3/21/2024 4:46:53 PM
GP CQC Health Check | Providing Evidence for Inspections
CQC Health Check system update - now live on the GP eLearning and Management platform.
Time flies when you're working on CQC preparation! The past two weeks have flown by, and we're pleased to announce that the fifth CQC Health Check update is live for CQC Health Check users.
What's New in CQC Health Check - Phase 5?
Document Examples
Examples of CQC evidence documents are now available for various CQC assessment subcategories, providing additional support and guidance throughout the ongoing CQC evidence preparation process.
What information does the Care Quality Commission (CQC) collect and request?
Pre Inspection Monitoring
The CQC ongoingly monitor health and social care providers, including GP practices, to prioritise their activity and notify the public and providers when there is no evidence that lower-risk services require re-assessing.
What information does the CQC ongoingly monitor for GP practices?
The CQC monitors a range of different data sources for GP practices using their ‘CQC Insight’ approach. CQC Insight collects data from:
- Patient feedback submitted directly to the CQC
- The NHS England GP Patient Survey (GPPS), run by IPSOS MORI
- The NHS Digital Quality and Outcomes Framework (QOF)
- NHS Business Services Authority (NHSBSA) ePACT2 prescription data
- UK Health Security Agency (UKHSA) cervical screening programme statistics, data on cancer services, and annual data on coverage achieved by the childhood immunisation programme.
The relative performance data indicators collected during the monitoring process are then used alongside the CQC Insight evidence tables to help decide the type of CQC inspection and what the CQC will focus on.
Rating Tiered Information Collection
Good and Outstanding Rated GP Practices
Any practices rated good or outstanding will need to complete an annual formal regulatory review. During this review, the CQC inspector will flag any potential by looking at CQC Insight data, key stakeholder data (e.g. Healthwatch and ICSs), and information collected from the practice during a structured telephone call and practice information collection request. The practice information collection will be requested with four weeks’ notice. Examples of the questions likely to be asked can be found on this page on the CQC’s website.
Requires Improvement and Inadequate Practices
Any practices rated as inadequate or requiring improvement will not receive an annual review and data collection call and instead will need to complete another inspection six months after the inadequate rating, or 12 months after the required improvement rating.
Different Types of CQC Inspections
The CQC undertakes different types of GP practice inspections in relation to ongoing monitoring.
Focused Inspections
Focused inspections are used to update overall CQC ratings. During focused inspections, the CQC inspector will not necessarily inspect each of the 5 key questions (is the provider safe, effective, caring, responsive to people’s needs and well-led?). Instead, the inspector will follow up on potential changes identified by the monitored activity that could affect the quality of care provided. Focused inspections prioritise individual key questions to review individual elements of care.
As standard, the CQC usually inspect whether the provider is safe, effective, responsive to people’s needs and well-led. If the CQC has any information that reflects the quality of care could have decreased since the last inspection, they may also inspect the caring key question. The inspection focus can change if further risks are identified during the inspection process.
The responsive key question is sometimes inspected remotely to update the individual responsive key question rating. These inspections are done via email or phone conversations. The CQC will usually provide one week’s notice for these inspections.
Some areas have had the CQC’s new single assessment framework introduced. Providers in these areas will be inspected in consideration with regard to the accessibility of services through assessment of the equity in access quality statement.
Comprehensive Inspections
New services that haven’t been inspected, services with concern flagged during a focused inspection and services with inadequate and required improvement ratings will require a comprehensive CQC inspection.
During a comprehensive inspection, all five questions (safe, effective, caring, responsive and well-led) are inspected.
Follow Up Inspections
If an inspection results in enforcement action or a member of the public, a staff member, or another individual raises an area of concern with the CQC, the provider may be required to complete a follow-up inspection.
Follow-up inspections only focus on the individual area relating to the area of concern. These inspections don’t require a notification period and can be without warning. The inspector may also assess the other key question areas if additional concern is identified during the inspection.
Evidence Collection for a CQC Inspection
Before a focused or comprehensive CQC inspection, the GP practice will receive a letter of notification from the CQC. A phone call will be made by the inspector and a letter will be sent out to advise the inspection date at least two weeks prior to the inspection date.
Prior to the inspection, the CQC will request certain information from the GP practice in relation to the areas that are being inspected. This request will often be provided in writing, alongside details on where the information should be sent and how to follow up if you have any questions.
CQC Inspection Assessment Frameworks
The CQC has referred to the key lines of enquiry (KLOEs) during the GP practice inspection process since 2017, however, in 2022 a single assessment framework approach was announced. Throughout 2024, the CQC is gradually introducing the new single assessment framework on a rolling locality basis. The rollout process began in November 2023, starting in the South region of England.
