Using our system as part of your defence in a CQC investigation

Case Study: False claims by disgruntled staff

Date: August 2025

Account by: Practice Manager

Location: Manchester

The CQC Complaint

Several disgruntled ex-employees got together to file “whistleblowing” complaint against the practice. The allegations included equity of access; failings in admin and governance; insufficient staff; stress at work; bullying and harassment; freedom to speak up …… and the kitchen sink !

We had no idea what evidence had been submitted to support the complaint.

1. We had four days to respond.
2. Failure to provide assurance would trigger a same-day unannounced visit.

How We Prepared

1. Preparation extended well beyond documents.
2. Reception and Admin staff focused on patient communication protocols, clinicians reviewed compliance logs, and managers checked evidence folders and were ready with an action plan.
3. Clear communication ensured that everyone understood their responsibilities if inspectors arrived without notice.

How We Responded

1. We acknowledged shortcomings where appropriate and presented clear action plans to address any gaps.
2. We countered inaccurate claims with a robust defence supported by actual evidence.
3. We showed our best in class “inspection-ready” system, incorporating a full annual compliance plan, and pointed the CQC to our suppliers web site

The Outcome

The CQC accepted our defence and were assured that we had a robust Quality Management System in place.

The case was closed and all action suspended.

What Saved the Day

The ability to compile a convincing defence in a professional manner is critical. Having dealt with inspectors over many years, the first port of call was to connect with the inspector to establish a working relationship. Familiarity with all types of systems from Ardens to TeamNet, and from Practice Index, QCS and FPM, made evidence gathering that much easier.

For Governance side, just 3 months ago we purchased a Quality Standards System that is fast becoming a National Standard. We explained this system to the CQC, and they checked out our supplier site.

With virtually no preparation, we were able to assure the Inspector that: -

1. We had an ISO 9001:2015 “inspection-ready anytime” system, incorporating a full annual compliance plan
2. It was a recognised Governance system to demonstrate HSCA and CQC Guidance compliance
3. We had an “Interview-ready” staff handbook, including Appraisals, personal development; competency and knowledge; critical policies
4. The system created a culture of self-responsibility and engagement where staff monitored their own competency; trained each other; and organised their own workshops

Key Takeaways: When dealing with a potential investigation

1. Demonstrate you are Well-Led and well managed; show that this was just an anomaly
2. Demonstrate that you have a robust Governance System; show how you operate in practice
3. Prepare your systems early; It's too late to start when they knock on the door

Product used:

Quality Standards Manual: A structured approach to being inspection-ready anytime

Staff Passports: A personal Staff Development handbook for every member of staff, containing Appraisals, CPD record; Best Practice Knowledge; Key Policies. Creates a culture of self-responsibility and teamwork.

How these providers failed at everything all at once

We looked at two particular inspection failures, one had as many resources as you could wish for and another being your usual smaller provider with one Manager.

Both had comprehensive policies; an online document management system; and generally provided good care.

Things ran smoothly. Everything looked fine.

At The inspection

It all looked good on paper, so the CQC Rating came as a shocker.

Senior Management is shocked!

Information isn’t to hand, processes are not always followed, there are gaps in the system, things are not done properly.

2024 Inspections will be even more challenging as the focus shifts to “Feedback” which most systems are not designed for

This rating will stay on their web site until the next inspection. That could be the next 5 Years, unless you ask for a reinspection.

Lessons learnt

• It is not just about having the best policies or more human resources
• 99% of the inspection is about continuous compliance
• Don’t let the inspector be the first to find your weaknesses

The solution

CQC inspections are based on your performance over the last 12-24 months. By the time an inspection is announced, it is already too late to prepare.

The registered Manager is central to an inspection. The uncomfortable truth is that the Registered Manager delegated everything, did not monitor, and took their eye off the ball.

You must be inspection-ready anytime, and your system should tell you this at the press of a button.

Apps for a robust Clinical Audits System.

A Clinical Audit System should comprise two elements:-

1. An effective Policy and Governance
2. A consistent process that records each audit

Our system will enable you to achieve these with two applications in tandem:-

1. Risk Assessment Channel

A comprehensive Risk Assessment based on the guide by NICE; CHI,RCN, University of Leicester.

This is a living document that combines Risk Assessment, Governance, and Policy Statement in one. The initial “one-off” review should take no more than 10 minutes to complete, and the Dashboard will automatically generate a Risk Matrix together with a  risk rated Governance and Policy Document, incorporating National Best Practice as published by NICE.

Regular reviews should take no more than 5 minutes at most, best be done as a team exercise as part of the individual clinical audits. This automatically achieves group training and development; enables discussion of improvement strategies; and acts as a team refresher and briefing, to demonstrate leadership and Well-Led criterion.

