency to another.
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Provide evidence that demonstrates that people who use services can be confident that when information about their care, treatment and support needs to be passed to another service, team, individual or agency.
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Provide evidence that demonstrates that people who use services can be confident that when more than one service, team, individual or agency is involved at the same time in their care, treatment and support, or are planned to be in the future.
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Provide evidence that demonstrates that people who use services benefit from a service that wherever it is required, has in place a planned and prepared response to major incident and emergency situations.
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Provide evidence that demonstrates that people who use services, can be confident that when more than one service, team, individual or agency is involved at the same time in their care, treatment and support or are planned to be in the future.
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Provide evidence that demonstrates that people who use services, can be confident that when more than one service, team, individual or agency are involved at the same time in their care, treatment and support, or are planned to be in the future, the services provided are organised so that the person who uses the service knows who to contact about their needs and if the needs are not being met.
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Provide evidence that demonstrates that people who use services, can be confident that when information about their care, treatment and support is, or needs to be, passed to another service, team, individual or agency, this is organised so that the person or others acting on their behalf are aware of the information about them that is being transferred and that they can be provided with a copy of the information transferred if they want it.
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Provide evidence that demonstrates that people who use services know that they can request information to be transferred to another service and that the service agrees to transfer the information requested unless there is a good reason why they cannot. If so, that reason is fully explained.
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Provide evidence that demonstrates that people who use services, are supported to access the care, treatment and support.
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Provide evidence that demonstrates that people who use rehabilitation or treatment services for substance misuse who are provided with accommodation when they use the service are able to register with a general practitioner, dentist and any other health service they may require, as far as possible of their choice depending on the length of the treatment programme.
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Provide evidence that demonstrates that people who use services are able to register with a general practitioner, dentist and any other health service they may require, as far as possible of their choice.
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Provide evidence that demonstrates that people with mental health needs who use services are, where necessary, supported by local Multi-Agency Public Protection Arrangements to protect themselves and others from harm.
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Provide evidence that demonstrates that people who use rehabilitation or treatment services for substance misuse will benefit from teams, individuals and/or agencies who assess at an early stage of their treatment, their need for services to support their reintegration into the wider community (including housing, employment, education and training services).
Outcome 7 (Regulation 11)
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Provide evidence that demonstrates that people receive a service from a provider who takes steps to prevent abuse and does not tolerate any abusive practice should it occur.
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Provide evidence that demonstrates that people who use services benefit from a service.
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People who use services are protected as staff and others involved in carrying on the regulated activity comply.
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Provide evidence that demonstrates that people who use services receive care, treatment and support from all staff who comply.
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Provide evidence that demonstrates that people who use services receive care, treatment and support from all staff that, in relation to restraint know and comply.
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Provide evidence that demonstrates that people who use services receive care, treatment and support from staff who, in relation to responding to behaviour that presents a risk to themselves or others.
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Provide evidence that demonstrates that people who use services benefit from practice where the use of restraint and management of behaviour that presents a risk is handled.
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Provide evidence that demonstrates that people who use services that have been abused or are suspected of being abused (or where appropriate, people acting on their behalf) are supported and cared for.
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Provide evidence that demonstrates that people who use services have access to information about abuse.
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Provide evidence that the service looks after people’s money and valuables.
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Provide evidence that demonstrates that people who use services can be confident that staff, and others involved in carrying on the regulated activity, will not take any person (including children) or pets into the home of the person using the service without their permission and that of the manager of the service.
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Provide evidence that demonstrates people who use services can be confident that rapid tranquilisation will only be used.
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Provide evidence that demonstrates that people who use services are protected from the risk and likelihood of abuse.
Outcome 8 (Regulation 12)
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Provide evidence that demonstrates systems to manage and monitor the prevention and control of infection. These systems use risk assessments and consider how susceptible service users are and any risks that their environment and other users may pose to them.
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Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.
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Provide suitable accurate information on infections to service users and their visitors.
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Provide suitable accurate information on infections to any person concerned with providing further support or nursing/medical care in a timely fashion.
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Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.
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Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.
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Provide or secure adequate isolation facilities.
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Secure adequate access to laboratory support as appropriate.
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Have and adhere to policies, designed for the individual’s care and provider organisations, that will help to prevent and control infections.
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Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to infections that can be caught at work and that all staff are suitably educated in the prevention and control of infection associated with the provision of health and social care.
Outcome 9 (Regulation 13)
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Provide evidence to demonstrate that people who use services receive medicines which are deemed appropriate for them as individuals .
