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Collecting evidence to support CQC registration

Practices will need evidence to show they comply with the CQC's essential standards. By Graham Knight

By 1 April 2013 the Care Quality Commission (CQC) will expect all GP practices to have been registered and to be able to demonstrate compliance to the essential standards of quality and safety.

Once the practice has enrolled online in July 2012, GPs should start working immediately towards gathering evidence to demonstrate the practice is delivering against key outcomes for each standard. You should work also towards closing any gaps identified in the action plan at the end of the online enrolment form.

Each outcome is described in detail in the CQC’s guidance Essential Standards of Quality and Safety.

Each outcome has a number of prompts that ask for additional evidence against the required outcome. There may also be additional prompts that are specific to your healthcare service type that you must also evidence.

Healthcare service type

Your healthcare service type is determined by the services you provide at a specific location. Each type is described using a three-digit code and are important because they may require you to address additional prompts within each outcome that are specific to your activities. 

Your service may fit into more than one of the categories. NHS GP practice is listed under ‘doctors consultation services’ (DCS) and ‘doctors treatment services’ (DTS), for example. This will not affect your enrolment, but it may impact on the scope for compliance.

Gathering and filing your evidence

The outcomes to the essential standards are split into five ‘families’ which each describe an area of activity you should already be engaged in as part of the day-to-day governance and running of your practice. 

Evidence can be anything from a policy or procedure, to an electronic record, audit or form. The challenge is to capture this evidence in a sustainable fashion so that it is updated regularly and can be easily produced for self-assessment or inspection.

There are several ways to do this. If your governance systems are robust with a comprehensive set of policies and procedures, you may wish to include a CQC index in the front of your files (electronic and/or paper) referencing each policy against the outcome it relates to and collecting evidence of audit or note

Alternatively, if your action plan identifies a number of areas that need to be developed to demonstrate compliance, a practice may choose to start a separate file with a section for each outcome, and all the evidence to show that that outcome is being delivered, filed behind it.

How your practice chooses to demonstrate compliance is up to you, but be mindful that whatever approach is taken, your index needs to enable you to locate and produce your evidence on self-assessment and inspection.

Outcomes for patients

The CQC does not give examples of evidence that might be provided against each outcome. It is up to the individual practice to identify how it is achieving specific outcomes.

For this reason it is often useful to think of each outcome within its outcome family – see box - and relate that to your day-to-day practice and the outcomes you will be required to demonstrate.

The Essential Standards of Quality and Safety provide a framework for evaluating all health and social care service types, and so not all outcomes are relevant to GPs. Practices will be exempt from such outcomes.

Outcome ‘families’

1 Involvement and information

Services should designed around patients and because of this people using your service should be actively engaged, their opinions sought and have information provided to them about your service to enable them to be fully involved and make informed choices about their treatment.  This is about patient dignity and respect (outcome 1) and informed consent (outcome 2) but may also include patient feedback reports, patient information, patient choice and so on.

2 Personalised care, treatment and support

Services should also be tailored to the individual, meeting all personal needs whether they are about welfare (outcome 4), nutrition and fasting (outcome 5) or continuity of care (outcome 6).

Understanding the diverse needs of your patient group is also an important consideration in the first and second outcome family, whether they are cultural, gender/orientation or access needs.

3 Safeguarding and safety

The Safeguarding and Safety family does not just relate to Criminal Records Bureau checks and safeguarding procedures (outcome 7). It also relates to your infection control (outcome 8) and medicines management processes (outcome 9), the safety and suitability of your premises (outcome 10) and equipment (outcome 11).

4 Suitability of staffing

Human resources and personnel standards are considered in this family.  It deals with requirements relating to workers (outcome 12), staffing (3) and supporting workers (14). It considers processes such as recruitment and retention, professional requirements, professional development, supervision and appraisal, workforce planning, locum and temping arrangements, and all process relating to staff.

5 Quality management

Ensuring your service is dedicated to continuous quality improvement is a core function of the CQC standards and outcomes. 

Areas you are asked to consider include: assessing and monitoring the quality of your service provision (outcome 16), which might include clinical governance, contract reviews, management of clinical audit processes, inspection reports, corporate governance and so on. Complaints handling (17) and records management (21) are another two areas.

Outcome numbers above are from CQC guidance the Essential Standards of Quality and Safety


  • For enquiries and information during the enrolment and registration process contact the CQC’s national contact centre: 03000 616161 or enquiries@cqc.org.uk or visit www.cqc.org.uk

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