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CQC Inspection Template

Outcomes being inspected:
Respecting & Involving Service Users

1. Staff explain and service users (or their carers) fully understand the care, treatment and support options available to them.

Evidence

Specify

2. Service users and their carers are able to access information about their care, treatment and support options.

Evidence

Specify

3. Service users feel involved in making decisions, so far as they are able or wish to, and feel listened to.

Evidence

Specify

4. Staff ensure that service users and their representatives are able to express their views and are involved appropriately in decision making.

Evidence

Specify

5. Service users feel that staff respect their privacy, dignity and independence.

Evidence

Specify

6. Staff act in a way that respects service users' privacy, dignity and independence.

Evidence

Specify

7. Staff ensure that the service users’ diversity, values and human rights are maintained.

Evidence

Specify

8. Staff encourage service users to care for themselves and promote independence where this is possible.

Evidence

Specify

9. Care, treatment and support plans reflect service user's needs, choices and preferences.

Evidence

Specify

10. Staff enable and encourage service users to be involved in how the service is run.

Evidence

Specify

11. Staff are aware of policies and procedures around respecting and involving people and where to find them.

Evidence

Specify

12. Staff have up to date training relating to respecting and involving people.

Evidence

Specify

13. Staff encourage and enable service users to be an active part of their community in appropriate settings.

Evidence

Specify

Consent to Care & Treatment

1. Service users have been given appropriate information to make an informed choice.

Evidence

Specify

2. Staff understand capacity to consent, undertake capacity assessments (where appropriate) and know what actions to take when a service users lacks capacity.

Evidence

Specify

3. Where a service user lacks capacity, a best interest meeting is held with people who know and understand the service user.

Evidence

Specify

4. Staff understand when children are able to give consent and enable them to make informed choices where appropriate.

Evidence

Specify

5. Staff should be able to provide evidence of service users giving consent.

Evidence

Specify

6. Service users have been informed of and understand how to change or withdraw their consent.

Evidence

Specify

7. Staff respect service users' right to refuse, explain the risks and benefits of refusing and alternate options.

Evidence

Specify

8. Staff are aware of the policies and procedures for gaining consent from service users and where to find them.

Evidence

Specify

9. Staff follow any advance decisions made by service users in line with MCA where the decision is known by the provider and enable service users to utilise this option.

Evidence

Specify

Care & Welfare

1. Service users’ individual needs are established by use of thorough and appropriate assessments which also establish risks, service users' goals and expectations.

Evidence

Specify

2. Service users should have the choice to be involved in decision making about all aspects of their care and plans are agreed with them.

Evidence

Specify

3. Plans of care, treatment and support are individualised, detailed, reviewed regularly and reflect service users' needs and choices.

Evidence

Specify

4. Staff plan for and recognise when a service user's needs change and act appropriately.

Evidence

Specify

5. Staff ensure that risk is managed through effective procedures including a system in place to cascade and respond to Patient Safety Alerts, Medical Device Alerts, Drug Alerts etc.

Evidence

Specify

6. The service has arrangements in place to deal with foreseeable emergencies to ensure continuity of care is provided.

Evidence

Specify

7. Service users will know the names and job titles of the staff and how to contact them.

Evidence

Specify

8. Staff make reasonable adjustments to reflect service users’ needs, values and diversity - promoting rights and choices.

Evidence

Specify

9. Service users receive care, treatment and support in an appropriate environment to their age and individual needs

Evidence

Specify

10. Staff enable and encourage service users to be involved in how the service is run.

Evidence

Specify

11. Service users are able to visit the service prior to using it so that they can decide whether or not they wish to use it, wherever it is practical or appropriate to do so.

Evidence

Specify

12. Service users receive care, treatment and support in single sex accommodation wherever it is available.

Evidence

Specify

13. Staff who undertake analysis of diagnostic tests and assessments are appropriately qualified/trained.

Evidence

Specify

14. Service users at the end of their life are involved in the assessment and planning, choices and decisions about their care particularly those relating to pain management.

Evidence

Specify

15. Service users at the end of their life can choose where they wish to die, they are able to have people who are important to them with them and can die with privacy, dignity and comfort.

Evidence

Specify

16. The plan of care records their wishes with regards to how their body and possessions are handled after their death and staff respect their values and beliefs.

Evidence

Specify

17. Children should be able to make informed decisions about their care and involve their parents/guardians in these decisions, where appropriate.

