CQC Evidence Required

May16 – CQC Evidence Required to Demonstrate to CQC Inspectors that we are Safe

Evidence Required to Demonstrate to CQC Inspectors that we are Safe, Effective, Caring, Responsive and Well Led

  • Are services safe?

Reporting and learning from incidents

  • Adverse incident reporting policy. Incident report forms and evidence of learning from them.
  • Complaints records and analysis (sharing, feedback, learning).
  • Accident report book. Entries for last year and evidence of learning.
  • RIDDOR – staff knowledge.
  • Duty of Candour.
  • National Safety Alerts.

Reliable safety systems and processes including safeguarding

  • Safeguarding policies and flow chart
  • Lead person and reporting
  • Training and awareness for all staff
  • Handling sharps
  • Use of rubber dam (how many kits in practice?)
  • RCT and single use instruments

Medical Emergencies

  • Systems in place for dealing with medical emergencies
  • Use of AED
  • Training
  • Location of equipment known to all staff
  • Monitoring of expiry dates and checks on oxygen and equipment

Staff Recruitment

  • Recruitment policy
  • Staff recruited in accordance with policy
  • Appropriate in formation complete and up to date

Monitoring health and safety and responding to risks

  • Risk assessments
  • COSHH – staff knowledge.
  • Radiation, health & safety, fire, water quality risk assessments
  • Maintenance fire equipment including alarms
  • Fire drills logged

Infection Control

  • Cleanliness/appearance
  • Policies
  • Compliance with HTM 01-05
  • No clutter on work surfaces of surgeries or in drawers
  • Demonstration of infection control process (person in decon room)
  • Legionella risk assessments
  • Treatment of DUWL
  • Disposal of sharps and clinical waste
  • IPS audit
  • Processing of instruments including packaging


  • Compliance with IRR99, IR(ME)R2000
  • Radiation protection file, local rules, safety survey
  • Justification and report in patient notes for every exposure
  • Film holders and beam aiming devices
  • Rectangular collimation
  • IRMER training
  • X-ray audits and reports

Equipment and medication

  • Autoclave service and safety reports
  • Autoclave data capture downloads
  • Autoclave daily and weekly logs
  • Prescription pads to be locked in safe overnight and logged
  • PAT testing
  • Batch number and expiry dates of LA recorded
  • Are services effective? 

Monitoring and improving outcomes for patients

  • Medical history questionnaires and updates
  • Treatment plans and FP17DC or equivalent
  • BPE scores at appropriate intervals
  • Compliance with DBOH
  • Patient information leaflets
  • Preventative advice given

Health promotion and prevention

  • Literature available
  • Products available
  • Dental health advice given
  • Advice on smoking cessation


  • Sufficient staff numbers, ratios, skills, experience
  • Records of training
  • Appraisals and feedback
  • Practice meetings
  • Recorded induction process
  • Personal development plans

Working with other services

  • Referrals policy
  • Sharing information when in best interests of patient 

Consent to care and treatment

  • Must have clear understanding of consent issues
  • Must discuss and record options, risks, benefits, costs
  • Mental Capacity Act
  • How would consent be obtained from a patient who suffered mental impairment that may mean they might not be able to fully understand the implications of their treatment?
  • If any doubt about ability to understand treatment should be postponed
  • Involve relatives, carers to ensure best interests of patient are served
  • Gillick competence 
  • Are services caring?

Respect, dignity, compassion and empathy

  • Treatment rooms – doors shut at all times
  • Conversations not heard outside rooms
  • Clinical records stored safely
  • Computers password protected and backed up
  • Staff aware of protecting patients’ privacy
  • Computers logged out when not in surgery

Involvement in decisions about care and treatment

  • Provision of signed treatment plans
  • Records show options, explanations, alternatives, costs risks/benefits, time given to consider
  • Information sources for patients
  • Charges poster and practice website 
  • Are services responsive to peoples’ needs?

Responding to and meeting patients’ needs

  • Information available to patients – opening hours, accessing urgent and emergency care
  • Appointment books checked to see that appropriate time is booked for care depending on complexity of care
  • Acting on patients’ preferences
  • Access and facilities

Tackling inequality and promoting equality

  • Equality and diversity policy
  • Information on Equality Act 2010
  • Translation service available
  • Languages spoken by staff
  • Hearing (induction) loops on reception desk
  • Access into building and surgeries. DDA compliance

Access to the service

  • Opening hours
  • Answerphone messages
  • Urgent and emergency care
  • Availability of appointments

Concerns and complaints

  • Complaints policy
  • Information on how to make a complaint for patients
  • Comments and suggestions
  • Complaints poster 
  • Are services well led

Governance arrangements

  • Leads and deputies
  • System of policies, procedures and risk assessments which are regularly reviewed
  • Regular audits with action plans and learning outcomes
  • Regular staff meetings with minutes and action points
  • Patient feedback

Leadership, openness and transparency

  • Shared vision and strategy
  • Whistle blowing procedure. No blame culture. Concerns can be raised without fear of reprisal
  • Staff empowered and supported

Management lead through learning and improvement

  • System to identify training needs
  • Staff appraisals
  • Check that appraisal is meeting needs of PDP
  • Dentist appraisal
  • Clinical audit – radiographs, infection control, record keeping
  • Learning through complaints, adverse incidents

Seeks and acts on feedback from patients, public and staff

  • Patient surveys and action on results
  • Friends and Family Test – sharing and learning from results
  • Compliments and complaints with actions
  • Staff newsletter
  • Staff suggestions
  • Patient suggestions
  • Feedback results of surveys/suggestions to service users

Compiled by Ken Hymas

Registered Manager

14th March 2016