Template Information
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.
Category: general
Template Questions
- Outcomes being inspected:
- 1. Staff explain and service users (or their carers) fully understand the care, treatment and support
- Evidence
- 2. Service users and their carers are able to access information about their care, treatment and supp
- 3. Service users feel involved in making decisions, so far as they are able or wish to, and feel list
- 4. Staff ensure that service users and their representatives are able to express their views and are
- 5. Service users feel that staff respect their privacy, dignity and independence.
- 6. Staff act in a way that respects service users' privacy, dignity and independence.
- 7. Staff ensure that the service users’ diversity, values and human rights are maintained.
- 8. Staff encourage service users to care for themselves and promote independence where this is possib
- 9. Care, treatment and support plans reflect service user's needs, choices and preferences.
- 10. Staff enable and encourage service users to be involved in how the service is run.
- 11. Staff are aware of policies and procedures around respecting and involving people and where to fi
- 12. Staff have up to date training relating to respecting and involving people.
- 13. Staff encourage and enable service users to be an active part of their community in appropriate s
- 1. Service users have been given appropriate information to make an informed choice.
- 2. Staff understand capacity to consent, undertake capacity assessments (where appropriate) and know
- 3. Where a service user lacks capacity, a best interest meeting is held with people who know and unde
- 4. Staff understand when children are able to give consent and enable them to make informed choices w
- 5. Staff should be able to provide evidence of service users giving consent.
- 6. Service users have been informed of and understand how to change or withdraw their consent.
- 7. Staff respect service users' right to refuse, explain the risks and benefits of refusing and alter
- 8. Staff are aware of the policies and procedures for gaining consent from service users and where to
- 9. Staff follow any advance decisions made by service users in line with MCA where the decision is kn
- 1. Service users’ individual needs are established by use of thorough and appropriate assessments whi
- 2. Service users should have the choice to be involved in decision making about all aspects of their
- 3. Plans of care, treatment and support are individualised, detailed, reviewed regularly and reflect
- 4. Staff plan for and recognise when a service user's needs change and act appropriately.
- 5. Staff ensure that risk is managed through effective procedures including a system in place to casc
- 6. The service has arrangements in place to deal with foreseeable emergencies to ensure continuity of
- 7. Service users will know the names and job titles of the staff and how to contact them.
- 8. Staff make reasonable adjustments to reflect service users’ needs, values and diversity - promotin
- 9. Service users receive care, treatment and support in an appropriate environment to their age and i
- 11. Service users are able to visit the service prior to using it so that they can decide whether or
- 12. Service users receive care, treatment and support in single sex accommodation wherever it is avai
- 13. Staff who undertake analysis of diagnostic tests and assessments are appropriately qualified/trai
- 14. Service users at the end of their life are involved in the assessment and planning, choices and d
- 15. Service users at the end of their life can choose where they wish to die, they are able to have p
- 16. The plan of care records their wishes with regards to how their body and possessions are handled
- 17. Children should be able to make informed decisions about their care and involve their parents/gua
- 18. Service users with a learning disability are supported to have a health action plan developed by
- 19. Service users with complex mental health needs who require support from a number of services and
- 20. Service users are aware that they are detained in the least restrictive environment and for the m
- 21. Services users are only put in to seclusion if it is in line with NICE guidance on Violence (2005
- 22. Searches are conducted in line with nationally recommended practice. The service will prevent and
- 23. Substance misuse service users have their care, treatment and support options explained before th
- 24. Substance misuse services have clear procedures followed in practice that are monitored and revie
- 1. Staff are aware of policies and procedures relating to nutrition and hydration and where to find t
- 2. Staff receive appropriate training.
- 3. Service users who may be at risk are identified and are appropriately assessed for their nutrition
- 4. Staff should act upon needs and risks identified in this assessment and include this in service us
- 5. Service users are given information about food and meal times and are offered a choice of food and
- 6. Service users should be provided with nutritionally balanced meal and should be happy with the qua
- 7. Service user independence should be encouraged when eating and drinking.
- 8. Service users should be assisted to eat and drink where this is required - this should be document
- 9. Service user's individual needs relating to diet are respected to enable them adequate nutrition.
- 10. Service users have protected meal times.
- 11. Service users should be offered food outside of meal times.
- 12. Fasting prior to procedures is kept to a minimum and food and drink provided as soon afterwards a
- 13. Service users are actively supported to plan and prepare their own meals (where safe and able to
- 1. A lead is always identified who is responsible for coordinating the care, treatment and support of
- 2. Service users are aware of who this lead is and how to contact them.
- 3. Multi-agency plan of care should be in place and all those contributing should have received a cop
- 4. Service users should have input into the coordinated care plan and feel all of their needs are met
- 5. When care/ treatment/ support is transferred: procedures should be in place to ensure that there a
- 6. Information should be shared in a timely and confidential way with all relevant service providers
- 7. Staff should be aware of policies and procedures for sharing information with other providers and
- 8. Staff should provide information about and support service users to access care, treatment and sup
- 1. Staff should be aware of actions to take to identify and prevent abuse. Staff are aware of types o
- 2. Staff understand that safeguarding applies to anyone in contact with the service and are able to i
- 3. Staff should be aware of actions to take when it is suspected that abuse has occurred.
