Title Page
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Site/Service
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Inspection Team Lead
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Address
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Conducted on
CQC Inspection Template
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Outcomes being inspected:
- Respecting & Involving Service Users
- Consent to Care & Treatment
- Care & Welfare
- Meeting Nutritional Needs
- Cooperating with Other Providers
- Safeguarding
- Cleanliness & Infection Control
- Medicines Management
- Safety & Suitability of Premises
- Safety, Availability & Suitability of Equipment
- Requirements Relating to Workers
- Staffing
- Supporting Workers
- Assessing & Monitoring the Quality of Service Provision
- Complaints
- Records
- Other
Respecting & Involving Service Users
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1. Staff explain and service users (or their carers) fully understand the care, treatment and support options available to them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Service users and their carers are able to access information about their care, treatment and support options.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Service users feel involved in making decisions, so far as they are able or wish to, and feel listened to.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff ensure that service users and their representatives are able to express their views and are involved appropriately in decision making.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Service users feel that staff respect their privacy, dignity and independence.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Staff act in a way that respects service users' privacy, dignity and independence.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Staff ensure that the service users’ diversity, values and human rights are maintained.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Staff encourage service users to care for themselves and promote independence where this is possible.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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9. Care, treatment and support plans reflect service user's needs, choices and preferences.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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10. Staff enable and encourage service users to be involved in how the service is run.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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11. Staff are aware of policies and procedures around respecting and involving people and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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12. Staff have up to date training relating to respecting and involving people.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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13. Staff encourage and enable service users to be an active part of their community in appropriate settings.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Consent to Care & Treatment
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1. Service users have been given appropriate information to make an informed choice.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Staff understand capacity to consent, undertake capacity assessments (where appropriate) and know what actions to take when a service users lacks capacity.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Where a service user lacks capacity, a best interest meeting is held with people who know and understand the service user.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff understand when children are able to give consent and enable them to make informed choices where appropriate.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Staff should be able to provide evidence of service users giving consent.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Service users have been informed of and understand how to change or withdraw their consent.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Staff respect service users' right to refuse, explain the risks and benefits of refusing and alternate options.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Staff are aware of the policies and procedures for gaining consent from service users and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Care & Welfare
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1. Service users’ individual needs are established by use of thorough and appropriate assessments which also establish risks, service users' goals and expectations.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Plans of care, treatment and support are individualised, detailed, reviewed regularly and reflect service users' needs and choices.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff plan for and recognise when a service user's needs change and act appropriately.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. The service has arrangements in place to deal with foreseeable emergencies to ensure continuity of care is provided.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Service users will know the names and job titles of the staff and how to contact them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Staff make reasonable adjustments to reflect service users’ needs, values and diversity - promoting rights and choices.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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9. Service users receive care, treatment and support in an appropriate environment to their age and individual needs
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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10. Staff enable and encourage service users to be involved in how the service is run.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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12. Service users receive care, treatment and support in single sex accommodation wherever it is available.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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13. Staff who undertake analysis of diagnostic tests and assessments are appropriately qualified/trained.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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17. Children should be able to make informed decisions about their care and involve their parents/guardians in these decisions, where appropriate.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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18. Service users with a learning disability are supported to have a health action plan developed by their primary care trust.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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)
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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21. Services users are only put in to seclusion if it is in line with NICE guidance on Violence (2005) and the MHA.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Meeting Nutritional Needs
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1. Staff are aware of policies and procedures relating to nutrition and hydration and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Staff receive appropriate training.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Service users who may be at risk are identified and are appropriately assessed for their nutrition and hydration needs.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff should act upon needs and risks identified in this assessment and include this in service user's care/support plans.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Service users should be provided with nutritionally balanced meal and should be happy with the quality of the food provided.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Service user independence should be encouraged when eating and drinking.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Service users should be assisted to eat and drink where this is required - this should be documented and included in care/support plan.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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9. Service user's individual needs relating to diet are respected to enable them adequate nutrition. (for example religious, allergies, intolerances etc.)
