Title Page

  • Site/Service

  • Inspection Team Lead

  • Address
  • Conducted on

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.