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'.
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 number||Description||Examples of prompts from the essential standards||Examples of evidence|
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
|2||Consent to care and treatment|
Manage risk through effective consent procedures
Assessments of children under 16 regarding their ability to consent to their own treatment
|4||Care 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|
|5||Meeting 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
|6||Co-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
|7||Safeguarding 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
|8||Cleanliness 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
|9||Management 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).
|10||Safety 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
|11||Safety, availability and sustainability of equipment|
Ensure equipment is adequate
|Risk assessments in relation to the use of technical equipment|
|12||Requirements relating to workers|
Manage quality by employing the right people
The practice's employment policies, including recruitment, disciplinary and grievance procedures
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
Lead effectively to support staff
A copy of the practice's staff appraisal policy.
|16||Assessing 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
Lead effectively to manage complaints
A copy of the practice's complaints policy, which is publicly available and is promoted or distributed to patients
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.
 Care Quality Commission. Essential standards. 2010. http://www.cqc.org.uk/organisations-we-regulate/registering-first-time/essential-standards (last accessed 23August 2012)