Cqc inspection template checklist

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