Evidence

Specify

18. Service users with a learning disability are supported to have a health action plan developed by their primary care trust.

Evidence

Specify

19. Service users with complex mental health needs who require support from a number of services and who are most at risk should receive the Care Programme Approach (2008)

Evidence

Specify

20. Service users are aware that they are detained in the least restrictive environment and for the minimal amount of time and, where appropriate, understand why.

Evidence

Specify

21. Services users are only put in to seclusion if it is in line with NICE guidance on Violence (2005) and the MHA.

Evidence

Specify

22. Searches are conducted in line with nationally recommended practice. The service will prevent and rapidly respond to incidents of illicit drug use and supply on or near the premises.

Evidence

Specify

23. Substance misuse service users 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.

Evidence

Specify

24. Substance misuse services have clear procedures followed in practice that are monitored and reviewed, for when service users leave the service, in a planned or unplanned way.

Evidence

Specify

Meeting Nutritional Needs

1. Staff are aware of policies and procedures relating to nutrition and hydration and where to find them.

Evidence

Specify

2. Staff receive appropriate training.

Evidence

Specify

3. Service users who may be at risk are identified and are appropriately assessed for their nutrition and hydration needs.

Evidence

Specify

4. Staff should act upon needs and risks identified in this assessment and include this in service user's care/support plans.

Evidence

Specify

5. Service users are given information about food and meal times and are offered a choice of food and drink and where they wish to eat.

Evidence

Specify

6. Service users should be provided with nutritionally balanced meal and should be happy with the quality of the food provided.

Evidence

Specify

7. Service user independence should be encouraged when eating and drinking.

Evidence

Specify

8. Service users should be assisted to eat and drink where this is required - this should be documented and included in care/support plan.

Evidence

Specify

9. Service user's individual needs relating to diet are respected to enable them adequate nutrition. (for example religious, allergies, intolerances etc.)

Evidence

Specify

10. Service users have protected meal times.

Evidence

Specify

11. Service users should be offered food outside of meal times.

Evidence

Specify

12. Fasting prior to procedures is kept to a minimum and food and drink provided as soon afterwards as feasible.

Evidence

Specify

13. Service users are actively supported to plan and prepare their own meals (where safe and able to do so)

Evidence

Specify

Cooperating with Other Providers

1. A lead is always identified who is responsible for coordinating the care, treatment and support of the service user.

Evidence

Specify

2. Service users are aware of who this lead is and how to contact them.

Evidence

Specify

3. Multi-agency plan of care should be in place and all those contributing should have received a copy.

Evidence

Specify

4. Service users should have input into the coordinated care plan and feel all of their needs are met.

Evidence

Specify

5. When care/ treatment/ support is transferred: procedures should be in place to ensure that there are no interruptions to continuity of care.

Evidence

Specify

6. Information should be shared in a timely and confidential way with all relevant service providers to enable SUs needs to be met.

Evidence

Specify

7. Staff should be aware of policies and procedures for sharing information with other providers and where to find them.

Evidence

Specify

8. Staff should provide information about and support service users to access care, treatment and support from other services relevant to their care.

Evidence

Specify

Safeguarding

1. Staff should be aware of actions to take to identify and prevent abuse. Staff are aware of types of abuse and neglect and signs/symptoms to a level expected of their role.

Evidence

Specify

2. Staff understand that safeguarding applies to anyone in contact with the service and are able to identify people more at risk.

Evidence

Specify

3. Staff should be aware of actions to take when it is suspected that abuse has occurred.

Evidence

Specify

4. Staff should act upon any concerns and record actions taken in an appropriate place.

Evidence

Specify

5. Safeguarding contact details within and outside the trust should be available for staff.

Evidence

Specify

6. Staff should be up to date with the appropriate safeguarding training.

Evidence

Specify

7. Staff should be aware of guidance, policies and procedures about safeguarding and where to find them.

Evidence

Specify

8. Service users should have access to information, advice and support to help them report abuse, and any reports should be taken seriously.

Evidence

Specify

9. Staff understand the application and impact of deprivation of liberty safeguards.

Evidence

Specify

10. The use of restraint is always appropriate, reasonable, proportionate and justifiable to that individual, respects dignity and human rights.

Evidence

Specify

11. Restraint is only used by staff that have had appropriate training.

Evidence

Specify

12. Service users with challenging behaviour have documented plans which record triggers and management plans which are agreed with the service user.

