Survelix CQC Compliance Resource

CQC Pre-Inspection Readiness Assessment

Comprehensive self-assessment across all five CQC inspection domains

Author: Cheta Ikemsinachi Ogbuzuru

Published via survelix.co

Date: 27 May 2026

CQC SAF 2024

How to use this assessment

Rate each item as: C (Compliant), PC (Partially Compliant), NC (Non-Compliant), or N/A. Record your evidence reference and note any actions required. Complete this assessment at least 8 weeks before an expected inspection. Repeat monthly as a governance quality check.

Safe

% compliant

Effective

% compliant

Caring

% compliant

Responsive

% compliant

Well-led

% compliant

Domain 1: Safe

People are protected from abuse and avoidable harm. This domain frequently features in Requires Improvement and Inadequate ratings due to medicines failures, safeguarding gaps, and inadequate risk management.

#	Requirement	Rating C / PC / NC / N/A	Evidence Reference	Action Required
1.1	All staff have completed safeguarding adults (Level 2) training and records are current within the required renewal period
1.2	A named safeguarding lead is identified and their contact details are accessible to all staff
1.3	All safeguarding concerns have been recorded, investigated, and referred to the local authority where required within the last 12 months
1.4	Deprivation of Liberty Safeguards (DoLS) authorisations are in place for all service users assessed as lacking capacity and being deprived of their liberty
1.5	Medicines are stored in locked, temperature-monitored cabinets. Storage records are maintained and audited monthly
1.6	MAR (Medicines Administration Record) charts are completed with no unexplained gaps or omissions in the last 3 months
1.7	Controlled Drug (CD) register entries are complete, signed by two staff, and balance-checked at every handover
1.8	PRN (as required) medicine protocols are in place for every PRN medicine, detailing symptoms, maximum dose, and review date
1.9	Medicines audits are completed monthly and findings are acted upon with evidence of improvement
1.10	Risk assessments are in place for all identified risks (falls, pressure care, nutrition, behaviour) and reviewed after every incident
1.11	Falls risk assessments use a validated tool (e.g. STRATIFY) and post-fall observations are documented using a recognised protocol
1.12	Pressure ulcer prevention plans are in place for all at-risk service users. Repositioning charts are completed and current
1.13	Infection prevention and control (IPC) audits are completed monthly. PPE is available and staff are trained in its correct use
1.14	Staff are trained in Mental Capacity Act principles and capacity assessments are documented where decisions are made on behalf of service users
1.15	RIDDOR-reportable incidents have been reported to the Health and Safety Executive within the required timeframe
1.16	Equipment is serviced, maintained, and records are available. No out-of-service equipment is in use with service users
1.17	All CQC-notifiable events (deaths, serious injuries, deprivation of liberty) have been notified within the required timeframes

Domain 2: Effective

People's care, treatment and support achieves good outcomes and promotes a good quality of life. Inspectors consistently identify poor care planning, inadequate training, and lack of nutrition monitoring in RI reports.

#	Requirement	Rating	Evidence Reference	Action Required
2.1	Care plans are person-centred, written in the first person, and reflect each service user's individual preferences, needs, and choices
2.2	Care plans are reviewed at least every 12 months, or immediately following a significant change in needs. Review dates are documented
2.3	Pre-admission assessments capture health, social, cultural, religious, and communication needs before the service user moves in
2.4	Nutritional screening (MUST or equivalent) is completed on admission, reviewed monthly, and action taken for any scores above zero
2.5	Weight monitoring is carried out at the frequency specified in the care plan. Unexplained weight loss is escalated to the GP
2.6	Fluid intake records are completed daily for service users on fluid monitoring. Dehydration risk is included in care plans
2.7	All staff have completed a Care Certificate or equivalent induction within 12 weeks of starting, with documented sign-off
2.8	Mandatory training completion rates meet the provider's own minimum standard (typically 85%+) for all mandatory subjects
2.9	Specialist training is in place for any clinical needs present in the service (e.g. PEG feeding, complex epilepsy, end of life care)
2.10	Staff supervision is carried out at the frequency specified in the supervision policy. Records are maintained for all staff
2.11	Annual appraisals are completed for all staff and records are retained. Development needs identified at appraisal are followed up
2.12	Mental capacity assessments are completed on a decision-specific basis. Best interest decisions are documented with relevant people involved
2.13	Oral health assessments are completed for all service users. Dental access is facilitated where required
2.14	Healthcare appointments (GP, dentist, optician, specialist) are tracked and attended. Outcomes are recorded in care notes
2.15	End of life care plans (including DNACPR status, advance directives, and preferred place of death) are in place for all service users with terminal conditions or advanced frailty

Domain 3: Caring

Staff involve and treat people with compassion, kindness, dignity, and respect. While Caring is the domain most frequently rated Good or Outstanding, specific failures around consent, dignity during personal care, and lack of involvement attract critical findings.

