Helping you prepare for when an inspector calls…
CQC Inspection Support is a new service at Insequa and something we have introduced after listening to our clients.
As you may have heard, it’s ‘all-change’ at the CQC and new ways of monitoring and measuring the performance of care providers are being phased in.
One of the most stressful aspects of running a social care company is dealing with CQC Inspections. We know how important it is for you to get positive ratings with the CQC and that’s why we’ve developed a number of support options to help you.
Do you have a CQC Inspection on the horizon? We can help you prepare. Our team of compliance experts and ex-CQC Inspectors help you carry out detailed audits and provide support to address any areas of concern ahed of CQC Inspections.
Wherever you are in your inspection cycle, we have support to make life easier and maximise the chances of positive ratings.
We can visit your company and carry out a detailed global or targeted audit to help you understand how prepared you are for your CQC Inspection. We will provide you with a detailed report highlighting any areas where there’s room for improvement and, if required, we can support you to address these.
Support following an inspection
If things haven’t gone well with an inspection, don’t worry, we can help you. We can write up your action plan and help you to address all remediation points.
We have a wide range of workshops to explain the revisions to the inspection process, evidence gathering and the Key Lines of Enquiry, and help you keep up to date with key legislation such as the Care Act, MCA and DoLS. We can also deliver workshops on issues such as team building and conflict resolution.
4 tips to help your CQC Inspection
1. Get informed
Read up on the Key Lines of Enquiry or attend a workshop or briefing to ensure you know what the CQC will be looking at. This will help you consider some of the areas they will inspect and the questions they may ask.
2. Good house-keeping
Ensure records are up to date, your policies, care plans and risk assessments are current, complete and have clear lines of responsibility. Make sure offices are clean and tidy, all staff wear name badges and noticeboards are current.
Make sure all staff are aware the inspection is taking place. Ensure staff and stakeholders are informed of and clear about your policies and procedures. Make sure that best practice is shared across all your teams.
4. Gather evidence
Evidence is required to back up your service across the board. It is important you gather evidence that your policies are effective, that Service Users and staff are consulted and that lessons learned are shared and improvements made.
Private Transport Services
Seven areas of concern highlighted
1. Patient Centred Care
General poor record keeping, inadequate communication of patient needs to crew. Patient assessments did not take into account current legislation and nationally recognised evidence based guidance. Incomplete incident reports. No evidence of acting upon patients’ views/feedback.
No policies or procedures covering mental capacity or consent. Staff had not completed training or in Mental Capacity Act 2005 or Deprivation of Liberty Safeguards. Paperwork missing regarding travel escort arrangements of patients who lacked capacity. RM unable to demonstrate awareness of The Code of Practice Mental Health Act 1983 .
3. Safe Care & Treatment
Inconsistency of risk assessments. Unsafe arrangements surrounding administration and recording of medicines and no medicines policy. No evidence paramedic staff were competent to administer medicines. Equipment out of date, poorly maintained and unsecured. No awareness of Health and Social Care Act 2008 (prevention and control of infections).
4. Good Governance
No formal governance framework or risk register to identify risks to service provision. No managerial or provider oversight of risk, performance, outcomes or safety quality assurance. RM was not up to date with relevant national guidance and there was no system to ensure policies available contained up to date, relevant information. No evidence RM recorded views of external stakeholders.
Safeguarding policy out of date. Safeguarding systems and procedures were out of date with legislation. Safeguarding concerns reported incorrectly.
6. Fit & Proper Persons Employed
Lack of Safe Recruitment procedure. Unsatisfactory identity and background checks on staff. No checks of healthcare professionals’ registration details. Lack of understanding of duty of candour and no policies or procedures in place to support a culture of openness and transparency.
No annual appraisals, supervision, competency assessments or induction checklists. No evidence to demonstrate ongoing competence checks of crew
Insequa completed a ‘mock’ inspection, taking the service provider through all the areas of weakness highlighted by the CQC. Following this, an Action Plan was drawn up addressing all key points and shortcomings. Actions taken and support provided by the Insequa CQC Inspection Support Team included detailed advisory input and provision of the following bespoke documents:
- Management spreadsheet
- Stakeholder questionnaire
- Complaints form
- Mental Capacity Policy
- DOLs Policy
- Supervision Policy
- Medication Administration Policy
- Safeguarding Adults Policy
- Infection Control Policy
- Hand Hygiene audit tool
- Risk Assessment templates – COSHH, Restraint, General
- Safeguarding flowchart
- Service Audit management dashboard
- Clinical Governance Policy
- Training Matrix
- Safer Recruitment and Selection Policy
- Duty of Candour Policy
The CQC Inspector paid a second visit to the provider. Following appraisal of the widespread internal changes made in response to their original concerns, and in accordance with the Insequa Action Plan, the suspension was lifted with immediate effect. This swift and satisfactory conclusion to all parties was achieved within a time-frame of eight weeks from initial suspension, minimising interruption of service to clients and provider.