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CQC Inspection Checklist

Safe

Do systems, processes and practices keep people safe and safeguarded from abuse?

Are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

Do systems, processes and practices protect people from abuse, neglect, harassment, and breaches of their dignity and respect? Are these monitored and improved?

Are people protected from discrimination, which might amount to abuse or cause psychological harm? (This includes harassment and discrimination in relation to protected characteristics under the Equality Act.)

Is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks?

Do staff receive effective training in safety systems, processes and practices?

Do staff understand their responsibilities and adhere to safeguarding policies and procedures, including working in partnership with other agencies?

Do staff identify adults and children at risk of, or suffering, significant harm?

Do the design, maintenance and use of facilities and premises keep people safe?

Are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?

Are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?

Do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?

Do arrangements for using bank, agency and locum staff keep people safe at all times?

Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively?

Do staff identify and respond appropriately to changing risks to people, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges?

Is the impact on safety assessed and monitored when carrying out changes to the service or the staff?

Do staff have all the information they need to deliver safe care and treatment to people?

Are people’s individual care records, including clinical data, written and managed in a way that keeps people safe?

Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way?

When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?

Do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment?

Does the provider ensure the proper and safe use of medicines, where the service is responsible?

Are medicines and medicines-related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.)

Are medicines appropriately prescribed, administered and/or supplied to people in line with the relevant legislation, current national guidance or best available evidence?

Do people receive specific advice about their medicines in line with current national guidance or evidence?

Does the service make sure that people receive their medicines as intended, and is this recorded appropriately?

Are people's medicines reconciled in line with current national guidance when transferring between locations or changing levels of care?

Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence?

Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?

Does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

What is the track record on safety?

What is the safety performance over time?

How does safety performance compare with other similar services?

How well is safety monitored using information from a range of sources (including performance against safety goals where appropriate)?

Are lessons learned and improvements made when things go wrong?

Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?

Are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?

Are lessons learned and themes identified, and is action taken as a result of investigations when things go wrong?

Is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?

Are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews effective?

Effective

Are people’s needs and choices assessed and care, treatment and support delivered in line with current legislation, standards, and evidence-based guidance to achieve effective outcomes?

Are people's physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes?

Are in place to ensure there is no discrimination, including on the grounds of protected characteristics under the Equality Act, when making care and treatment decisions?

Is technology and equipment used to enhance the delivery of effective care and treatment and to support people’s independence?

Are the rights of people subject to the Mental Health Act 1983 (MHA) protected and do staff have regard to the MHA Code of Practice?

Are people told when they need to seek further help and advised what to do if their condition deteriorates?

Are people's care and treatment outcomes monitored and how do they compare with other similar services?

Is information about the outcomes of people's care and treatment (both physical and mental where appropriate) routinely collected and monitored?

Does this information show that the intended outcomes for people are being achieved?

Do outcomes for people in this service compare with other similar services and how have they changed over time?

Is there participation in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, (approved) accreditation schemes, peer review, research, trials and other quality improvement initiatives? Are all relevant staff involved in activities to monitor and use information to improve outcomes?

Does the service make sure that staff have the skills, knowledge and experience to deliver effective care and support?

Do people have their assessed needs, preferences and choices met by staff with the right skills and knowledge?

Are the learning needs of all staff identified? Do staff have appropriate training to meet their learning needs that covers the scope of their work, and is there protected time for this training?

Are staff encouraged and given opportunities to develop?

What are the arrangements for supporting and managing staff to deliver effective care and treatment? (This includes one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.)

Is poor or variable staff performance identified and managed? How are staff supported to improve?

Are volunteers recruited where required, and are they trained and supported for the role they undertake?

Do staff, teams, and services within and across organisations work well together to deliver effective care, support, and treatment?

Are all necessary staff, including those in different teams, services and organisations, involved in assessing, planning and delivering care and treatment?

Is care delivered and reviewed in a coordinated way when different teams, services or organisations are involved?

Are people assured that they will receive consistent, coordinated, person-centred care and support when they use, or move between different services?

Are people supported to live healthier lives and, where the service is responsible, does it improve the health of its population?

Are people identified who may need extra support?

Are people involved in regularly monitoring their health, including health assessments and checks, where appropriate and necessary?

Are people who use services empowered and supported to manage their own health, care and wellbeing and to maximise their independence?