Key Lines of Enquiry (KLOEs)
New CQC Single Assessment Framework
The introduction of the new framework has confirmed that the five key questions and quality ratings will remain the same, however, the key lines of enquiry (KLOEs) will be replaced with new ‘we’ quality statements. The CQC’s new ‘we’ quality statements have been developed from a provider’s perspective to help healthcare providers understand what the CQC expects from them.
Evidence collected under the new assessment framework will be categorised into:
- people’s experiences
- feedback from staff and leaders
- observations of care
- feedback from partners
- processes
- outcomes of care.
The CQC’s new framework will provide a clear outline of what evidence they will collect and review for each type of service, alongside the different evidence required for services operating for different lengths of time (e.g. new services vs existing services).
Primary Health Services (Including NHS GP practices) – Evidence Categories
According to the CQC, during a CQC inspection, the following evidence categories will usually be used for NHS GP practices.
In the latest CQC Health Check system update, practice managers and CQC Health Check administrators can access a range of different document examples, templates and Standard Operating Procedures (SOPs). These documents have been designed to guide and support GP practices whilst developing processes and procedures to improve patient care in line with the CQC’s five key questions.
Safe category:
- Learning culture
- Safe systems, pathways and transitions
- Safeguarding
- Involving people to manage risks
- Safe environments
- Safe and effective staffing
- Infection prevention and control
- Medicines optimisation
Effective category:
- Assessing needs
- Delivering evidence-based care and treatment
- How staff, teams and services work together
- Supporting people to live healthier lives
- Monitoring and improving outcomes
- Consent to care and treatment
Care category:
- Kindness, compassion and dignity
- Treating people as individuals
- Independence, choice and control
- Responding to people’s immediate needs
- Workforce wellbeing and enablement
Responsive category:
- Person-centred care
- Care provision, integration and continuity
- Providing information
- Listening to and involving people
- Equity in access
- Equity in experience and outcomes
- Planning for the future
Well-led category:
- Shared direction and culture
- Capable, compassionate and inclusive leaders
- Freedom to speak up
- Workforce equality, diversity and inclusion
- Governance management and sustainability
- Partnership and communities
- Learning, improvement and innovation
- Environmental sustainability – sustainable development
Organising Inspection Data with Blue Stream Academy
Blue Stream Academy’s CQC Health Check system provides a straightforward data organisation system to store and organise evidence of practice compliance and quality care. Split into five categories covering Clinical Governance, Health & Safety, Medicines Safety, People and Practice Safety, the CQC Health Check system provides a clear framework to monitor evidence gaps and overall practice progression.
The first time you use the system, you’ll be asked to set up your rooms and assets and configure your task and schedule settings. Once complete, you can begin uploading your organisation’s processes, risk assessments, completion certificates and much more.
The CQC Health Check system shows a RAG (red, amber and green) completion rating for:
- each site within the organisation
- each of the five categories within the site
- and each of the compliance subcategories (e.g. Clinical Governance > Infection Control | Emergency Protocols and Training | Patient Group Directives etc.)
The latest update includes a range of examples of documents and procedures to support your practice whilst continuing to improve processes and improving the quality of patient care.
A complete list of new document templates and examples can be found below:
Example Documents:
- Anaphylaxis Standard Operating Procedure
- Clinical Meeting Agenda
- Clinical Meeting Minutes
- Control of Substances Hazardous to Health (COSHH) Policy
- Control of Substances Hazardous to Health (COSHH) Risk Assessment
- Coping with a Death Leaflet
- Defibrillator Standard Operating Procedure
- Emergency Drugs Bag Standard Operating Procedure
- Emergency Incident Procedure
- Gold Standards Framework (GSF) Meeting Agenda
- Gold Standards Framework (GSF) Meeting Minutes
- Handling Complaints Standard Operating Procedure
- Locum Booking Form
- New Starter Checklist Clinical GP Staff
- New Starter Checklist for Administration GP Staff
- NHS Data Security and Protection Toolkit (DSPT) Guidance
- Oxygen Bag Standard Operating Procedure
- Patient Complaints Acknowledgement Letter
- Patient Complaints Investigation Outcome Letter
- Patient Group Directive (PGD) Standard Operating Procedure
- Patient Information - Comments Concerns and Complaints
- Practice Meeting Agenda
- Practice Meeting Minutes
- Refusal Childhood Immunisation Form
- Staff Induction Checklist
Remove Documents
Alongside our new document examples, subcategory document requirements are now optional and individual uploads can be disabled if not required for your organisation, making the CQC Health Check system completely customisable for your organisation.