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Preparing for Site-Inspections

Last minute preparations

Update your evidence

Make sure all your evidence and logs are up to date. If you are short of time, make sure at least the following are updated and create a quick schedule of when you plan to review the rest, even if this is after the inspection, to demonstrate it's under control.

  • Infection control checks
  • Complaints logs
  • Incident logs
  • Safeguarding events log
  • Fire alarm checks
  • Recruitment and DBS checks

Overlooked problems

It is easy to become used to things that are not quite right.

This is not dissimilar to moving into a new house and thinking that the first thing you will change are the bright purple carpets. Two weeks later you think that you will concentrate on doing the walls and change the carpets later. Six months down the line, other things have taken priorities and you almost don't notice the bright purple carpets anymore, till someone visits and points them out to you.

Always carry out a walk-through of the premises with a fresh pair of eyes, perhaps get independent persons to do this objectively

Disruptive Staff

If you have a difficult staff member, especially with grievances, give them the day off

  • Tell Inspector up front, better still have a pre-prepared note explaining why you have done this
  • Give inspector contact details (ensure you have permission) if the Inspector wants to interview them
  • Make full disclosure of what you have done and why

Why do this

  • You have control of the narrative
  • You will demonstrate that you are aware of the problem
  • You ensure that the 99% GOOD is not tainted by the 1% bad
  • You declared it up front so the CQC have to include this in their report
  • If they don't give you credit, you can challenge on factual inaccuracy and get the report amended

If you don't take these steps, then the CQC will hear from staff first, and if it goes into the report, you have no other grounds to mitigate or challenge factual accuracy of the findings

Disruptive staff and grievances are part of life, there is no need to hide it, but you can show you are trying to manage it responsibly. Some staff can be hard to manage and employment laws favour employees, the Inspector will understand this

Misuse of Medical Fridges

Poor practices to avoid

  • Staff storing their sandwiches and other edibles in the medicine fridges
  • Dirty and stained insides of fridge
  • Fridge temperature logs not being maintained

Staff Briefing

A staff briefing will help calm nerves and instill confidence. Use it to boost morale and remind them of positive achievements.
Remind people about basics such as:-

  • Signing in procedures
  • Infection control
  • Hand Hygiene
  • Safeguarding
  • Confidentiality and IG Governance

Brief key staff

  • Inform the key members of your team about the inspection.
  • Keep a good perspective and don't panic staff
  • Have a quick staff meeting to assure staff that everything is under control. Answer questions if they are worried
  • Let them be themselves without fear of saying or doing the wrong thing on the day
  • Make sure all key staff are avalable on the day, and you are not short-staffed on the day

Notice Boards

Public Notice Board
Purge the notice public boards of all old and dog eared notices and replace with current information. Remember, one out of date poster undermines the relevancy of all other information

Staff Notice Boards
This indicates how well informed your staff are. e.g. a work place risk assessment pinned to the notice board gives assurance that not only have you conducted the Risk assessment but have ensured that staff are aware of the risks.

Things that you may consider displaying are
• Statutory notices (required by law)
• Current employers liability insurance
• Workplace Risk Assessment
• Health & Safety Law Poster
• Safe Working Practices poster
• Manual Handling techniques poster
• Fire extinguishers – what the different types are for and how to use them
• Health and Safety Policy

Medicines Management

  • Check your security of storage is up to scratch
  • Ensure that your fridge monitoring temperature logs are available
  • Discard any out of date medicines
  • Ensure that there are no medicines 'lying' around in office or clinical areas
  • Ensure there are no medicines lying around in public areas

Deep Clean your premises

A CQC visit is about putting your best foot forward.

  • If you need to, get a professional cleaning service to deep clean
  • Get specialists if you are in a clinical environment
  • Spring clean your premises, first impressions matter
  • Infection control walks hand in hand with cleaning
  • Ask your infection control lead to carry out a quick infection control audit so that nothing is missed

Questions CQC Inspectors ask your staff

Some of the most common questions CQC inspectors ask your staff.

Can your staff answer these? Print this out and use as your checklist    
1.1 How long have you been working here?      
1.2 How did you apply for the job?      
1.3 What it is that you do at the practice?      
1.4 Do you have a job description/ clear role responsibility?      
1.5 Do you have a contract?      
1.6 Were you given a staff handbook when you joined or since?      
1.7 Do you know where to locate the staff handbook?      
1.8 Name one good thing you like about your work?      
1.9 Do you have any concerns?      
1.10 Do you feel supported?      
2.1 How are you treated by the management and Partnership?      
2.2 Did you have an interview when you applied for the job?      
2.3 Were references taken when you were appointed?      
2.4 Did you have a CRB/DBS check for the current position?      
2.5 Do you have staff appraisal?      
2.6 When was your last appraisal?      
2.7 How did you follow up to the objectives & action plan set out in your appraisal?      
3.1 Do you have regular meetings as a practice or individual?      
3.2 Are you included in adding to the agenda?      
3.3 Do you receive meeting minutes?      
3.4 How are action points arising from the meetings followed up?      
4.1 Do you know about vulnerable adults and children?      
4.2 Who is the safeguarding lead at the practice?      
4.3 What are the practices' out of hours' arrangements?      
4.4 Are you aware of a whistle blowing policy?      
4.5 Do you feel free to blow the whistle if and when necessary?      
4.6 Do you know about the complaints procedure and can you describe it?      
4.7 How do you react when you read NHS choices, if there is a complaint?      
4.8 Have you received training?      
4.9 What courses have you been on?      
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