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Meeting the CQC standard on involving patients

The MDU's Dr Sally Old provides an overview of CQC registration and explains how your practice can demonstrate it meets the standard for respecting and involving patients.

Feedback: how well informed are patients about treatment options?
Feedback: how well informed are patients about treatment options?

By the end of 2012, your GP practice should have submitted its application for registration with the Care Quality Commission (CQC) during one of four time windows for submissions.

If you have missed your practice’s 28-day application window, you need to act quickly as the registration process must be completed before April 2013.

While you may be apprehensive about what CQC registration means and about the prospect of a periodic visit to the practice from CQC inspectors, it is likely that most of the evidence inspectors ask to see – practice policies and procedures, employment records and so forth – will be information you already have or which is readily available.

However, the CQC can take action against practices that have failed to register. This could lead to a fixed penalty notice, a caution, or even criminal prosecution. The GMC is also likely to be notified if sanctions are taken against you.

Core outcomes

The CQC’s role is to ensure registered providers meet 28 essential standards of quality and safety, called outcomes. The standards relate to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

As part of the application process you are required to make a declaration of compliance with 16 core outcomes that apply to all providers of healthcare services. These directly relate to the quality and safety of care such as medicines management, consent, staffing, and management of complaints.

You will not be asked to submit evidence when you apply but the CQC says practices may later need to make this available to them (or to show that you have an action plan to provide  it).

The other 12 outcomes are primarily concerned with responsible day-to-day management, and the CQC says it will make checks where concerns are raised.

From next spring, the CQC will begin a programme of inspections of GP practices to monitor their compliance. You can expect a visit from the CQC at least every two years.

CQC guidance

The CQC has produced detailed guidance, Essential standards of quality and safety, to help healthcare providers meet their obligations. It divides outcomes into six areas:

  • Involvement and information
  • Personalised care, treatment and support
  • Safeguarding and safety  
  • Suitability of staffing  
  • Quality and management  
  • Suitability of management.  

Each section includes prompts for providers to ensure they understand what is involved and examples of how to comply.

Respecting and involving patients outcome

For example, to comply with outcome for respecting and involving patients, practices need to ensure patients understand the care and treatment available and are involved in decisions about their care. Their privacy, dignity and independence should be respected and their views and experiences taken into account.

The table below outlines some examples of evidence practices can use to demonstrate compliance in this area.

Evidence to demonstrate complaince

Practice policies and procedures

For obtaining consent;access for those with disabilities; confidentiality and privacy; use of laptops and computers; chaperones; and your practice’s equality and diversity protocol and others. You should be able to demonstrate these are regularly reviewed and updated.

Staff training

Certificates, training modules undertaken and notes in personnel records to show when staff completed training in communication skills; confidentiality; the Mental Capacity Act 2005; safeguarding children; the role and use of chaperones; and diversity and equality.

Patient information

Leaflets, posters or on your website (in different languages if applicable) about practice services; any fees charged (for example, for travel immunisations); practice complaints procedure; Patient Advice and Liaison Service (PALS) and other advice services; use of chaperones; explanations of what common diagnostic tests involve.

Patient feedback

Anonymised examples of written, verbal, electronic patient feedback, such as surveys. This would cover areas such as how well informed patients feel about treatment/care options; whether they feel their views are taken into account; and patient privacy. You could also provide evidence of how you take the views of representative patient groups into account.


Regular audits such as looking at the use of chaperones.


For example, of when interpreters/signers are used.

Patient care plan

Consider providing an example of an anonymised patient care plans and explaining how frequently it is reviewed.

  • Dr Old is a medico-legal adviser at the MDU. The MDU has developed an interactive online CQC registration tool for members of its GROUPCARE SCHEME, which helps GP members collate evidence for each essential outcome and generate an action plan.

External link
CQC Essential standards of quality and safety

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