Evidence

Specify

13. Where the service is responsible for the service user's finances, receipts are kept and all transactions recorded, SU money is not used to run the service and they can access their money in a timely way.

Evidence

Specify

Cleanliness & Infection Control

1. Staff should follow the infection control procedures and know where to find the policy.

Evidence

Specify

2. Staff should have access to protective equipment.

Evidence

Specify

3. Staff should be up to date with infection control training.

Evidence

Specify

4. Staff should be aware of the correct procedures for sharps injury and exposure to body fluids and chemicals.

Evidence

Specify

5. Sharps should be stored and disposed of safely and in line with sharps procedures.

Evidence

Specify

6. The environment should be visibly clean and there should be evidence that this is monitored.

Evidence

Specify

7. Hand cleaning facilities should be available.

Evidence

Specify

8. Equipment should be cleaned in line with regulations.

Evidence

Specify

Medicines Management

1. Staff handle and store medicines safely, securely and appropriately.

Evidence

Specify

2. Service users receive medications at the times they need them, in a safe way and according to their prescription.

Evidence

Specify

3. Staff prescribe and administer medications safely.

Evidence

Specify

4. Staff are aware of the policies and procedures relating to administration and disposal of medication and the reporting of drug errors, and how to access them.

Evidence

Specify

5. Service users or their carers receive information about the medication they are prescribed.

Evidence

Specify

6. Staff receive appropriate training for the safe handling and administration of medications.

Evidence

Specify

Safety & Sustainability of Premises

1. Staff are aware of policies and procedures relating to safety and security and where to find them.

Evidence

Specify

2. The premises should be suitable for the service and allow privacy, dignity and safety to be maintained.

Evidence

Specify

3. A system should be in place for staff to summon urgent assistance.

Evidence

Specify

4. The service should be accessible to service users and staff with disabilities.

Evidence

Specify

5. Staff are up to date with training (Health and Safety, Fire etc).

Evidence

Specify

6. Staff should be aware of emergency procedures.

Evidence

Specify

7. The site should have safe and secure storage facilities for COSHH, medicines, service user belongings etc.

Evidence

Specify

8. Correct procedures should be in place and followed relating to security.

Evidence

Specify

9. Premises and grounds should be adequately maintained.

Evidence

Specify

10. There should be an up to date workplace risk assessment (including ligature assessments where applicable) and appropriate action should be taken to manage any risks.

Evidence

Specify

Safety, Availability and & Sustainability of Equipment

1. Equipment is suitable for purpose

Evidence

Specify

2. Equipment is suitable for purpose. Equipment is readily available. A medical Device inventory should be kept.

Evidence

Specify

3. Equipment is properly maintained, a service schedule should be kept.

Evidence

Specify

4. Equipment is used correctly and safely by those that have had appropriate training.

Evidence

Specify

5. Equipment promotes independence and is comfortable.

Evidence

Specify

6. Staff are aware of policies and procedures relating to equipment and how to access these.

Evidence

Specify

Requirements Relating to Workers

1. Effective recruitment and selection procedures are in place.

Evidence

Specify

2. Relevant checks are carried out on staff before employment.

Evidence

Specify

3. Staff are registered with the relevant professional body when necessary.

Evidence

Specify

4. Staff have relevant qualifications, knowledge, skills and experience to carry out their role.

Evidence

Specify

5. Concerns about fitness to practice are referred through the appropriate route.

Evidence

Specify

6. Temporary, agency, bank and voluntary staff are subject to the same level of checks and selection process.

Evidence

Specify

Staffing

1. There is sufficient numbers of staff to ensure adequate service provision

Evidence

Specify

2. There is an appropriate level of skill, knowledge and experience amongst staff to provide the service.

Evidence

Specify

3. Provisions are in place to respond to unexpected changing circumstances (sickness, vacancies, absences and emergencies)

Evidence

Specify

Supporting Workers

1. Staff should feel supported in the provision of care and treatment for service users.

Evidence

Specify

2. Staff should have up to date appropriate training.

Evidence

Specify

3. Staff should have regular supervision and appraisals.

Evidence

Specify

4. Staff are given the opportunity to gain further qualifications and skills relevant to their role.

Evidence

Specify

5. Staff are aware of procedures for raising concerns, whistle blowing, bullying and harassment and should be supported to do so.

