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Preparing a CQC action plan

Practices not meeting the quality and safety standards when registering with the CQC must prepare an action plan for compliance. The MDU's Dr Michael Devlin explains how.

Action plans should detail steps you will take to become compliant (Picture: iStock)
Action plans should detail steps you will take to become compliant (Picture: iStock)

Once registered with the Care Quality Commission (CQC), from 1 April 2013 onwards you must be able to demonstrate that you comply with the CQC’s essential standards of quality and safety.

Although this may sound a daunting task, the CQC says it is confident that most practices are already meeting most of the basic standards.

For most practices, there are likely to be at least some core outcomes that you cannot immediately meet. If you are unable to comply with any of the CQC’s 16 core quality and safety outcomes (also known as essential standards) at the point of registration, you will need to draw up an action plan explaining how you intend to comply in future.

The CQC will still accept your registration application provided it considers your practice does not represent a risk to patients.

You will need to submit your action plan before April 2013, so it’s advisable to give yourself plenty of time to prepare it.

What should your action plan contain?

The CQC says that each action plan should include the following:

  • How and why you are not compliant with the specific essential standard – this would include how people’s experiences of your services differ from the patient outcomes described in Essential Standards of Quality and Safety, details of the actual part of the regulations that is not being met, and information about whether this relates to a particular location or regulated activity.
  • How you will become compliant – You should include details of what improvements are needed to meet the relevant regulation, the resource implications of these improvements, whether urgent action needed to mitigate the risk to patients and information about whether the plan feasible and realistic.
  • Your timescale for achieving compliance.
  • What you will do to ensure you stay compliant – this would cover any improvements needed to the day-to-day running of your practice, details of the further quality assurance checks necessary to identify potential problems at an early stage and information about how you will ensure the improvements made are understood and followed by staff.

Action plan template

The CQC has provided an action plan template for GP practices on its website and suggests you copy and paste from this directly into your application form.  

Of course, practices which meet all the essential standards are not obliged to submit an action plan, so if you have time before your registration window closes and have not already done so it is advisable to assess your practice’s compliance and address any gaps.

How to know if you comply

If we take Outcome 7 (Safeguarding people who use services from abuse) as an example, we can look at how practices can assess if they comply.

Outcome 7 aims to ensure that the practice has measures in place to identify and prevent abuse.
Staff should understand how to respond appropriately when abuse is suspected. In this context, abuse means sexual, physical or psychological ill-treatment; theft or misappropriation or misuse of money or property; and neglect.

This outcome also covers safeguards for the deprivation of liberty of patients.

These are some of the sort of questions a practice should be asking itself.

  1. Do you have a safeguarding children policy?
  2. Do you have a safeguarding adults policy? 
  3. Do you train your staff, including temporary or agency staff, to identify the signs of abuse?
  4. Do your staff know which aspects of the safeguarding process apply to them? Are they aware of their own roles and responsibilities?
  5. Does your practice work collaboratively with others in relation to all safeguarding matters and do your safeguarding policies link with local authority policies?
  6. Do you support patients or those close to them in raising concerns about suspected abuse?
  7. In relation to safeguarding, do you ensure that staff are committed to maximising people’s rights and choices and protecting their human rights?
  8. Do you take action to ensure patients are properly supported following an alleged abuse incident?

Practices should be able to answer yes to all of these questions – and have evidence or further information to support this should the CQC request to see this. If you answer no to these questions it is advisable to address the issues ahead of April 2013, if not you will need to put together an action plan.

Finally, a word of warning: if your practice has successfully registered without the need for an action plan, don’t be tempted to rest on your laurels as the CQC plans to begin its programme of inspections from April 2013. 

  • Dr Devlin is head of advisory services at the MDU
  • Members of the MDU’s GROUPCARE scheme can take advantage of an interactive online CQC registration tool, which guides practices through all 28 essential outcomes, helping them collate evidence and generate action plans, if required. For each outcome you are asked a series of questions, such as those detailed for Outcome 7 above.

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