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Provide evidence to demonstrate that where people who use services receive care, treatment and support that involves medicines, clear procedures and systems exist and are followed in practice, monitored and reviewed ensure the safe and appropriate use of medicines.
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Provide evidence to demonstrate that people who use services benefit from a service that takes into account relevant guidance set out in the Care Quality Commission’s Schedule of Applicable Publications.
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Provide evidence to demonstrate that people who use services benefit from a service that ensures that they are given and understand up to date information about they medicines they are taking.
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Provide evidence that demonstrates that people who use services detained under the Mental Health Act 1983 receive medicines that are duly authorised and administered in line with the Mental Health Act 1983 Code of Practice.
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Provide evidence that demonstrates that people who use services receive care, treatment and support that follows clear procedures in practice, which are monitored and reviewed and that explain how staff may be permitted to administer homely remedies.
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Provide evidence that demonstrates that where people who use services receive support with their medicines to ensure the safe handling of medicines.
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Provide evidence that demonstrates that people using services are not at risk of harm because medicines used for resuscitation or other medical emergencies is available, accessible for quick use and where necessary, is tamper proof.
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Provide evidence that demonstrates that people who use services receive care, treatment and support from staff who ensure that patient safety alerts, rapid response reports and patient safety recommendations disseminated by the NPSA and which require action are acted upon within required time-scales.
Outcome 10 (Regulation 15)
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Provide evidence to demonstrate that people who use services and others who work in or visit the premises can be confident that in relation to the design and layout.
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Provide evidence to demonstrate that people who work, visit or use services can be confident that in relation to design and layout, premises where care, treatment or support is provided.
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Provide evidence to demonstrate that people who work, visit or use services can be confident that in relation to security, premises and grounds where care, treatment or support comply.
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Provide evidence to demonstrate that people who work, visit or use services can be confident that in relation to maintenance of premises and grounds, renewal and service continuity, premises where care, treatment and support is provided.
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Provide evidence to demonstrate that people who use services and staff are not placed at risk of harm as staff understand what to do in the event of an emergency.
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Provide evidence that demonstrates that people who use services and others who work in or visit the premises can be confident that in relation to design and layout, the premises will comply.
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Provide evidence that demonstrates that people who work, visit or use services can be confident that facilities where care, treatment and support is provided are appropriately managed.
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Provide evidence that demonstrates that people who work in, visit or use services can be confident that facilities where care, treatment and support is provided are maintained.
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Provide evidence that demonstrates that people who work in, or visit the premises can be confident that facilities where care, treatment and support are provided have sufficient space.
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Provide evidence that demonstrates that people who work in, visit or use services can be confident that facilities exist and are maintained in line with legislation for the safe handling of radionucleides required for scanning and treatment.
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Provide evidence that demonstrates that people who use services can be confident that the staff caring for them are able to work effectively because suitable facilities are provided for them.
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Provide evidence that demonstrates that people who use the service have bedrooms which comply with the specifications.
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Provide evidence that demonstrates that people who use the service have access to the facilities.
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Provide evidence that demonstrates that people who use services are able to access support from the service because there are clear contingency procedures followed in practice, monitored and reviewed, should the communication systems that the service uses to enable people to access it, fail.
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Provide evidence that demonstrates that people who use services receive care, treatment and support provided in a vehicle complies.
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Provide evidence that demonstrates that people who use services protected from harm because providers take precautions.
Outcome 11 (Regulation 16)
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Provide evidence to demonstrate that people who use services are not placed at risk of harm because where equipment is provided or used as part of the regulated activity, the equipment is safe and appropriate.
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Provide evidence to demonstrate the needs of people who use services are met because staff using any equipment do so in a way that has regard to their dignity, comfort and safety and promotes their independence.
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Provide evidence to demonstrate that people who use services are safe because where equipment is provided as part of the regulated activity, there are clear procedures followed in practice, monitored and reviewed.
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Provide evidence to demonstrate that where people who use services receive care, treatment or support that involves the use of medical devices, the provider has clear procedures that are followed in practice, monitored and reviewed for the use of medical devices.
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Provide evidence to demonstrate that people who use services receive care, treatment and support from a service that takes into account relevant guidance including that from the Care Quality Commission’s Schedule of Applicable Publications.
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Provide evidence to demonstrate that people who use services receive care, treatment and support with medical devices that meet the requirement.
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Provide evidence that demonstrates that people who use services are safe because when equipment is used in a person’s own home, staff address any concerns in a timely manner where they have identified problems around the safety of the equipment.
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Provide evidence that demonstrates that people using services are not at risk of harm because the equipment used for resuscitation or other medical emergencies is available, accessible for quick use and where necessary, is tamper proof.
