Before you make a start preparing for your CQC inspection, make sure you have read the GP provider handbook and its appendices to help you through
See the list of CQC provider handbooks
You should also be aware of the five key questions that the CQC asks of all care providers
Learn more about the 5 key questions
Prepare for a Care Quality Commission (CQC) inspection
This is a practical guide for GP practices preparing for their inspection by the CQC.
Step 1 - Get ready for pre-inspection
Step 2 - On the day of inspection
Step 3 - Outcomes from the inspection
Download guidance and appendices
Step 1 - Get ready for pre-inspection
Before a provider can begin to provide services, they must apply for CQC registration and meet a number of requirements.
Once registered the GP practice details must be kept up to date and include any recent changes to the partnership, registered manager, regulated activities and statement of purpose.
Find out how to register with the CQC
Prior to the inspection GP practices will receive a letter of notification. An inspector will phone the practice to announce the inspection and a letter will also be sent to confirm the date. You should be given two weeks' notice of your inspection. Practices should display the comment cards and posters that are supplied with the GP practice inspection letter notification.
The CQC will also write to the practice to ask for some information. Practices have five working days to respond to this request. In the letter it should be clear what information needs to be sent to the CQC, where to send the information, and who to contact if you have any queries.
You will most likely be asked to send the following:
- An action plan that addresses the findings from any patient survey carried out
- A summary of any complaints received in the last 12 months, any action taken and how learning was implemented
- A summary of any serious adverse events that occurred in the previous 12 months, any action taken and how learning was implemented
- Evidence to show that the quality of treatment and services has been monitored. This includes evidence of two completed clinical audit cycles carried out in the last 12 months and evidence of any other audits, with evidence of actions or outcomes taken as a result
- Recruitment and training policies and procedures (for example, how staff are recruited and vetted before commencing work, arrangements for European Economic Area (EEA) and foreign doctors and what induction they receive)
- Number of staff by role (whole time equivalent)
- A copy of the current Statement of Purpose
Your LMC can help
When your practice receives a notification letter from the CQC, practices should speak to their Local Medical Committee office if they wish an LMC representative to attend as an 'observer'. Please note, this may not always be possible due to capacity issues.
Find your LMC
Key documentation to prepare
It is likely that the following items and information will be requested on the day of the inspection. Practices should collate these beforehand as much as possible and have them ready for inspection. This is a non-exhaustive list.
These items and infromation could include:
- Significant events
- Audits to include infection control and cleanliness and disability access
- Risk assessments (with evidence reasonable action has been taken - an active document)
- Health and Safety documentation
- Business continuity plan
- HR staff files, policies and procedures to include a Locum Policy and induction programmes
- Service operational policies to include safeguarding, complaints, chaperoning, medicine management and repeat prescribing
Table setting out the CQC's safeguarding requirements (courtesy of Londonwide LMCs)
- Equipment calibration reports
- PAT testing reports
- Palliative care registers
- Workforce training matrix and schedules
The practice walkthrough
The registered manager and the practice manager or deputy should take responsibility to walk through all areas of the GP practice to check the following. This is a non-exhaustive list.
Use the practice walkthrough checklist (Appendix A)
- De clutter and tidy all areas of the GP practice
- Remove all (clinical and non-clinical) out of date stock, material and medical related resources e.g. British National Formulary (BNFs)
- Ensure that the GP practice has good stock control systems
- Ensure that the medical supplies cupboards are locked
- Be aware that the CQC inspector may ask about the contents of the doctor's bag, the emergency drugs and contents, fridge temperatures and associated logs
- Identify where controlled drugs are kept and carry out an appropriate risk assessment to identify any potential hazards and risks, which may remain in a locked fridge
- Make sure 'important' keys are kept in a secure place
- Ensure there is an accident or incident book available for the workforce to complete and is kept in recognised area
- Ensure all fire equipment is in the right place and with appropriate dates
- Have a safe aid box in a recognised area and an appointed first aider trained lead
- Ensure you have an appropriate 'place' for patients and people to comment (positive and negative) and about the GP practice's care and service
- Check that you make it easy for all the population groups to complain. Are you displaying notices?