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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10. Service users have protected meal times.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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11. Service users should be offered food outside of meal times.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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12. Fasting prior to procedures is kept to a minimum and food and drink provided as soon afterwards as feasible.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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13. Service users are actively supported to plan and prepare their own meals (where safe and able to do so)
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Cooperating with Other Providers
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1. A lead is always identified who is responsible for coordinating the care, treatment and support of the service user.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Service users are aware of who this lead is and how to contact them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Multi-agency plan of care should be in place and all those contributing should have received a copy.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Service users should have input into the coordinated care plan and feel all of their needs are met.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. When care/ treatment/ support is transferred: procedures should be in place to ensure that there are no interruptions to continuity of care.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Information should be shared in a timely and confidential way with all relevant service providers to enable SUs needs to be met.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Staff should be aware of policies and procedures for sharing information with other providers and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Staff should provide information about and support service users to access care, treatment and support from other services relevant to their care.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Safeguarding
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Staff understand that safeguarding applies to anyone in contact with the service and are able to identify people more at risk.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Staff should be aware of actions to take when it is suspected that abuse has occurred.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff should act upon any concerns and record actions taken in an appropriate place.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Safeguarding contact details within and outside the trust should be available for staff.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Staff should be up to date with the appropriate safeguarding training.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Staff should be aware of guidance, policies and procedures about safeguarding and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Service users should have access to information, advice and support to help them report abuse, and any reports should be taken seriously.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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9. Staff understand the application and impact of deprivation of liberty safeguards.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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10. The use of restraint is always appropriate, reasonable, proportionate and justifiable to that individual, respects dignity and human rights.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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11. Restraint is only used by staff that have had appropriate training.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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12. Service users with challenging behaviour have documented plans which record triggers and management plans which are agreed with the service user.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Cleanliness & Infection Control
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1. Staff should follow the infection control procedures and know where to find the policy.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Staff should have access to protective equipment.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Staff should be up to date with infection control training.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. Staff should be aware of the correct procedures for sharps injury and exposure to body fluids and chemicals.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Sharps should be stored and disposed of safely and in line with sharps procedures.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. The environment should be visibly clean and there should be evidence that this is monitored.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. Hand cleaning facilities should be available.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Equipment should be cleaned in line with regulations.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Medicines Management
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1. Staff handle and store medicines safely, securely and appropriately.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. Service users receive medications at the times they need them, in a safe way and according to their prescription.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. Staff prescribe and administer medications safely.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Service users or their carers receive information about the medication they are prescribed.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Staff receive appropriate training for the safe handling and administration of medications.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
Safety & Sustainability of Premises
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1. Staff are aware of policies and procedures relating to safety and security and where to find them.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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2. The premises should be suitable for the service and allow privacy, dignity and safety to be maintained.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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3. A system should be in place for staff to summon urgent assistance.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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4. The service should be accessible to service users and staff with disabilities.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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5. Staff are up to date with training (Health and Safety, Fire etc).
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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6. Staff should be aware of emergency procedures.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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7. The site should have safe and secure storage facilities for COSHH, medicines, service user belongings etc.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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8. Correct procedures should be in place and followed relating to security.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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9. Premises and grounds should be adequately maintained.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
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Specify
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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.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Safety, Availability and & Sustainability of Equipment
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1. Equipment is suitable for purpose
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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2. Equipment is suitable for purpose. Equipment is readily available. A medical Device inventory should be kept.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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3. Equipment is properly maintained, a service schedule should be kept.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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4. Equipment is used correctly and safely by those that have had appropriate training.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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5. Equipment promotes independence and is comfortable.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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6. Staff are aware of policies and procedures relating to equipment and how to access these.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Requirements Relating to Workers
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1. Effective recruitment and selection procedures are in place.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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2. Relevant checks are carried out on staff before employment.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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3. Staff are registered with the relevant professional body when necessary.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
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4. Staff have relevant qualifications, knowledge, skills and experience to carry out their role.
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
5. Concerns about fitness to practice are referred through the appropriate route.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
6. Temporary, agency, bank and voluntary staff are subject to the same level of checks and selection process.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Staffing
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1. There is sufficient numbers of staff to ensure adequate service provision
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
2. There is an appropriate level of skill, knowledge and experience amongst staff to provide the service.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
3. Provisions are in place to respond to unexpected changing circumstances (sickness, vacancies, absences and emergencies)
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Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Supporting Workers
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1. Staff should feel supported in the provision of care and treatment for service users.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
2. Staff should have up to date appropriate training.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
3. Staff should have regular supervision and appraisals.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
4. Staff are given the opportunity to gain further qualifications and skills relevant to their role.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
5. Staff are aware of procedures for raising concerns, whistle blowing, bullying and harassment and should be supported to do so.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
6. Staff are supported in their health needs to enable them to carry out their role.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Assessing & Monitoring the Quality of Service Provision
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1. Staff identify, monitor and manage risks to people who use, work in or visit the service.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
2. Processes are in place to monitor the quality of service that people receive including complaints, records, investigations, audits etc.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
3. Actions should be taken to reduce risks or make improvements based on the findings of the above.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
4. Processes are in place to improve the service by learning from adverse events, incidents, errors and near misses that happen.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
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
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
6. Staff should be aware of how to report and escalate concerns, for example the Ulysses Safeguard system.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Complaints
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1. Systems should be in place for dealing with comments and complaints.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
2. Information should be readily available for service users, carers or those acting on their behalf about the comments and complaints process.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
3. Service users should feel that their comments and complaints are listened to and acted on effectively.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
4. Service users know that they will not be discriminated against for making a complaint.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
5. Staff should consider fully, respond appropriately and resolve where possible any comments and complaints.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
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
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
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
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
3. Records are accurate, up to date and are written contemporaneously.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
4. Staff are aware of policies and procedures about record keeping and confidentiality, including sharing information and where to find them.
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
5. Staff should be appropriately trained (IG)
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
6. Records should be kept for the correct amount of time and disposed of securely
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
-
Specify
-
Evidence
- Observing Staff & Service Users
- Speaking to Staff
- Speaking to Service Users, Family Members & Carers
- Documentation
- Others
-
Specify
Sign Off
-
Additional Observations
-
Inspection Team Lead Name & Signature
Inspection Team
-
Member Name & Signature