Evidence

Specify

6. Staff are supported in their health needs to enable them to carry out their role.

Evidence

Specify

Assessing & Monitoring the Quality of Service Provision

1. Staff identify, monitor and manage risks to people who use, work in or visit the service.

Evidence

Specify

2. Processes are in place to monitor the quality of service that people receive including complaints, records, investigations, audits etc.

Evidence

Specify

3. Actions should be taken to reduce risks or make improvements based on the findings of the above.

Evidence

Specify

4. Processes are in place to improve the service by learning from adverse events, incidents, errors and near misses that happen.

Evidence

Specify

5. The service should monitor compliance to the CQC outcomes and should have evidence available to demonstrate this. Where the service is non-compliant, actions should be taken to amend this.

Evidence

Specify

6. Staff should be aware of how to report and escalate concerns, for example the Ulysses Safeguard system.

Evidence

Specify

Complaints

1. Systems should be in place for dealing with comments and complaints.

Evidence

Specify

2. Information should be readily available for service users, carers or those acting on their behalf about the comments and complaints process.

Evidence

Specify

3. Service users should feel that their comments and complaints are listened to and acted on effectively.

Evidence

Specify

4. Service users know that they will not be discriminated against for making a complaint.

Evidence

Specify

5. Staff should consider fully, respond appropriately and resolve where possible any comments and complaints.

Evidence

Specify

Records

1. Accurate records should be kept securely and confidentially for every service user in an organised way which enables them to be located and accessed quickly.

Evidence

Specify

2. Computers are not left unattended and accessible. Smart cards are not left in computers. Staff MUST not use another user's log in details.

Evidence

Specify

3. Records are accurate, up to date and are written contemporaneously.

Evidence

Specify

4. Staff are aware of policies and procedures about record keeping and confidentiality, including sharing information and where to find them.

Evidence

Specify

5. Staff should be appropriately trained (IG)

Evidence

Specify

6. Records should be kept for the correct amount of time and disposed of securely

Evidence

Specify

Specify

Evidence

Specify

Sign Off

Additional Observations

Inspection Team Lead Name & Signature
Inspection Team
Member Name & Signature

CQC Inspection Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 13

This customizable CQC inspection template enables health or social care facilities to easily determine their compliance to any of the 16 key essential standards. Simply select the outcome(s) to be inspected and indicate the evidence for compliance such as observation of staff and service users, documentation, and/or speaking to staff, service users, family members, and carers.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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CQC Inspection Template

Outcomes being inspected:
Respecting & Involving Service Users

1. Staff explain and service users (or their carers) fully understand the care, treatment and support options available to them.

Evidence

Specify

2. Service users and their carers are able to access information about their care, treatment and support options.

Evidence

Specify

3. Service users feel involved in making decisions, so far as they are able or wish to, and feel listened to.

Evidence

Specify

4. Staff ensure that service users and their representatives are able to express their views and are involved appropriately in decision making.

Evidence

Specify

5. Service users feel that staff respect their privacy, dignity and independence.

Evidence

Specify

6. Staff act in a way that respects service users' privacy, dignity and independence.

Evidence

Specify

7. Staff ensure that the service users’ diversity, values and human rights are maintained.

Evidence

Specify

8. Staff encourage service users to care for themselves and promote independence where this is possible.

Evidence

Specify

9. Care, treatment and support plans reflect service user's needs, choices and preferences.

Evidence

Specify

10. Staff enable and encourage service users to be involved in how the service is run.

Evidence

Specify

11. Staff are aware of policies and procedures around respecting and involving people and where to find them.

Evidence

Specify

12. Staff have up to date training relating to respecting and involving people.

Evidence

Specify

13. Staff encourage and enable service users to be an active part of their community in appropriate settings.

Evidence

Specify

Consent to Care & Treatment

1. Service users have been given appropriate information to make an informed choice.

Evidence

Specify

2. Staff understand capacity to consent, undertake capacity assessments (where appropriate) and know what actions to take when a service users lacks capacity.

Evidence

Specify

3. Where a service user lacks capacity, a best interest meeting is held with people who know and understand the service user.

Evidence

Specify

4. Staff understand when children are able to give consent and enable them to make informed choices where appropriate.

Evidence

Specify

5. Staff should be able to provide evidence of service users giving consent.

Evidence

Specify

6. Service users have been informed of and understand how to change or withdraw their consent.

Evidence

Specify

7. Staff respect service users' right to refuse, explain the risks and benefits of refusing and alternate options.

Evidence

Specify

8. Staff are aware of the policies and procedures for gaining consent from service users and where to find them.

Evidence

Specify

9. Staff follow any advance decisions made by service users in line with MCA where the decision is known by the provider and enable service users to utilise this option.