Where abnormalities or risk factors are identified that may require additional support or intervention, are changes to people’s care or treatment discussed and followed up between staff, people and their carers where necessary?

Is consent to care and treatment always sought in line with legislation and guidance?

Do staff understand the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004 and other relevant national standards and guidance?

Are people supported to make decisions in line with relevant legislation and guidance?

Is possible lack of mental capacity to make a particular decision assessed and recorded?

Is the process for seeking consent monitored and reviewed to ensure it meets legal requirements and follows relevant national guidance?

When people lack the mental capacity to make a decision, do staff ensure that best interests decisions are made in accordance with legislation?

Caring

Does the service ensure that people are treated with kindness, respect, and compassion and that they are given emotional support when needed?

Do staff understand and respect the personal, cultural, social and religious needs of people and how these may relate to care needs, and do they take these into account in the way they deliver services? Is this information recorded and shared with other services or
providers?

Do staff take the time to interact with people who use the service and those close to them in a respectful and considerate way?

Do staff show an encouraging, sensitive and supportive attitude to people who use services and those close to them?

Do staff raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes?

Do staff understand the impact that a person’s care, treatment or condition will have on their wellbeing and on those close to them, both emotionally and socially?

Are people given appropriate and timely support and information to cope emotionally with their care, treatment or condition? Are they advised how to find other support services?

Does the service support people to express their views and be actively involved on making decisions about their care, treatment, and support as far as possible?

Do staff communicate with people so that they understand their care, treatment and condition and any advice given?

Do staff seek accessible ways to communicate with people when their protected equality or other characteristics make this necessary?

Do staff make sure that people who use services and those close to them are able to find further information, including community and advocacy services, or ask questions about their care and treatment?

Are people empowered and supported, where necessary, to use and link with support networks and advocacy, so that it will have a positive impact on their health, care and wellbeing?

Do staff routinely involve people who use services and those close to them (including carers and dependants) in planning and making shared decisions about their care and treatment? Do people feel listened to, respected and have their views considered?

Are people’s carers, advocates and representatives, including family members and friends, identified, welcomed and treated as important partners in the delivery of their care?

Is emotional support and information provided to those close to people who use services, including carers, family and dependants?

Are people's privacy, dignity and independence respected and promoted?

Does the service and staff make sure that people’s privacy and dignity needs are understood and always respected, including during physical or intimate care and examinations?

Do staff respond in a compassionate, timely and appropriate way when people experience physical pain, discomfort or emotional distress?

Are people assured that information about them is treated confidentially in a way that complies with the Data Protection Act and that staff support people to make and review choices about sharing their information?

Responsive

Do people receive personalised care that is responsive to their needs?

Do the services provided reflect the needs of the population served and do they ensure
flexibility, choice and continuity of care?

Where people’s needs and choices are not being met, is this identified and used to inform how services are improved and developed?

Are the facilities and premises appropriate for the services that are delivered?

Does the service identify and meet the information and communication needs of people with a disability or sensory loss? Does it record, highlight and share this information with others when required, and gain people’s consent to do so?

Are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances?

Are services delivered and coordinated to be accessible and responsive to people with complex needs?

Are people supported during referral, transfer between services and discharge?

Are reasonable adjustments made so that people with a disability can access and use services on an equal basis to others?

Do key staff work across services to coordinate people's involvement with families and carers, particularly for those with multiple long-term conditions?

Do services take account of the particular needs and choices of different people?

Can people access care and treatment in a timely way?

Do people have timely access to initial assessment, test results, diagnosis or treatment?

Is action taken to minimise the length of time people have to wait for care, treatment or advice?

Do people with the most urgent needs have their care and treatment prioritised?

Are appointments, care and treatment only cancelled or delayed when absolutely necessary? Are delays or cancellations explained to people, and are people supported to access care and treatment again as soon as possible?

Do services run on time, and are people kept informed about any disruption?

Are people’s concerns and complaints listened and responded to and used to improve the quality of care?

Do people who use the service know how to make a complaint or raise concerns and how comfortable do they feel doing so in their own way? How are people encouraged to make a complaint, and how confident are they to speak up?

Is it easy for people to use the complaints process or raise a concern? Are people treated compassionately and given help and support, by using accessible information or protection measures, if they need to make a complaint?

Are complaints effectively handled, including ensuring openness and transparency, confidentiality, regular updates for the complainant, a timely response and explanation of the outcome, and a formal record?