Outcome 12 (Regulation 21)
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Provide evidence to demonstrate that people who use services benefit from staff (including volunteers, students, temporary and ancillary staff and practitioners working under practising privileges) on whom the relevant checks have been carried out in the recruitment process.
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Provide evidence to demonstrate that people who use services benefit from staff (including volunteers, students, temporary and ancillary staff and practitioners working under practising privileges) who are competent and have the required qualifications, knowledge, skills and experience to carry out the roles which they have been assigned.
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Provide evidence to demonstrate that people who use services benefit from staff (including volunteers, students, temporary and ancillary staff and practitioners working under practising privileges) who are recruited through a rigorous selection process that complies with the relevant legislation and guidelines.
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Provide evidence that demonstrates that people who use services can be confident that necessary checks are made and additional safeguards put in place are in the exceptional cases where staff have been allowed to start work without a full and satisfactory CRB check.
Outcome 13 (Regulation 22)
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Provide evidence to demonstrate that people who use services benefit from sufficient staff to meet their needs.
Outcome 14 (Regulation 23)
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Provide evidence to demonstrate that people who use services receive safe and quality care, treatment and support from staff who are competent to carry out their roles.
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Provide evidence to demonstrate that children who use services can be confident that they are treated by staff who are appropriately trained to provide safe and quality care, treatment and support to them.
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Provide evidence to demonstrate that people receive a service from a provider that supervises its staff.
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Provide evidence to demonstrate that people receive a service from a provider that supports its staff.
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Provide evidence that demonstrates that people who use services receive care treatment and support from staff who have undertaken the appropriate Skills for Care standards and qualifications.
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Provide evidence that demonstrates that people using services can be confident that they are treated by staff who carry out sufficient levels of activity to maintain their professional competence.
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Provide evidence that demonstrates that children who use services can be confident that they are treated by staff who carry out sufficient levels of activity to maintain their professional competence in the area of paediatrics.
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Provide evidence that demonstrates that children using services receive care, treatment and support by nursing staff who are qualified and registered by the Nursing and Midwifery Council to do so.
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Provide evidence that demonstrates that people who use services are cared for by staff who have received training about the assessment of suicide and homicide risk and behaviours that challenge.
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Provide evidence that demonstrates that people who use services are cared for by staff who have received training about the assessment of suicide and homicide risk and behaviours that challenge.
Outcome 16 (Regulation 10)
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Provide evidence to demonstrate that people who use services receive safe and appropriate care, treatment and support because there is an effective system for assessing and monitoring the quality of the services.
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Provide evidence to demonstrate that people who use services are not harmed as they receive safe, quality care, treatment and support as a result of clear lines of reporting, accountability and responsibility.
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Provide evidence to demonstrate that people who use services receive a level of quality care, treatment and support which is continually improved with input from their comments and learning’s from adverse events, incidents, errors and near misses.
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Provide evidence to demonstrate that people who use services or those acting on their behalf are involved (or supported) in making important decisions about their care, treatment and support.
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Provide evidence to demonstrate that people who use services are not harmed or their health, welfare and safety put at risk as a consequence of the care, treatment or support they receive because risks are identified, assessed, managed, monitored and recorded.
Outcome 17 (Regulation 19)
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Provide evidence to demonstrate that people who use services and those acting on their behalf can be confident that their comments and complaints are listened to and dealt with effectively.
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Provide evidence to demonstrate that people who use services whose care, treatment and support is shared with more than one provider, or has been transferred to another provider, know that their comments and complaints are listened to.
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Provide evidence to demonstrate that as a provider, you are able to produce a summary of complaints at a time and in a format set out by the Care Quality Commission and then send the summary within the time frame specified.
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Provide evidence to demonstrate that people who use services benefit from a service that takes into account relevant guidance, including that from the Care Quality Commission’s Schedule of Applicable Publications.
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Provide evidence to demonstrate that people who use services or those acting on their behalf are able to use the comments and complaints process.
Outcome 21 (Regulation 20)
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People who use services can be confident that their personal records for their care, treatment and support are properly managed.
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Provide evidence that demonstrates that people who use services can be confident that their health care records are kept or disposed of in accordance with the Data Protection Act 1998, Department of Health’s Records Management.
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Provide evidence that demonstrates that people using services can be confident that their social care records are kept and disposed of in accordance with the Data Protection Act 1998 for the appropriate duration.
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Provide evidence that demonstrates that people who use services are supported through clear procedures that are followed in practice, monitored and reviewed.
Completion
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Additional Recommendations
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Inspection Team Lead Name & Signature
