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CQC Audits, Outcomes & Action Planning

NIFES Consulting Group has worked with a large number of Health Centres and GP surgeries to prepare for CQC audits and demonstrate compliance with required standards, ensuring they meet the requirements of Outcome 8 (Cleanliness and Infection Control) and Outcome 10 (Safety and Suitability of Premises).

What is a CQC Audit?

The Care Quality Commission (CQC) makes sure hospitals, care homes, dental and GP surgeries and all other care services in England provide people with safe, effective, compassionate and high-quality care, and encourages these services to make improvements.

They do this by measuring the performance of providers against the essential standards of quality and safety which consists of 28 regulations (and associated outcomes) that are set out in two pieces of legislation: the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

CQC may arrange visits to inspect registered care providers at any time, and the frequency of visitation will vary rather than occurring on a predefined schedule.

What are Outcomes 8 & 10?

During their inspections the Care Quality Commission focus on 16 outcomes as they come within Part 4 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and are the ones that most directly relate to the quality and safety of care. Providers must have evidence that they meet the outcomes.

In plain terms, Outcome 8: Cleanliness and Infection Control, means healthcare practices must provide care in a clean environment, and patients should be protected from acquiring infections. Outcome 10: Safety and Suitability of Premises requires providers to demonstrate that care is provided on premises that are fit for purpose, and the environment is safe to deliver these care services.

Preparing for a CQC Audit

One of NIFES core competencies in assisting clients with CQC audits is preparing the necessary documentation and evidence of compliance in advance of the auditors visit. This documentation will typically involve collating summaries of complaints, evidencing processes for monitoring the quality of treatment provided, staff recruitment and training policies, or patient surveys.

CQC Inspectors will also interview staff as part of their audit and as such reasonable space and time must be set aside for this to occur. It is likely that interviews may involve questioning about the collated documentation, especially involving policies and processes, so staff should be up-to-date with all relevant practice protocols.

What NIFES Can Offer

NIFES CQC Audit Services

NIFES assessments are carried out by undertaking a gap analysis in order to determine their compliance with respect to meeting the requirements of the standard.

An action plan is then proposed to instigate improvements towards meeting the standards where gaps in current practices or procedures have been identified. Both the assessment and action plan are normally completed on the day and the practice manager taken through them so that they fully understand the findings and necessary actions.

It is important to understand that the CQC inspectors aren’t necessarily looking for 100% compliance. A Practice/Health Centre is classed as suitable if they have identified areas where improvements are required and have plans in place to implement them.

NIFES can not only help with analysis and documentation to demonstrate compliance assurance but can also support the implementation process if required.

Previous examples of tailored commissions by NIFES include:

The New Victoria Hospital – CQC Audit Advisors

The New Victoria Hospital is one of the UK’s leading specialist independent hospitals. As a private healthcare operator, it provides specialist care and health services including operating theatres, outpatients, imaging and x-ray, endoscopy and plastic surgery amongst others.

NIFES has been contracted on a health advisory basis to the Hospital since 2007, providing advice and recommendations, and leading on capital projects and refurbishments targeting health and safety improvements. This includes assisting in preparing for inspections and CQC audits to demonstrate the hospital operates in the safest way possible.

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