- Ensure you have an identified isolation room and appropriate policies for its use
- Ensure you have a confidential or private area for patients to use, to include a breast feeding area where possible.
- Ensure you have information about the Patient Participation Group displayed
Prepare your staff in advance
Take the appropriate steps in getting the your practice workforce organised and ready for the CQC inspection.
Create a shared resource for all the CQC compliance documents to include policies, procedures, protocols, templates, etc. so that the entire GP practice workforce can access these easily.
Plan now for absences of the practice manager and registered manager when a CQC inspection is to take place.
Promoting your practice
Start thinking now about how your practice can best present and promote its services and care.
Consider the following suggestions:
- Ensure the 'right' people (for example, partners) are working at the GP practice on the day of the inspection
- Prepare a welcome pack for the CQC inspectors and include the workforce rota for the day with lead names on particular areas e.g. infection control and cleanliness and safeguarding etc.
- Display the CQC registration within a public space in the GP practice and on the GP practice website
- All premises and equipment used must be clean, secure, suitable and used properly
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Step 2 - On the day of inspection
At the start of the visit, the CQC inspector will meet with your registered manager. If the registered manager is not available the inspector can meet with another senior member of staff, for example a partner. The inspector should briefly introduce and explain who the inspection team are, the scope and purpose of the inspection, how any concerns they have identified will be escalated, and how their findings will be communicated.
30 minute presentation
After the introductory session, the CQC will ask the GP practice to present their own view of their performance, particularly in relation to the five key questions and six population groups and to include any examples of outstanding care and practice. There is no specified format or media for this briefing; you can choose whichever format suits the practice. You may wish to include a patient view. This should take no longer than 30 minutes.
Tips on how to prepare for your presentation (Appendix B)
GP practices are now able to submit some notifications on changes, events and incidents, by using a CQC online service account.
Read more information in the CQC notifications for GP providers
Practice leaflet and website
Ensure that the practice leaflet is up to date in line with the GMS/PMS regulations and is available in the practice with equivalent information on the practice website.
CQC inspectors may use websites as a resource to influence its decision making.
- Consider the pros and cons of building a GP practice website
- If you have a practice website, ensure it is regularly maintained and up to date
- Create a new webpage containing information about CQC to include the following:
- Registration and inspection
- Lead contact and deputy for each CQC outcome
- Lead contact and deputy for each of the five CQC chapters
- Keep your practice information on the NHS Choices website up to date
Involve the Patient Participation Group (PPG) in discussions around care, experience, quality and safety.
- GP practices must demonstrate that all people and population groups received the same outcomes, so practices should ask themselves how they will demonstrate this when asked.
- Install a hearing loop in the practice with associated signage.
- Wherever possible, the inspectors will observe interaction of staff and patients (for example, in the reception area). It would be worthwhile the practice manager, a member of the PPG or a colleague from a neighbouring practice sitting in the reception area to act as an observer for a period of time and report back on whether any changes should be made (e.g. improving confidentiality at the reception desk, making sure posters and displayed information is relevant and clear).
Read more information in the CQC guide working together with the PPG
CQC inspectors may ask the GP practice about how it shares the patterns and trends of complaints and the evidence of change to improve the service offered.
- The practice may wish to consult with patients and the Patient Participation Group (PPG) on at least an annual basis and provide evidence of change.
- Be aware of the human rights approach taken by CQC.
Learn more about the CQC's approach to human rights
Access to appointments
Be aware that the CQC inspector will ask about appointment availability for patients to access:
- female GPs and nurses
- male GPs and nurses
- pre-bookable appointments in advance
- urgent apoointments
Ensure that you are aware of the systems in place, but also be open and honest about the challenges in achieving good access.
