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What evidence do I need to provide to meet the CQC’s essential standards?

Jonny Landau explains what evidence you'll need to meet CQC's essential standards

The Care Quality Commission's registration of GPs is under way, and whether doctors agree with the process or not, GPs who wish to continue practicing need to comply. While it remains to be seen whether the concerns of some doctors regarding the CQC's impending regulation are well founded, the consequences of practicing without being registered are serious and could lead to prosecution.

 

GP practices seeking to register with the CQC should be aware of its requirements for compliance and familiarise themselves with the CQC's regulatory framework, which is based on the provisions of the Health and Social Care Act Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

GPs should pay greatest attention to the regulations, which are mandatory legal requirements for compliance. The CQC has published guidance about compliance, Essential Standards of Quality and Safety, which available on its website. This guidance assists providers in complying with the regulations by breaking down the requirements of each to ‘outcomes' and ‘prompts'.[1]

GPs should bear in mind that while the essential standards do not carry the same legal weight as the regulations, regulation 26 stipulates providers must have regard to the essential standards if they are to comply with the regulations.

In compiling evidence under each regulation or outcome, GPs may wish to consider the below table, which offers a sample of prompts taken from the essential standards – the standards themselves contain significantly more detail in relation to each prompt.

Each sample prompt is accompanied by examples of documentation that may help to illustrate compliance with it. We must stress that while the table is not exhaustive, it is intended to help managers appreciate that any declaration about compliance must be capable of being verified by evidence. Managers should start to think not only in terms of whether their practices comply, but also how they can illustrate compliance when the inspector calls.

Please note the examples and prompts given are not exhaustive lists. We suggest you read ‘Ten steps to gathering evidence for CQC registration', the second article in this series, after reading the table.

 

Outcome numberDescriptionExamples of prompts from the essential standards Examples of evidence
1

Respecting and involving people who use services

 

Ensure personalised care, treatment and support through patient involvement

 

Auditing of patient notes to ensure patients are informed of information relevant to their treatment

 

2Consent to care and treatment

Manage risk through effective consent procedures

 

Assessments of children under 16 regarding their ability to consent to their own treatment

 

4Care and welfare of people who use the service

Ensure effective, safe and appropriate, personalised care, treatment and support through co-ordinated assessment, planning and delivery

 

Clear referral protocols for patients who have suspected illnesses or diseases, in line with published guidelines
5Meeting nutritional needs

Prompts relate to all registered providers where they prepare, or support people who use services to prepare, food and drink

 

If this standard does not apply to you, you should declare that you are compliant in your registration application

 

6Co-operating with other providers

Ensure personalised care through adequate co-ordination of services

 

Documented protocols for sharing patient information with other services generally and in an emergency

 

7Safeguarding people who use services from abuse

Lead effectively to reduce the potential of abuse

 

A copy of the practice's policy outlining steps to be taken and agencies to be informed of suspected abuse

 

8Cleanliness and infection control

Providers of services comply with the requirement of regulation 12 with regard to the Department of Health's Code of practice for health and adult social care on the prevention and control of infections and related guidance, available on the DH's website

 

The practice's prevention and control of infection policy and details of how it has been implemented

 

9Management of medicines

Providing personalised care through the effective use of medicines

 

Documented processes in place to ensure practitioners are prescribing in line with published guidance (including that from the Royal Pharmaceutical Society, the BNF and NICE).

 

10Safety and suitability of premises

Ensure the premises are adequate

 

Health and safety policies that have been signed by staff to confirm they have read and are aware of the policies, and copies of up-to-date fire risk assessments

 

11Safety, availability and sustainability of equipment

Ensure equipment is adequate

 

Risk assessments in relation to the use of technical equipment
12Requirements relating to workers

Manage quality by employing the right people

 

The practice's employment policies, including recruitment, disciplinary and grievance procedures

 

13Staffing

Lead effectively to ensure there are sufficient staff

 

The practice's procedure for sourcing locum GPs and support staff if and when they are required

 

14Supporting workers

Lead effectively to support staff

 

A copy of the practice's staff appraisal policy.

 

16Assessing and monitoring the quality of service provision

Lead effectively to manage risk

 

Copies of up-to-date patient satisfaction surveys, including an analysis of results and any action that has been taken in response to any negative feedback

 

17Complaints

Lead effectively to manage complaints

 

A copy of the practice's complaints policy, which is publicly available and is promoted or distributed to patients

 

21Records

Manage risk through effective procedures about records

 

Protocols ensuring records are stored, shared and destroyed properly, in line with the Freedom of Information Act 2000, Data Protection Act 1998 and the DH's Code of Practice for Records Management

 

 

Click here to read ‘Ten steps to gathering evidence for CQC registration', the second article in this series.

Jonny Landau is a partner at Ridouts LLP

Reference

[1] Care Quality Commission. Essential standards. 2010. http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards (last accessed 23August 2012)

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