Are people who raise concerns or complaints protected from discrimination, harassment or disadvantage?

Are concerns and complaints used as an opportunity to learn and drive continuous improvement?

Well-led

Is there the leadership capacity and capability to deliver high-quality, sustainable care?

Do leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis?

Do leaders understand the challenges to quality and sustainability, and can they identify the actions needed to address them?

Are leaders visible and approachable?

Are there clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and is there a leadership strategy or development programme, which includes succession planning?

Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver?

Is there a clear vision and a set of values, with quality and sustainability as the top priorities?

Is there a robust, realistic strategy for achieving the priorities and delivering good quality sustainable care?

Have the vision, values and strategy been developed using a structured planning process in collaboration with staff, people who use services, and external partners?

Do staff know and understand what the vision, values and strategy are, and their role in achieving them?

Is the strategy aligned to local plans in the wider health and social care economy, and how have services been planned to meet the needs of the relevant population?

Is progress against delivery of the strategy and local plans monitored and reviewed, and is there evidence to show this?

Is there a culture of high-quality, sustainable care?

Do staff feel supported, respected and valued?

Is the culture centred on the needs and experience of people who use services?

Do staff feel positive and proud to work in the organisation?

Is action taken to address behaviour and performance that is inconsistent with the vision and values, regardless of seniority?

Does the culture encourage openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? Do leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised?

Are there mechanisms for providing all staff at every level with the development they need, including high-quality appraisal and career development conversations?

Is there a strong emphasis on the safety and wellbeing of staff?

Are equality and diversity promoted within and beyond the organisation? Do all staff, including those with particular protected characteristics under the Equality Act, feel they are treated equitably?

Are there cooperative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively?

Are there clear responsibilities, roles and systems of accountability to support good governance and management?

Are there effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services? Are these regularly reviewed and improved?

Do all levels of governance and management function effectively and interact with each other appropriately?

Are staff at all levels clear about their roles and do they understand what they are accountable for, and to whom?

Are arrangements with partners and third-party providers governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care?

Are there clear and effective processes for managing risks, issues, and performance?

Are there comprehensive assurance systems, and are performance issues escalated appropriately through clear structures and processes? Are these regularly reviewed and improved?

Are there processes to manage current and future performance? Are these regularly reviewed and improved?

Is there a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken?

Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions? Is there alignment between the recorded risks and what staff say is ‘on their worry list’?

Are potential risks taken into account when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities?

When considering developments to services or efficiency changes, is the impact on quality and sustainability assessed and monitored? Are there examples of where financial pressures have compromised care?

Is appropriate and accurate information being effectively processed, challenged, and acted on?

Is there a holistic understanding of performance, which sufficiently covers and integrates people’s views with information on quality, operations and finances? Is information used to measure for improvement, not just assurance?

Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? Do all staff have sufficient access to information, and do they challenge it appropriately?

Are there clear and robust service performance measures, which are reported and monitored?

Are there effective arrangements to ensure that the information used to monitor, manage and report on quality and performance is accurate, valid, reliable, timely and relevant? Is action taken when issues are identified?

Are information technology systems used effectively to monitor and improve the quality of care?

Are there effective arrangements to ensure that data or notifications are submitted to external bodies as required?

Are there robust arrangements (including appropriate internal and external validation) to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches?

Are the people who use services, the public, staff, and external partners engaged and involved to support high-quality sustainable services?

Are people’s views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups?

Are people who use services, those close to them and their representatives actively engaged and involved in decision-making to shape services and culture? Does this include people in a range of equality groups?

Are staff actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? Does this include those with a protected equality characteristic?

Are there positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs?

Is there transparency and openness with all stakeholders about performance?

Are there robust systems and processes for learning, continuous improvement, and innovation?

Do leaders and staff strive for continuous learning, improvement and innovation? Does this include participating in appropriate research projects and recognised accreditation schemes?

Are there standardised improvement tools and methods, and do staff have the skills to use
them?

Is participation in and learning from internal and external reviews effective, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements?

Do all staff regularly take time out to work together to resolve problems and to review individual and team objectives, processes and performance? Does this lead to improvements and innovation?

Are there systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work?

Completion

Additional Observations

Head of Assurance, Compliance & Quality

CQC Inspection Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 6

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CQC Inspection Checklist

Safe

Do systems, processes and practices keep people safe and safeguarded from abuse?