Co-operation with other providers of services and care
The CQC will expect the practice to demonstrate how it co-operates with other providers. The inspectors may want to know more about:
- any interpreter service used, including access to sign language if required
- the hand over to the out of hours service and in particular for patients near the end of life
Demonstrating - managing risk and quality
When monitoring compliance the CQC inspectors may request evidence from the GP practice to demonstrate how they are meeting requirements.
If asked by a CQC inspector to demonstrate compliance, you might use some of the following examples. This is a non-exhaustive list.
- GP practice systems and processes
- The systems in place for risk management and clinical governance and any evidence of any change in practice as a result.
- Conducting clinical audits
- Conducting regular significant event reviews and analysis
- Conducting risk assessments as and when appropriate and undertake all reasonable actions (see outcomes 8, 10, 11, 14 and 21)
- Incident reporting related to controlled drugs and other medicines and any evidence of learning or action taken
- Reviewing and updating the process for the workforce to read relevant policies, protocols or procedures
- Relevant local or national guidance having been taken into account
- Reviewing of all information gathered about the safety and quality of the services GP practices provide. From these reviews practices can identify any risks and the action to be taken to address them and pinpoint ways to improve the service to patients. There is a lot of data available about practices on the CQC website, including its intelligent monitoring report
- Circulating and acting on clinical guidance, medical alerts and safety alerts and any other relevant local or national reports, so that staff can change their working practices, if necessary, for the benefit of patients.
- Learning and development
- Any external accreditation process
- Records of training and development for all members of staff
- Information related to misconduct investigations of the staff
- Discussing key information collected at practice team meetings so that learning and development changes to working practice are identified if necessary. However, the practice workforce should feel able to raise concerns about risks to patients and staff in a confidential manner at any time. See BMA guidance on raising concerns
- Patient feedback
- Having a mechanism for patient feedback and comments
- Evaluating changes to ensure improvements have been achieved
- Having a publicised and robust complaints procedure for handling complaints from patients, this should comply with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009
- Showing data about the quality of the GP practice in some form, within the public areas of the practice reception or on practice website. For example, results of a practice survey or a summary of patient feedback received via a suggestion box. Similarly, for the safety of patients, display health and safety information (including information about own responsibilities for contributing to health and safety) in the practice reception.
The CQC published a series of mythbusters with the aim of clarifying some of the common myths about GP and out-of-hours services inspections and to share agreed guidance.
Read the CQC Mythbuster series
Infection control and cleanliness
The CQC may inspect areas for cleanliness and infection control based on the CQC Outcome 8 requirement. You may find some of these actions helpful in ensuring you meet the minimum standards.
- Ask a practice nurse to lead on CQC Outcome 8 (Infection control and cleanliness) and ensure they have adequate training to carry out this role effectively.
- Evidence of infection control audits, cleaning schedules (including deep clean), cleaning logs and training undertaken on a systematic basis, documented and saved in a shared domain or place as a minimum.
- Notices and logs when areas were last cleaned e.g. in toilets, clinical rooms and waiting rooms.
- Ensure there is hand gel available in key areas.
- Where practically possible ensure there are no stains or discolouration on carpets.
- The GP practice needs to show how it is mitigating risks to include dealing with sharp disposal and injury.
Make sure your practice considers how it can demonstrate clear leadership within the business and across the team and workforce.
- Conduct frequent workforce meetings with a shared agenda and minutes.
- Ensure the workforce has read, understood and signed up to the CQC GP practice Statement of Purpose.
- Ensure that the workforce feels supported and valued and they have the appropriate employment policies, procedures and systems in place.
- Be aware that CQC inspectors may ask for evidence of formal recorded supervised support for the entire workforce.
- CQC inspectors may be interested in talking to the workforce about whistleblowing and whether staff feel safe to do so.
- CQC inspectors may wish to speak to staff on a one to one basis or as a group.
- Evidence that the entire workforce is able to identify and learn from mistakes when appropriate.
Staff and workforce
Ensure that the GP practice is ready to answer any questions related to CQC Outcomes 12, 13 and 14 and have the evidence to support those answers. You may find the following list helpful in preparing your staff. This is a non-exhaustive list.