2. Processes Channel: Clinical Audits Record

The process for conducting regular Clinical Audits is to be found in the “Quality Audits” section in the Processes Channel.

This App covers the required principles of Topic Selection; Criteria; Standards; Outcomes; and Reflection, ensuring your approach meets the stringent NICE standards. A printable checklist allows offline planning, training and general discussion of the principles before the formal meeting.

Recording the process and outcomes takes just minutes, and the  Dashboard will automatically generate your log of audits with a detailed record of your risk rated decision making.

Benefits:-

The ready-made processes take no more than a few minutes to record, and ensure that we follow a stringent quality process mapped directly to the highest standards.

What you will achieve is:-

• A record of adherence to National Standards
• Consistent and structured approach to every Clinical Audit
• Dashboards to show Risk Analytics

IPC Risk Assessed in ONE Day

98% NHS England audit score

1.                The Challenge:

I joined as the interim PM of this Practice and one of my first urgent tasks was to complete the IPC audit for an imminent NHS England IPC Audit.

This was a bigger challenge than I had anticipated as there was nothing to work from, the last IPC Risk Assessment was done some 4 years ago and could not be located. There were limited regular checks, and as with many smaller Practices, there were limited staff and resources.

The Lead Nurse was faced with the daunting prospect of the 45-page NHS IPC Audit, which would have taken 3 to 6 weeks to implement on her own, with no other resource that would allow her to meet the robust requirements in such a short space of time and the inspection was due in 2 weeks.

The challenge was two-fold: Doing an IPC Risk Assessment to National Standards in a short time frame, identifying and fixing any potential issues before the auditors arrived. The only viable option seemed to be contracting an independent commercial audit.

2.                NHSE Audits:

NHSE inspectors take a constructive approach in getting practices compliant.
However, a low score will likely trigger a CQC inspection as the IPC team is duty-bound to notify the CQC.

3.                Solution:

By happenstance, we found that X-Genics, our Compliance System provider, was testing a prototype IPC Audit tool based directly on the NHS Toolkit and international best practice and were looking for volunteers to field test it before launch. This system was part of the digital automation bid project, we had collaborated on and had already implemented this bespoke automation software solution for general CQC Compliance and IIF Reporting.

4.                How we did it

The process turned out to be both simpler and faster than we had expected.

How the system works:-

1. The National Standards are broken down into bite sized mini-Apps.
2. Each App has an integrated mini checklist(s) to easily manage individual IPC areas.
3. Each checklist is delegated to different staff, spreading the workload across the practice.
4. Results are collated, risk evaluated and summarised into the App.
5. Automatic Dashboards generate an Action Planner and Risk Matrix
6. Action Points are addressed, and the Apps updated.
7. Checklists are reused daily/weekly/monthly to achieve continuous compliance.
8. The process of evaluation and summarising into the App is repeated through the year.

We distributed the user-friendly checklists to our staff, outlining specific tasks for hazard review. Each staff member received a checklist, and they were tasked with assessing and reporting on identified hazards, and staff were encouraged to fix minor issues on the spot. The nursing team and practice manager took charge of conducting reviews in key and high-risk areas. We added an element of fun by offering chocolates as rewards for timely completion and team achievements.

After completing the assessments, the checklists were collected the following day, and entered into the mini-apps. The software generated a user-friendly visual plan, with our risk mitigation steps, and our action plan for any outstanding action points.

Our strategy focused on starting with low-risk items that were more easily manageable and within our immediate control. Having achieved these "easy wins" and gaining experience, we progressed to focusing resources on higher risk areas. Identifying at an early stage, areas that required external assistance. For instance, we identified that the original door handles in a converted residential property were not easily wipeable, necessitating replacement and scheduled this in as an action point.

5.                Completion:

This approach created an efficient workflow and allowed us to tackle potential risks in a systematic manner, prioritising actions to achieve maximum impact with minimum effort.

There was zero training needed. The entire IPC Risk Assessment was completed in one day, leaving sufficient time to address issues for remedial action.

6.                Outcome:

98% score achieved at the NHS England audit two weeks after our risk assessment.
We achieved well over 100% return on investment compared to external contractors, on this App alone, and have started using others such as Fire Risk Assessment. We have taken full control of IPC, and this has now become continuous compliance instead of an annual exercise.

Going forward, the checklists are now used as our regular reviews, and results used to update the Apps. In addition, we rotate the staff and checklists, so staff learn about a different area every month, in effect a continuous training regime by “learning on the job”.