Are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

Do systems, processes and practices protect people from abuse, neglect, harassment, and breaches of their dignity and respect? Are these monitored and improved?

Are people protected from discrimination, which might amount to abuse or cause psychological harm? (This includes harassment and discrimination in relation to protected characteristics under the Equality Act.)

Is safety promoted in recruitment practice, arrangements to support staff, disciplinary procedures, and ongoing checks?

Do staff receive effective training in safety systems, processes and practices?

Do staff understand their responsibilities and adhere to safeguarding policies and procedures, including working in partnership with other agencies?

Do staff identify adults and children at risk of, or suffering, significant harm?

Do the design, maintenance and use of facilities and premises keep people safe?

Are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?

Are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?

Do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?

Do arrangements for using bank, agency and locum staff keep people safe at all times?

Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively?

Do staff identify and respond appropriately to changing risks to people, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges?

Is the impact on safety assessed and monitored when carrying out changes to the service or the staff?

Do staff have all the information they need to deliver safe care and treatment to people?

Are people’s individual care records, including clinical data, written and managed in a way that keeps people safe?

Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way?

When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?

Do the systems that manage information about people who use services support staff, carers and partner agencies to deliver safe care and treatment?

Does the provider ensure the proper and safe use of medicines, where the service is responsible?

Are medicines and medicines-related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.)

Are medicines appropriately prescribed, administered and/or supplied to people in line with the relevant legislation, current national guidance or best available evidence?

Do people receive specific advice about their medicines in line with current national guidance or evidence?

Does the service make sure that people receive their medicines as intended, and is this recorded appropriately?

Are people's medicines reconciled in line with current national guidance when transferring between locations or changing levels of care?

Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence?

Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?

Does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

What is the track record on safety?

What is the safety performance over time?

How does safety performance compare with other similar services?

How well is safety monitored using information from a range of sources (including performance against safety goals where appropriate)?

Are lessons learned and improvements made when things go wrong?

Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?

Are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?

Are lessons learned and themes identified, and is action taken as a result of investigations when things go wrong?

Is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?

Are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews effective?

Effective

Are people’s needs and choices assessed and care, treatment and support delivered in line with current legislation, standards, and evidence-based guidance to achieve effective outcomes?

Are people's physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes?

Are in place to ensure there is no discrimination, including on the grounds of protected characteristics under the Equality Act, when making care and treatment decisions?

Is technology and equipment used to enhance the delivery of effective care and treatment and to support people’s independence?

Are the rights of people subject to the Mental Health Act 1983 (MHA) protected and do staff have regard to the MHA Code of Practice?

Are people told when they need to seek further help and advised what to do if their condition deteriorates?

Are people's care and treatment outcomes monitored and how do they compare with other similar services?

Is information about the outcomes of people's care and treatment (both physical and mental where appropriate) routinely collected and monitored?

Does this information show that the intended outcomes for people are being achieved?

Do outcomes for people in this service compare with other similar services and how have they changed over time?

Is there participation in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, (approved) accreditation schemes, peer review, research, trials and other quality improvement initiatives? Are all relevant staff involved in activities to monitor and use information to improve outcomes?

Does the service make sure that staff have the skills, knowledge and experience to deliver effective care and support?

Do people have their assessed needs, preferences and choices met by staff with the right skills and knowledge?

Are the learning needs of all staff identified? Do staff have appropriate training to meet their learning needs that covers the scope of their work, and is there protected time for this training?

Are staff encouraged and given opportunities to develop?

What are the arrangements for supporting and managing staff to deliver effective care and treatment? (This includes one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.)

Is poor or variable staff performance identified and managed? How are staff supported to improve?

Are volunteers recruited where required, and are they trained and supported for the role they undertake?

Do staff, teams, and services within and across organisations work well together to deliver effective care, support, and treatment?

Are all necessary staff, including those in different teams, services and organisations, involved in assessing, planning and delivering care and treatment?

Is care delivered and reviewed in a coordinated way when different teams, services or organisations are involved?

Are people assured that they will receive consistent, coordinated, person-centred care and support when they use, or move between different services?

Are people supported to live healthier lives and, where the service is responsible, does it improve the health of its population?

Are people identified who may need extra support?

Are people involved in regularly monitoring their health, including health assessments and checks, where appropriate and necessary?

Are people who use services empowered and supported to manage their own health, care and wellbeing and to maximise their independence?