- Create a robust recruitment and selection policy that meets the equality agenda and minimises risk.
- Evidence of recruiting new staff to include advert and interview notes in the personnel file.
- Evidence that the GP practice has in place a workforce induction programme to include a section on CQC and disclosure of any criminal activity.
- Ensure staff annual performance appraisals are undertaken and documented and saved in an appropriate domain. It is good practice to include a section on managing risk during the annual appraisal to include any criminal activity disclosures.
- Ensure evidence of DBS check (or risk assessment if non-clinical) is available. Undertake a risk assessment (to include all non-clinical staff without a DBS); take reasonable actions and use it as a working resource and tool.
- CQC inspectors may wish to discuss recruitment processes, in particular GP locum appointments
- Ensure that the GP practice holds HR personnel folders for the entire workforce (including GP locums and partners) in place with an index of key information containing:
- emergency contact details
- professional membership registration
- GMC registration
- NMC pin number
- performers list detail
- indemnity details
- photo ID - CQC inspectors may wish to see evidence in each HR folder that photo ID has been seen during the recruitment process (this may include a photocopy of the document seen or, at least, a record of its type and serial number)
Read a list of example questions aimed at non-clinical staff (Appendix C)
Read hints and tips for answering questions aimed at clinical staff (Appendix D)
Staff and workforce training
You may find the following list helpful in preparing your staff. This is a non-exhaustive list.
- Create a workforce training matrix and share with the workforce.
- People should be cared for by staff who are properly qualified and able to do their job.
- Staff should be properly trained and supervised and have the chance to develop and improve their skills.
- Create a training portfolio for the entire workforce. Copies to include one for the member of staff and one for the Practice Manager.
- Key areas of training evidence to include:
- managing risk and learning from mistakes
- health and safety
- equality and diversity
- informed consent
- informed decision making
- safeguarding for children and adults - CQC inspectors may want to have evidence that safeguarding for both adults and children is discussed in multidisciplinary meetings and outcomes recorded where appropriate and all policies and procedures are followed. In particular, CQC may be interested in information sharing (for both children and adults) so that any matters can be resolved quickly and easily. The CQC inspectors may also want to discuss the management of access to sensitive information e.g. patient at risk register.
- GP awareness around Deprivation of Liberty Safeguarding (DOLS) the Mental Health Act and the Mental Capacity Act and what this means for GPs and their patients.
- CQC inspectors may ask to see proof of attendance certificates in connection with staff training
To help you evidence competencies and appraisals for practice nurses, use the following resources:
RCGP General Practice Nurse competencies (PDF)
Policies and procedures
CQC inspectors may also wish to see policies, procedures, guidelines and protocols if felt appropriate and necessary, but what is most essential is that the GP practice workforce understands what these mean in operational terms.
It is vital for any documents to reflect what the workforce does on a day to day basis. It may help to have a practice intranet site which contains these policies and is easily accessible by all members of the practice.
There are practical steps that a practice can take to ensure that staff members are always aware of CQC and what would be expected in any visit. This is a non-exhaustive list.
- Include CQC as an agenda item for all appropriate meetings and take minutes.
- Meeting minutes must be available as evidence to the CQC inspector that the meeting has taken place.
- Ensure all meetings have agendas and minutes - the entire workforce should be able to add items to the agenda and read copies of the minutes.
- Consider adding new agenda items for all meetings to include the following:
- managing risk
- improving quality
Your patients, and their experience of care
CQC inspectors want to get to the heart of people's experience of care, so the focus of their inspections is on the quality and safety of services, based on the things that matter to people.
- Use past case examples to help demonstrate your compliance.
- Describe in detail the service offered and how staff go that 'extra mile' to help achieve the best possible outcome for ALL patients.
- CQC inspectors will talk to patients (pre and post consultation) about their experience, particularly around whether they felt listened to, consent, informed decision making, choice, access to appointments and information about a particular treatment or referral options, prescribed medication including about the risks and benefits, and general safeguarding.