Evidence

Specify

Care & Welfare

1. Service users’ individual needs are established by use of thorough and appropriate assessments which also establish risks, service users' goals and expectations.

Evidence

Specify

2. Service users should have the choice to be involved in decision making about all aspects of their care and plans are agreed with them.

Evidence

Specify

3. Plans of care, treatment and support are individualised, detailed, reviewed regularly and reflect service users' needs and choices.

Evidence

Specify

4. Staff plan for and recognise when a service user's needs change and act appropriately.

Evidence

Specify

5. Staff ensure that risk is managed through effective procedures including a system in place to cascade and respond to Patient Safety Alerts, Medical Device Alerts, Drug Alerts etc.

Evidence

Specify

6. The service has arrangements in place to deal with foreseeable emergencies to ensure continuity of care is provided.

Evidence

Specify

7. Service users will know the names and job titles of the staff and how to contact them.

Evidence

Specify

8. Staff make reasonable adjustments to reflect service users’ needs, values and diversity - promoting rights and choices.

Evidence

Specify

9. Service users receive care, treatment and support in an appropriate environment to their age and individual needs

Evidence

Specify

10. Staff enable and encourage service users to be involved in how the service is run.

Evidence

Specify

11. Service users are able to visit the service prior to using it so that they can decide whether or not they wish to use it, wherever it is practical or appropriate to do so.

Evidence

Specify

12. Service users receive care, treatment and support in single sex accommodation wherever it is available.

Evidence

Specify

13. Staff who undertake analysis of diagnostic tests and assessments are appropriately qualified/trained.

Evidence

Specify

14. Service users at the end of their life are involved in the assessment and planning, choices and decisions about their care particularly those relating to pain management.

Evidence

Specify

15. Service users at the end of their life can choose where they wish to die, they are able to have people who are important to them with them and can die with privacy, dignity and comfort.

Evidence

Specify

16. The plan of care records their wishes with regards to how their body and possessions are handled after their death and staff respect their values and beliefs.

Evidence

Specify

17. Children should be able to make informed decisions about their care and involve their parents/guardians in these decisions, where appropriate.

Evidence

Specify

18. Service users with a learning disability are supported to have a health action plan developed by their primary care trust.

Evidence

Specify

19. Service users with complex mental health needs who require support from a number of services and who are most at risk should receive the Care Programme Approach (2008)

Evidence

Specify

20. Service users are aware that they are detained in the least restrictive environment and for the minimal amount of time and, where appropriate, understand why.

Evidence

Specify

21. Services users are only put in to seclusion if it is in line with NICE guidance on Violence (2005) and the MHA.

Evidence

Specify

22. Searches are conducted in line with nationally recommended practice. The service will prevent and rapidly respond to incidents of illicit drug use and supply on or near the premises.

Evidence

Specify

23. Substance misuse service users 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.

Evidence

Specify

24. Substance misuse services have clear procedures followed in practice that are monitored and reviewed, for when service users leave the service, in a planned or unplanned way.

Evidence

Specify

Meeting Nutritional Needs

1. Staff are aware of policies and procedures relating to nutrition and hydration and where to find them.

Evidence

Specify

2. Staff receive appropriate training.

Evidence

Specify

3. Service users who may be at risk are identified and are appropriately assessed for their nutrition and hydration needs.

Evidence

Specify

4. Staff should act upon needs and risks identified in this assessment and include this in service user's care/support plans.

Evidence

Specify

5. Service users are given information about food and meal times and are offered a choice of food and drink and where they wish to eat.

Evidence

Specify

6. Service users should be provided with nutritionally balanced meal and should be happy with the quality of the food provided.

Evidence

Specify

7. Service user independence should be encouraged when eating and drinking.

Evidence

Specify

8. Service users should be assisted to eat and drink where this is required - this should be documented and included in care/support plan.

Evidence

Specify

9. Service user's individual needs relating to diet are respected to enable them adequate nutrition. (for example religious, allergies, intolerances etc.)