Where abnormalities or risk factors are identified that may require additional support or intervention, are changes to people’s care or treatment discussed and followed up between staff, people and their carers where necessary?

Is consent to care and treatment always sought in line with legislation and guidance?

Do staff understand the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004 and other relevant national standards and guidance?

Are people supported to make decisions in line with relevant legislation and guidance?

Is possible lack of mental capacity to make a particular decision assessed and recorded?

Is the process for seeking consent monitored and reviewed to ensure it meets legal requirements and follows relevant national guidance?

When people lack the mental capacity to make a decision, do staff ensure that best interests decisions are made in accordance with legislation?

Caring

Does the service ensure that people are treated with kindness, respect, and compassion and that they are given emotional support when needed?

Do staff understand and respect the personal, cultural, social and religious needs of people and how these may relate to care needs, and do they take these into account in the way they deliver services? Is this information recorded and shared with other services or
providers?

Do staff take the time to interact with people who use the service and those close to them in a respectful and considerate way?

Do staff show an encouraging, sensitive and supportive attitude to people who use services and those close to them?

Do staff raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes?

Do staff understand the impact that a person’s care, treatment or condition will have on their wellbeing and on those close to them, both emotionally and socially?

Are people given appropriate and timely support and information to cope emotionally with their care, treatment or condition? Are they advised how to find other support services?

Does the service support people to express their views and be actively involved on making decisions about their care, treatment, and support as far as possible?

Do staff communicate with people so that they understand their care, treatment and condition and any advice given?

Do staff seek accessible ways to communicate with people when their protected equality or other characteristics make this necessary?

Do staff make sure that people who use services and those close to them are able to find further information, including community and advocacy services, or ask questions about their care and treatment?

Are people empowered and supported, where necessary, to use and link with support networks and advocacy, so that it will have a positive impact on their health, care and wellbeing?

Do staff routinely involve people who use services and those close to them (including carers and dependants) in planning and making shared decisions about their care and treatment? Do people feel listened to, respected and have their views considered?

Are people’s carers, advocates and representatives, including family members and friends, identified, welcomed and treated as important partners in the delivery of their care?

Is emotional support and information provided to those close to people who use services, including carers, family and dependants?

Are people's privacy, dignity and independence respected and promoted?

Does the service and staff make sure that people’s privacy and dignity needs are understood and always respected, including during physical or intimate care and examinations?

Do staff respond in a compassionate, timely and appropriate way when people experience physical pain, discomfort or emotional distress?

Are people assured that information about them is treated confidentially in a way that complies with the Data Protection Act and that staff support people to make and review choices about sharing their information?

Responsive

Do people receive personalised care that is responsive to their needs?

Do the services provided reflect the needs of the population served and do they ensure
flexibility, choice and continuity of care?

Where people’s needs and choices are not being met, is this identified and used to inform how services are improved and developed?

Are the facilities and premises appropriate for the services that are delivered?

Does the service identify and meet the information and communication needs of people with a disability or sensory loss? Does it record, highlight and share this information with others when required, and gain people’s consent to do so?

Are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances?

Are services delivered and coordinated to be accessible and responsive to people with complex needs?

Are people supported during referral, transfer between services and discharge?

Are reasonable adjustments made so that people with a disability can access and use services on an equal basis to others?

Do key staff work across services to coordinate people's involvement with families and carers, particularly for those with multiple long-term conditions?

Do services take account of the particular needs and choices of different people?

Can people access care and treatment in a timely way?

Do people have timely access to initial assessment, test results, diagnosis or treatment?

Is action taken to minimise the length of time people have to wait for care, treatment or advice?

Do people with the most urgent needs have their care and treatment prioritised?

Are appointments, care and treatment only cancelled or delayed when absolutely necessary? Are delays or cancellations explained to people, and are people supported to access care and treatment again as soon as possible?

Do services run on time, and are people kept informed about any disruption?

Are people’s concerns and complaints listened and responded to and used to improve the quality of care?

Do people who use the service know how to make a complaint or raise concerns and how comfortable do they feel doing so in their own way? How are people encouraged to make a complaint, and how confident are they to speak up?

Is it easy for people to use the complaints process or raise a concern? Are people treated compassionately and given help and support, by using accessible information or protection measures, if they need to make a complaint?