- CQC inspectors may also like to sit in the waiting room listening and talking to patients and observe the meeting and greeting of the patient at the reception (as mentioned in Section 11 - Patient involvement).
Consider creating patient surveys that incorporate the five questions about services that are provided to people in the six population groups. Familiarise yourself with CQC's population group definitions, as follows:
- Older people
- People with long-term conditions
- Families, children and young people
- Working age people (including those recently retired and students)
- People whose circumstances may make them vulnerable
- People experiencing poor mental health (including people with dementia.
Read more detailed information on these population groups and their definitions
Key lines of enquiry
As part of the new approach to inspecting, CQC inspectors follow Key Lines of Enquiry (KLOE). It is therefore vital to respond adequately to CQC inspector questions to illustrate best the quality and safety of services. CQC will undertake a matrix approach around the 6 population groups, and the 5 categories of questions.
There are 5 categories of questions:
- Safe - people are protected from abuse and avoidable harm.
- Effective - people's care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
- Caring - staff are involved and treat people with compassion, kindness, dignity and respect.
- Responsive - services are organised so that they meet people's needs.
- Well-led - the leadership, management and governance of the practice assures the delivery of high quality person centred care, supports learning and innovation, and promotes an open and fair culture.
Most KLOEs are 'mandatory' and must be followed at each inspection. Others are 'additional' and will only be checked if the CQC pre inspection checking suggests they should be.
The KLOEs are underpinned by prompts (CQC have these prompts at hand during inspections) that give examples of how KLOEs can be followed.
Consider the Key Lines of Enquiry approach of asking the GP practice questions during preparing for inspection.
The following guide includes the types of KLOE and types of questions asked within each category
Download the CQC Appendices to provider handbook
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Step 3 - Outcomes from the inspection
Ratings and special measures
The CQC inspection evidence gathered is set against the 'Characteristics of Ratings', to determine the rating awarded to each of the five key question ratings. A final overall location rating is aggregated from these five ratings.
GP practices will be rated as either:
- requires Improvement
GP ratings will be published on the CQC's website when finalised, must be displayed in the GP practice and on the GP practice website of applicable.
- If you have been awarded a rating from CQC, you must display it in each and every premises where a regulated activity is being delivered, in your main place of business, and on your website(s), where people will be sure to see it. This is a legal requirement from 1 April 2015.
- Your ratings must be displayed at the premises where your service is being provided unless you are delivering care to someone in their own home.
- CQC will assess whether or not your ratings are displayed legibly and conspicuously when they inspect.
- CQC will make posters for physical display of your rating available to download from their website. You will be able to access your posters from the CQC website from 1 April 2015. Information about how to download and print your posters is available here.
- Practices will have a maximum of 21 calendar days to display their ratings from the date the inspection report is published on the CQC website.
The requirement to display ratings comes into force from 1 April 2015. If you have already received a rating from CQC prior to this date you will have 21 calendar days from 1 April in which to download, print and display your poster(s) for physical display and to make amends to your website to meet the online display requirement.
GP practices rated as inadequate for 1 or more of the 5 key questions or 6 population groups will be placed into 'special measures' following consultation with NHS England. The practice will be given a specified time period for re-inspection. This will be no later than six months after the initial rating is confirmed. During this period the practice must demonstrate improvement, ahead of another CQC inspection.
GP practices will be placed into special measures for a maximum of six months. Being placed into special measures will represent a decision by CQC that a practice has to improve within six months to avoid having its registration cancelled.
Requesting a rating review
GP practices or GP out of hours service can request a rating review following certain conditions. Refer to the list below before making a decision to request a rating review.
- The only grounds for requesting a review is that the inspector did not follow the process for awarding them properly, as described in published policies and procedures.
- A rating review cannot be requested on the basis that you disagree with the judgments made by an inspector. Such disagreements would have been dealt with through the factual accuracy checks and Warning Notice representations.
- If you feel that the CQC has not followed the published process properly and you wish to request a review of one or more of your ratings, you must inform the CQC of your intentions once the report is published.