- 4. Staff should act upon any concerns and record actions taken in an appropriate place.
- 5. Safeguarding contact details within and outside the trust should be available for staff.
- 6. Staff should be up to date with the appropriate safeguarding training.
- 7. Staff should be aware of guidance, policies and procedures about safeguarding and where to find th
- 8. Service users should have access to information, advice and support to help them report abuse, and
- 9. Staff understand the application and impact of deprivation of liberty safeguards.
- 10. The use of restraint is always appropriate, reasonable, proportionate and justifiable to that ind
- 11. Restraint is only used by staff that have had appropriate training.
- 12. Service users with challenging behaviour have documented plans which record triggers and manageme
- 13. Where the service is responsible for the service user's finances, receipts are kept and all trans
- 1. Staff should follow the infection control procedures and know where to find the policy.
- 2. Staff should have access to protective equipment.
- 3. Staff should be up to date with infection control training.
- 4. Staff should be aware of the correct procedures for sharps injury and exposure to body fluids and
- 5. Sharps should be stored and disposed of safely and in line with sharps procedures.
- 6. The environment should be visibly clean and there should be evidence that this is monitored.
- 7. Hand cleaning facilities should be available.
- 8. Equipment should be cleaned in line with regulations.
- 1. Staff handle and store medicines safely, securely and appropriately.
- 2. Service users receive medications at the times they need them, in a safe way and according to thei
- 3. Staff prescribe and administer medications safely.
- 4. Staff are aware of the policies and procedures relating to administration and disposal of medicati
- 5. Service users or their carers receive information about the medication they are prescribed.
- 6. Staff receive appropriate training for the safe handling and administration of medications.
- 1. Staff are aware of policies and procedures relating to safety and security and where to find them.
- 2. The premises should be suitable for the service and allow privacy, dignity and safety to be mainta
- 3. A system should be in place for staff to summon urgent assistance.
- 4. The service should be accessible to service users and staff with disabilities.
- 5. Staff are up to date with training (Health and Safety, Fire etc).
- 6. Staff should be aware of emergency procedures.
- 7. The site should have safe and secure storage facilities for COSHH, medicines, service user belongi
- 8. Correct procedures should be in place and followed relating to security.
- 9. Premises and grounds should be adequately maintained.
- 10. There should be an up to date workplace risk assessment (including ligature assessments where app
- 1. Equipment is suitable for purpose
- 2. Equipment is suitable for purpose. Equipment is readily available. A medical Device inventory shou
- 3. Equipment is properly maintained, a service schedule should be kept.
- 4. Equipment is used correctly and safely by those that have had appropriate training.
- 5. Equipment promotes independence and is comfortable.
- 6. Staff are aware of policies and procedures relating to equipment and how to access these.
- 1. Effective recruitment and selection procedures are in place.
- 2. Relevant checks are carried out on staff before employment.
- 3. Staff are registered with the relevant professional body when necessary.
- 4. Staff have relevant qualifications, knowledge, skills and experience to carry out their role.
- 5. Concerns about fitness to practice are referred through the appropriate route.
- 6. Temporary, agency, bank and voluntary staff are subject to the same level of checks and selection
- 1. There is sufficient numbers of staff to ensure adequate service provision
- 2. There is an appropriate level of skill, knowledge and experience amongst staff to provide the serv
- 3. Provisions are in place to respond to unexpected changing circumstances (sickness, vacancies, abse
- 1. Staff should feel supported in the provision of care and treatment for service users.
- 2. Staff should have up to date appropriate training.
- 3. Staff should have regular supervision and appraisals.
- 4. Staff are given the opportunity to gain further qualifications and skills relevant to their role.
- 5. Staff are aware of procedures for raising concerns, whistle blowing, bullying and harassment and s
- 6. Staff are supported in their health needs to enable them to carry out their role.
- 1. Staff identify, monitor and manage risks to people who use, work in or visit the service.
- 2. Processes are in place to monitor the quality of service that people receive including complaints,
- 3. Actions should be taken to reduce risks or make improvements based on the findings of the above.
- 4. Processes are in place to improve the service by learning from adverse events, incidents, errors a
- 5. The service should monitor compliance to the CQC outcomes and should have evidence available to de
- 6. Staff should be aware of how to report and escalate concerns, for example the Ulysses Safeguard sy
- 1. Systems should be in place for dealing with comments and complaints.
- 2. Information should be readily available for service users, carers or those acting on their behalf
- 3. Service users should feel that their comments and complaints are listened to and acted on effectiv
- 4. Service users know that they will not be discriminated against for making a complaint.
- 5. Staff should consider fully, respond appropriately and resolve where possible any comments and com
- 1. Accurate records should be kept securely and confidentially for every service user in an organised
- 2. Computers are not left unattended and accessible. Smart cards are not left in computers. Staff MUS
- 3. Records are accurate, up to date and are written contemporaneously.
- 4. Staff are aware of policies and procedures about record keeping and confidentiality, including sha
- 5. Staff should be appropriately trained (IG)
- 6. Records should be kept for the correct amount of time and disposed of securely
- Additional Observations
- Inspection Team Lead Name & Signature
- Member Name & Signature