Care Quality Commission (CQC)

The CQC is the Care Quality Commission (CQC).  The CQC  regulates all health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisation. It also protects the interests of people detained under the Mental Health Act.

Web site:

Care Quality Commission
Newcastle upon Tyne

Available in PDF format and for your perusal and download:


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