All staff feel empowered, engaged and enthused with their new responsibilities, a total culture change for the Practice, and a reduced workload for the Manager and Lead Nurse. In effect, our IPC runs automatically and autonomously thanks to our motivated staff.

7.                Improvements:

1. We are IPC inspection ready at all times
2. Professional compliance reports at the press of a button
3. Saved the cost of external contractors
4. Continuous Risk Assessments carried out every month at no extra cost
5. A positive IPC Culture
6. Reduced management workload
7. Formal training sessions largely replaced by training on the job
8. Staff teach each other when uncertain

8.                Credits:

Author: Shabana Dehlavi           Provider type: GP Practice         Date of study: February 2024

The system supplier is X-Genics via their CQC focused web site everythingCQC.com.
The Audit and Risk Assessment Channel includes risk assessments for Infection Control and Fire Risk; with COSHH, Display and Screen Equipment and Safeguarding currently in the pipeline.

Case Study:

Investment and Impact Fund – NHS England

Turning a Simple Spreadsheet into a £20,000 Income in One Week

Introduction

IIF, or Investment and Impact Fund, is a funding mechanism in the UK that provides financial incentives to general practices for improving their performance in various areas, such as immunizations, cancer screening, and chronic disease management. However, tracking and reporting on the progress and achievements of these targets can be a tedious and time-consuming task for practices, especially when working collaboratively in a Primary Care Network (PCN). This case study outlines how a group of practices in a PCN used a simple spreadsheet and a mini-app platform to develop an innovative solution that not only made tracking and reporting more efficient but also helped them identify missed opportunities and easy wins, resulting in a £20,000 income in one week.

The Problem

The practices in the PCN were struggling to keep up with the IIF targets due to various reasons, including the complexity of the funding mechanism, lack of clarity on what to do next after identifying gaps, and the burden of communicating and reporting the progress to PCN managers. This is the first year practices have had a high amount of incentivised indicators to achieve, with the potential for  missed opportunities and underperformance. To address these challenges, the practices decided to develop a simple yet effective solution that would not only make tracking and reporting more efficient but also help them engage and motivate each other.

The Design

The practices used a mini-app platform called eManager by X-Genics to create a custom solution that would allow them to enter data quickly and generate automated dashboards that provided instant insights into missed opportunities and easy wins. The solution was designed to focus on forward planning rather than looking back, with a month-by-month record of achievements and missed targets. The solution was financially focused, highlighting the value of missed targets and identifying easy-to-reach targets. It automatically highlighted priorities and made it easy to understand and plan. Importantly, the solution was designed to engage practices by making every practice enter data and self-examine, resulting in better targeting of patients, focused meetings on group-wide achievements, and better collaboration across the network.

Achievements

The solution had a significant impact on the practices and the PCN, resulting in a £20,000 income in one week. The financially focused dashboard enabled the practices to differentiate profitable indicators from easy kills, resulting in better decision-making and a more targeted approach to achieving the IIF targets. The practices reported better engagement and collaboration, with all four practices working together in this and other areas, resulting in a joint Patient Participation Group (PPG) for better use of common resources. The solution enabled the practices to track progression over 12 months, plan and achieve goals without any last-minute rush, and identify coding errors. The practices reported that they achieved £20,000 across the PCN in the first two weeks of using the solution, and they understood how to work with IIF for the first time as a team.

Using a fully managed system and automated Dashboards, has allowed the team to focus on performance, never having to worry about updates to the requirements or the latest version of spreadsheets. The impact on the team is evident in a single comment by Dr Peter Brown the Clinical Director of Northwest Merton PCN said “I don’t know how other PCN’s are managing without this”.

Practice Managers reported feeling a sense of achievement and feeling valued as they were able to make more effective contributions to financial performance and clinical quality measures.

“So far the system has made a real impact on visualising targets and added value as well as holding practices accountable for their end of delivery.” Said Pinar Johnson, PCN Manager of Northwest Merton PCN

Conclusion

The IIF case study demonstrates how a simple app platform that generates intelligent Dashboards can be used to develop innovative solutions to address complex teamwork challenges in the healthcare system. The practices in the PCN were able to turn a tedious and time-consuming task into a financially profitable one, using a focused dashboard that not only made tracking and reporting more efficient but also helped them identify missed opportunities and easy wins, resulting in a £20,000 income in one week. The solution enabled the practices to engage and motivate each other, resulting in better collaboration and decision-making. The success of the solution can be attributed to the practices' focus on planning forward, financially focused design, and engagement of every practice in the network.

The system can be used solely by the PCN Manager to input already consolidated data, but involving and engaging member practices has the added benefits of self-responsibility; effective delegation; grass root improvements; and individual learning, not to mention that it makes the PCN Managers life that much easier.