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Policies to check ahead of a CQC inspection - a checklist

The CQC will expect practices to have policies and procedures in place for almost every eventuality. Practices can use this checklist to ensure they have correct policies in place and that they are all up-to-date.

The CQC expects practices to have policies and procedures in place for almost every eventuality. During an inspection inspectors will be less interested in the piece of paper than in evidence that the policies are understood by all staff and that the policies are updated regularly to reflect current practice.  

Below is a list of policies that it is worth checking that you have. It is a good idea to share these with staff and ensuring that staff would know what to say if asked about policies and processes on the day.  

The policies below have been grouped into staff groups, and if you can get the whole team involved in checking the policies it will share the workload and should mean that the policies do reflect current practice.  

What is most important is that if you asked the staff groups below about the policies assigned to their staff group, they could confidently tell you what the policies are. Bear in mind that some policies and procedures will run across all staff groups, for example safeguarding.

Practice management

  • HR policies (such as disciplinary and grievance, bullying, equal opportunities, whistleblowing etc)
  • Adequate staffing levels
  • Health and safety policy
  • Fire and evacuation policy
  • Computer security policy
  • Social media policy
  • NHS smartcard policy
  • Business continuity plan
  • Dissemination of safety alerts
  • Complaints procedure
  • Payroll management and accounts management
  • Petty cash control

Reception/admin team

  • Induction handbook
  • Registration of new patients
  • Violent and abusive patients policy
  • Patient access to online services
  • Death reporting procedures
  • Access to medical records
  • Transfer of medical records
  • Choose and Book

Nursing team

  • Cleanliness and infection control
  • Decontamination
  • Waste disposal
  • COSHH
  • Controlled drugs
  • Cold chain policy

GP team

  • Consent
  • Chaperone policy
  • Identification of minors
  • Safeguarding children and vulnerable adults (whoever is the safeguarding lead should be responsible for this policy and ensuring all staff understand their responsibilities)
  • Assessing and managing mental capacity
  • Management of lithium therapy
  • Repeat prescribing policy and dispensing policy (if you are a dispensing practice)
  • Drug formulary
  • Record keeping
  • Summarising records
  • Allergy recording
  • Workflow of clinical letters, i.e. how are letters from hospitals/other services assigned to doctors, what happens if a GP is away, how are urgent letters dealt with
  • Follow up of hospital referrals for vulnerable patients who failed to attend their appointment to see a specialist
  • Care and support to patients in vulnerable circumstances e.g. homeless people
  • Management of drug and alcohol abuse

Fionnuala O'Donnell is a practice manager in Ealing, West London, and a CCG board member

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Picture: iStock

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