Evidence

Specify

10. Service users have protected meal times.

Evidence

Specify

11. Service users should be offered food outside of meal times.

Evidence

Specify

12. Fasting prior to procedures is kept to a minimum and food and drink provided as soon afterwards as feasible.

Evidence

Specify

13. Service users are actively supported to plan and prepare their own meals (where safe and able to do so)

Evidence

Specify

Cooperating with Other Providers

1. A lead is always identified who is responsible for coordinating the care, treatment and support of the service user.

Evidence

Specify

2. Service users are aware of who this lead is and how to contact them.

Evidence

Specify

3. Multi-agency plan of care should be in place and all those contributing should have received a copy.

Evidence

Specify

4. Service users should have input into the coordinated care plan and feel all of their needs are met.

Evidence

Specify

5. When care/ treatment/ support is transferred: procedures should be in place to ensure that there are no interruptions to continuity of care.

Evidence

Specify

6. Information should be shared in a timely and confidential way with all relevant service providers to enable SUs needs to be met.

Evidence

Specify

7. Staff should be aware of policies and procedures for sharing information with other providers and where to find them.

Evidence

Specify

8. Staff should provide information about and support service users to access care, treatment and support from other services relevant to their care.

Evidence

Specify

Safeguarding

1. Staff should be aware of actions to take to identify and prevent abuse. Staff are aware of types of abuse and neglect and signs/symptoms to a level expected of their role.

Evidence

Specify

2. Staff understand that safeguarding applies to anyone in contact with the service and are able to identify people more at risk.

Evidence

Specify

3. Staff should be aware of actions to take when it is suspected that abuse has occurred.

Evidence

Specify

4. Staff should act upon any concerns and record actions taken in an appropriate place.

Evidence

Specify

5. Safeguarding contact details within and outside the trust should be available for staff.

Evidence

Specify

6. Staff should be up to date with the appropriate safeguarding training.

Evidence

Specify

7. Staff should be aware of guidance, policies and procedures about safeguarding and where to find them.

Evidence

Specify

8. Service users should have access to information, advice and support to help them report abuse, and any reports should be taken seriously.

Evidence

Specify

9. Staff understand the application and impact of deprivation of liberty safeguards.

Evidence

Specify

10. The use of restraint is always appropriate, reasonable, proportionate and justifiable to that individual, respects dignity and human rights.

Evidence

Specify

11. Restraint is only used by staff that have had appropriate training.

Evidence

Specify

12. Service users with challenging behaviour have documented plans which record triggers and management plans which are agreed with the service user.

Evidence

Specify

13. Where the service is responsible for the service user's finances, receipts are kept and all transactions recorded, SU money is not used to run the service and they can access their money in a timely way.

Evidence

Specify

Cleanliness & Infection Control

1. Staff should follow the infection control procedures and know where to find the policy.

Evidence

Specify

2. Staff should have access to protective equipment.

Evidence

Specify

3. Staff should be up to date with infection control training.

Evidence

Specify

4. Staff should be aware of the correct procedures for sharps injury and exposure to body fluids and chemicals.

Evidence

Specify

5. Sharps should be stored and disposed of safely and in line with sharps procedures.

Evidence

Specify

6. The environment should be visibly clean and there should be evidence that this is monitored.

Evidence

Specify

7. Hand cleaning facilities should be available.

Evidence

Specify

8. Equipment should be cleaned in line with regulations.

Evidence

Specify

Medicines Management

1. Staff handle and store medicines safely, securely and appropriately.

Evidence

Specify

2. Service users receive medications at the times they need them, in a safe way and according to their prescription.

Evidence

Specify

3. Staff prescribe and administer medications safely.

Evidence

Specify

4. Staff are aware of the policies and procedures relating to administration and disposal of medication and the reporting of drug errors, and how to access them.

Evidence

Specify

5. Service users or their carers receive information about the medication they are prescribed.

Evidence

Specify

6. Staff receive appropriate training for the safe handling and administration of medications.

Evidence

Specify

Safety & Sustainability of Premises

1. Staff are aware of policies and procedures relating to safety and security and where to find them.

Evidence

Specify

2. The premises should be suitable for the service and allow privacy, dignity and safety to be maintained.

Evidence

Specify

3. A system should be in place for staff to summon urgent assistance.

Evidence

Specify

4. The service should be accessible to service users and staff with disabilities.

Evidence

Specify

5. Staff are up to date with training (Health and Safety, Fire etc).

Evidence

Specify

6. Staff should be aware of emergency procedures.

Evidence

Specify

7. The site should have safe and secure storage facilities for COSHH, medicines, service user belongings etc.

Evidence

Specify

8. Correct procedures should be in place and followed relating to security.

Evidence

Specify

9. Premises and grounds should be adequately maintained.

Evidence

Specify

10. There should be an up to date workplace risk assessment (including ligature assessments where applicable) and appropriate action should be taken to manage any risks.