Are complaints effectively handled, including ensuring openness and transparency, confidentiality, regular updates for the complainant, a timely response and explanation of the outcome, and a formal record?

Are people who raise concerns or complaints protected from discrimination, harassment or disadvantage?

Are concerns and complaints used as an opportunity to learn and drive continuous improvement?

Well-led

Is there the leadership capacity and capability to deliver high-quality, sustainable care?

Do leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis?

Do leaders understand the challenges to quality and sustainability, and can they identify the actions needed to address them?

Are leaders visible and approachable?

Are there clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and is there a leadership strategy or development programme, which includes succession planning?

Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver?

Is there a clear vision and a set of values, with quality and sustainability as the top priorities?

Is there a robust, realistic strategy for achieving the priorities and delivering good quality sustainable care?

Have the vision, values and strategy been developed using a structured planning process in collaboration with staff, people who use services, and external partners?

Do staff know and understand what the vision, values and strategy are, and their role in achieving them?

Is the strategy aligned to local plans in the wider health and social care economy, and how have services been planned to meet the needs of the relevant population?

Is progress against delivery of the strategy and local plans monitored and reviewed, and is there evidence to show this?

Is there a culture of high-quality, sustainable care?

Do staff feel supported, respected and valued?

Is the culture centred on the needs and experience of people who use services?

Do staff feel positive and proud to work in the organisation?

Is action taken to address behaviour and performance that is inconsistent with the vision and values, regardless of seniority?

Does the culture encourage openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? Do leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised?

Are there mechanisms for providing all staff at every level with the development they need, including high-quality appraisal and career development conversations?

Is there a strong emphasis on the safety and wellbeing of staff?

Are equality and diversity promoted within and beyond the organisation? Do all staff, including those with particular protected characteristics under the Equality Act, feel they are treated equitably?

Are there cooperative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively?

Are there clear responsibilities, roles and systems of accountability to support good governance and management?

Are there effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services? Are these regularly reviewed and improved?

Do all levels of governance and management function effectively and interact with each other appropriately?

Are staff at all levels clear about their roles and do they understand what they are accountable for, and to whom?

Are arrangements with partners and third-party providers governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care?

Are there clear and effective processes for managing risks, issues, and performance?

Are there comprehensive assurance systems, and are performance issues escalated appropriately through clear structures and processes? Are these regularly reviewed and improved?

Are there processes to manage current and future performance? Are these regularly reviewed and improved?

Is there a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken?

Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions? Is there alignment between the recorded risks and what staff say is ‘on their worry list’?

Are potential risks taken into account when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities?

When considering developments to services or efficiency changes, is the impact on quality and sustainability assessed and monitored? Are there examples of where financial pressures have compromised care?

Is appropriate and accurate information being effectively processed, challenged, and acted on?

Is there a holistic understanding of performance, which sufficiently covers and integrates people’s views with information on quality, operations and finances? Is information used to measure for improvement, not just assurance?

Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? Do all staff have sufficient access to information, and do they challenge it appropriately?

Are there clear and robust service performance measures, which are reported and monitored?

Are there effective arrangements to ensure that the information used to monitor, manage and report on quality and performance is accurate, valid, reliable, timely and relevant? Is action taken when issues are identified?

Are information technology systems used effectively to monitor and improve the quality of care?

Are there effective arrangements to ensure that data or notifications are submitted to external bodies as required?

Are there robust arrangements (including appropriate internal and external validation) to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches?

Are the people who use services, the public, staff, and external partners engaged and involved to support high-quality sustainable services?

Are people’s views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups?

Are people who use services, those close to them and their representatives actively engaged and involved in decision-making to shape services and culture? Does this include people in a range of equality groups?

Are staff actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? Does this include those with a protected equality characteristic?

Are there positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant population, and to deliver services to meet those needs?

Is there transparency and openness with all stakeholders about performance?

Are there robust systems and processes for learning, continuous improvement, and innovation?

Do leaders and staff strive for continuous learning, improvement and innovation? Does this include participating in appropriate research projects and recognised accreditation schemes?

Are there standardised improvement tools and methods, and do staff have the skills to use
them?

Is participation in and learning from internal and external reviews effective, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements?

Do all staff regularly take time out to work together to resolve problems and to review individual and team objectives, processes and performance? Does this lead to improvements and innovation?

Are there systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work?

Completion

Additional Observations

Head of Assurance, Compliance & Quality