The Pulse: A Quick Guide to CQC Evidence

CQC’s registration of GPs is underway and whether doctors agree with the process or not, GPs who wish to continue practicing need to comply.  Whilst it remains to be seen whether the concerns of some doctors regarding CQC’s impending regulation are well-founded, the consequences of practicing without being registered are serious and could lead to prosecution.

The Regulatory Framework

GP practices seeking to register with CQC should be aware of CQC’s requirements for compliance and familiarise themselves with CQC’s regulatory framework, which is based on the provisions of the Health and Social Care Act 2008 (the “Act”) and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (“Regulations”).  GPs should pay greatest attention to the Regulations, which are mandatory legal requirements for compliance.  CQC has published guidance about compliance entitled the Essential Standards of Quality and Safety (the “Essential Standards”), available on CQC’s website, which assists providers to comply with the Regulations by breaking down the requirements of each Regulation in to ‘outcomes’ and ‘prompts’.  GPs should bear in mind that whilst the Essential Standards do not carry the same legal weight as the Regulations, regulation 26 of the Regulations stipulates that providers must have regard to the Essential Standards if they are to comply with the Regulations.

In compiling evidence under each regulation/outcome, GPs may wish to consider the following table, which offers a sample of prompts taken from the Essential Standards (the Essential Standards contains significantly more detail in relation to each prompt).  Each sample prompt is accompanied by examples of documentation that may help to illustrate compliance with each prompt.  We must stress that whilst the table is not exhaustive, it is intended to help managers appreciate that any declaration about compliance must be capable of being verified by evidence.  Managers should start to think not only in terms of whether their practices comply, but also how they can illustrate compliance when the inspector calls.

A table illustrating examples of compliance can be downloaded at the bottom of this page.

Gathering Evidence

At the point of registration, CQC will not require the vast majority of GP practices to submit any evidence with their application for registration.  CQC will, however, require a declaration of compliance against the Essential Standards.  Before submitting applications for registration, GPs should ensure that evidence demonstrating compliance is available, should CQC request copies.

CQC’s website states that GPs are able to use any evidence they already have to demonstrate compliance, including, but not limited to, evidence gathered by practices participating in the General Medical Service’s Quality and Outcomes Framework (QOF) or RCGP Quality Programmes.

We have prepared a 10 step guide that each practice may wish to consider in collating evidence to demonstrate compliance:

Prepare 16 folders, one in respect of each of the 16 core Essential Standards.

  1. Refer to CQC’s Essential Standards in respect of each regulation/outcome and familiarise yourself with CQC’s requirements (http://www.cqc.org.uk/content/essential-standards-quality-and-safety)
  2. Assess what evidence the practice requires to demonstrate compliance under each regulation/outcome.
  3. Assess whether the practice already has documentation in place to satisfactorily evidence compliance under each regulation/outcome and if so, file evidence in the relevant folders.
  4. Assess the robustness of the evidence.  Is the evidence:
    • current? (this may vary, depending on the data source)
    • reliable? (is the source credible?)
    • usable? (is it good quality?)
    • relevant? (is it specific to the regulations?)
    • sufficient? (is there an adequate amount of evidence to evidence compliance?)
  5. Assess whether the practice has a procedure to monitor the evidence and keep it up to date.
  6. Assess whether there are systems in place to regularly audit and review systems and practices.
  7. Identify the steps needed to obtain any remaining evidence required to meet compliance.
  8. Draft an action plan in relation to any outcomes with which the practice is not compliant.
  9. Declare compliance in respect of all/remaining outcomes.

Whilst CQC’s requirements for registration may seem onerous, there have been indications from CQC that it will take a pragmatic approach to the registration of GPs.  CQC has stated that most good quality practices will already be meeting CQC’s Essential Standards without the need to purchase external tools or consultancy services to demonstrate compliance.  GPs should take a similarly pragmatic approach to this registration process and should not panic if they have concerns about their compliance.  If GPs do have any queries or concerns about the registration process however, they should not hesitate to seek further advice from CQC.  Ridouts has extensive experience of advising on registration and we are also available if you have any specific challenges or would just like a little support.

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