- The CQC will reply with full instructions on how to request a review. You will have a single opportunity to request a review of your inspection ratings.
- In the request for review form, you must say which rating(s) you want to be reviewed and all relevant grounds and circumstances.
- If the CQC does not uphold a request for review, you cannot request a subsequent review of the ratings from the same inspection report.
- When the CQC receives a request for review, they will explain on their website that the ratings in a published report are being reviewed.
- The request for a review will be handled by CQC staff who were not involved in the original inspection, with access to an independent reviewer.
- The outcome of the review will be sent to the GP practice or GP out-of-hours service following the final decision. Where a rating is changed as a result of a review, the report and ratings will be updated on the CQC website as soon as possible. It should be noted that following the conclusion of the review, ratings can go down as well as up.
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Read about some experiences from practice managers, who have had inspection visits from the CQC.
We received a call from the CQC on 24th September, 13 days prior to the inspection date of 6th October.
As a practice we had to submit certain pieces of work such as Significant Event Reviews, clinical audits, policies and any patient surveys carried out. The fact we were successfully inspected 12 months earlier helped but we still needed to ensure our policies and procedures were appropriately updated.
We took time out to brief the staff and ensure that any appropriate online training had been completed in preparation of the inspection. We prepared a 15 minute power point presentation to highlight areas of good practice and any challenges facing the practice. We were informed prior to the inspection that we had to give a 15 minute briefing on the day.
The CQC sent a patient survey box for patients to complete in the interim which they took away with them on the day to collate. We also arranged for a member of our Patient Participation Group to be available to meet with CQC.
On the day
Five inspectors visited the practice involving a GP, practice manager, lay person and two inspectors. During the initial 15 minute briefing the inspectors requested us to inform our front of house to ask patients at random if they would be prepared to speak with the lay inspector. We provided a separate room for this to take place.
In terms of disturbance the GP inspector spent 1.5 hours in the morning with the senior partner and re-visited him in the afternoon for another half hour. They also spoke to another partner for around 20 minutes and with our advanced nurse practitioner for 20 minutes.
In terms of questions the inspector had a list of questions to go through and were based upon whether the practice had policies and procedures for various aspects of primary care. We were asked to provide examples to clinical audit and examples of child safeguarding. They also questioned us on chaperoning policies. They selected receptionists at random to speak to throughout their visit and asked questions such as safeguarding, whether they felt supported and asked about the hearing loop.
The practice manager inspector spent a total of five hours with our practice manager going through an extensive checklist for which evidence had to be provided. We did realise that the information we had sent toCQC prior to the inspection had not been forwarded to the inspectors and we raised this during our feedback session.
Our minor surgery room was also inspected together with our defibrillator equipment, emergency drugs and our drug fridge, and policies on monitoring the fridge temperature and ensuring stock level appropriate and in date.
After 6 hours on inspection, 3 of the inspectors gave the team feedback on our performance and we were told that the report would take around 6 weeks to complete. We received the report 6 weeks after the inspection for fact checking and informed the CQC of 3 minor details which we amended before publication of our report.
We were pleased to be mentioned on the CQC website but were informed prior to this of the notification to the public.
Practice Manager, Beeston Village Surgery
Our CQC inspection was not as horrendous as we expected. We were notified of our inspection 14 days prior to the event. We used this period to ensure all our policies and protocols were up to date and easily accessible. We did book a locum for the day to free up one of the partners as our senior partner was on annual leave.
We were asked to provide documentation prior to the inspection - i.e. various audits, our statement of purpose, staff qualifications and our complaints file. We were asked to give a short presentation to the inspectors at the start of the inspection so they could get a feel for the surgery and asked us to list what we felt was good and not so good about our practice.
On inspection day we had two inspectors who were here all day. They were very friendly and not at all intrusive - they spoke to members of our PPG and to members of staff (both clinical and admin). At the end of the visit we were de-briefed on their findings and recommendations. All in all not such a bad experience as we expected.
Acting Practice Manager, Park Edge Practice
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