Evidence

Specify

Safety, Availability and & Sustainability of Equipment

1. Equipment is suitable for purpose

Evidence

Specify

2. Equipment is suitable for purpose. Equipment is readily available. A medical Device inventory should be kept.

Evidence

Specify

3. Equipment is properly maintained, a service schedule should be kept.

Evidence

Specify

4. Equipment is used correctly and safely by those that have had appropriate training.

Evidence

Specify

5. Equipment promotes independence and is comfortable.

Evidence

Specify

6. Staff are aware of policies and procedures relating to equipment and how to access these.

Evidence

Specify

Requirements Relating to Workers

1. Effective recruitment and selection procedures are in place.

Evidence

Specify

2. Relevant checks are carried out on staff before employment.

Evidence

Specify

3. Staff are registered with the relevant professional body when necessary.

Evidence

Specify

4. Staff have relevant qualifications, knowledge, skills and experience to carry out their role.

Evidence

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5. Concerns about fitness to practice are referred through the appropriate route.

Evidence

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6. Temporary, agency, bank and voluntary staff are subject to the same level of checks and selection process.

Evidence

Specify

Staffing

1. There is sufficient numbers of staff to ensure adequate service provision

Evidence

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2. There is an appropriate level of skill, knowledge and experience amongst staff to provide the service.

Evidence

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3. Provisions are in place to respond to unexpected changing circumstances (sickness, vacancies, absences and emergencies)

Evidence

Specify

Supporting Workers

1. Staff should feel supported in the provision of care and treatment for service users.

Evidence

Specify

2. Staff should have up to date appropriate training.

Evidence

Specify

3. Staff should have regular supervision and appraisals.

Evidence

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4. Staff are given the opportunity to gain further qualifications and skills relevant to their role.

Evidence

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5. Staff are aware of procedures for raising concerns, whistle blowing, bullying and harassment and should be supported to do so.

Evidence

Specify

6. Staff are supported in their health needs to enable them to carry out their role.

Evidence

Specify

Assessing & Monitoring the Quality of Service Provision

1. Staff identify, monitor and manage risks to people who use, work in or visit the service.

Evidence

Specify

2. Processes are in place to monitor the quality of service that people receive including complaints, records, investigations, audits etc.

Evidence

Specify

3. Actions should be taken to reduce risks or make improvements based on the findings of the above.

Evidence

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4. Processes are in place to improve the service by learning from adverse events, incidents, errors and near misses that happen.

Evidence

Specify

5. The service should monitor compliance to the CQC outcomes and should have evidence available to demonstrate this. Where the service is non-compliant, actions should be taken to amend this.

Evidence

Specify

6. Staff should be aware of how to report and escalate concerns, for example the Ulysses Safeguard system.

Evidence

Specify

Complaints

1. Systems should be in place for dealing with comments and complaints.

Evidence

Specify

2. Information should be readily available for service users, carers or those acting on their behalf about the comments and complaints process.

Evidence

Specify

3. Service users should feel that their comments and complaints are listened to and acted on effectively.

Evidence

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4. Service users know that they will not be discriminated against for making a complaint.

Evidence

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5. Staff should consider fully, respond appropriately and resolve where possible any comments and complaints.

Evidence

Specify

Records

1. Accurate records should be kept securely and confidentially for every service user in an organised way which enables them to be located and accessed quickly.

Evidence

Specify

2. Computers are not left unattended and accessible. Smart cards are not left in computers. Staff MUST not use another user's log in details.

Evidence

Specify

3. Records are accurate, up to date and are written contemporaneously.

Evidence

Specify

4. Staff are aware of policies and procedures about record keeping and confidentiality, including sharing information and where to find them.

Evidence

Specify

5. Staff should be appropriately trained (IG)

Evidence

Specify

6. Records should be kept for the correct amount of time and disposed of securely

Evidence

Specify

Specify

Evidence

Specify

Sign Off

Additional Observations

Inspection Team Lead Name & Signature
Inspection Team
Member Name & Signature