#	Requirement	Rating	Evidence Reference	Action Required
3.1	Consent is obtained and documented before all care interventions. Where capacity is absent, best interest decisions are recorded
3.2	Privacy and dignity is maintained during personal care. Room doors are closed, curtains are drawn, and staff knock before entering
3.3	Care notes use respectful, person-centred language. Derogatory, dismissive, or infantilising language is absent from all records
3.4	Service users' cultural, religious, and personal preferences are documented and actively incorporated into daily care
3.5	Service users are involved in their care planning reviews and their views are documented. Where a person lacks capacity, families or advocates are involved
3.6	Relatives and next of kin receive regular updates about their family member's wellbeing. Communication preferences are respected
3.7	Emotional wellbeing assessments are in place for all service users. Low mood, withdrawal, or changed behaviour is identified and responded to
3.8	Complaints about dignity, respect, or personal care are taken seriously. Investigation records show the service user's experience was considered central
3.9	Staff training includes dignity in care, equality and diversity, and person-centred approaches. Completion records are current
3.10	Service users can access an independent advocate where required. Information about advocacy services is available to all service users and families

Domain 4: Responsive

Services are organised so that they meet people's needs. Common RI findings in this domain include poor complaints handling, activities that are not tailored to individuals, and waiting times for care.

#	Requirement	Rating	Evidence Reference	Action Required
4.1	A complaints policy is in place and accessible to service users and families. Complaint records for the last 12 months are available
4.2	All complaints are acknowledged within 3 working days and investigated within the timescales set in the policy. Written outcomes are sent to complainants
4.3	Learning from complaints is evidenced. Changes made as a result of complaints are documented in governance records
4.4	Activities are tailored to individual preferences, abilities, and cultural interests. Generic group activities are not the only provision offered
4.5	Activity records show evidence of individual engagement and note the service user's response. Activities are not recorded as simply "attended"
4.6	The service has a clear system for identifying when a service user's needs have changed and care plans are updated accordingly
4.7	Hospital transitions and discharge planning are documented. Handover information is shared with receiving services in a timely manner
4.8	Service users who have protected characteristics (disability, race, religion, sexual orientation) have their specific needs considered in care planning
4.9	Interpreter or communication support is arranged for service users for whom English is not their first language, or who have communication needs
4.10	Visiting times and visiting arrangements do not unnecessarily restrict family and friends. Any restrictions are proportionate, justified, and documented

Domain 5: Well-led

Leadership, management, and governance assures high-quality, person-centred care, supports learning and innovation, and promotes an open, fair culture. Well-led failures are the single most common root cause behind Inadequate overall ratings.

#	Requirement	Rating	Evidence Reference	Action Required
5.1	A registered manager is in post and registered with CQC. Their registration is current. They are available and visible to staff and service users
5.2	The service has a documented governance framework. Audits are carried out on a scheduled cycle and results are reviewed by the registered manager or provider
5.3	Audit results are acted upon. Quality improvement plans are produced, monitored, and completed. No audit has been filed without action
5.4	Quality assurance meetings are held monthly. Minutes include agenda items, attendance, actions agreed, and completion of previous actions
5.5	An incident register is maintained. All incidents are reviewed for themes. Root cause analysis is completed for serious incidents
5.6	Staff are aware of the whistleblowing policy and feel safe to raise concerns. There is evidence that concerns raised by staff have been taken seriously
5.7	The service's Statement of Purpose is current, accurate, and reflects the services actually provided. It is submitted to CQC within required timeframes
5.8	All policies are reviewed within the required cycle (typically annually). Out-of-date policies have been identified and updated
5.9	The Regulation 17 (Good Governance) quality assurance system produces documented evidence of oversight, including audits, surveys, and spot checks
5.10	Service user and family satisfaction surveys are completed at least annually. Results are analysed and communicated to staff and families
5.11	CQC notifications have been submitted for all notifiable events in the last 12 months. The notifications register is current
5.12	The service has a current business continuity plan covering staffing emergencies, system failures, and pandemic or major incident scenarios
5.13	The registered manager and senior team are up to date with CQC guidance, regulatory changes, and sector developments. Evidence of CPD is maintained

Priority Action Plan

List your top priority NC and PC items below. Assign responsibility and a target completion date. Review at your next governance meeting.

Ref	Gap / Issue	Root Cause	Action Required	Lead Person	Target Date

Authored by: Cheta Ikemsinachi Ogbuzuru

Published via Survelix (survelix.co) for Custoris Ltd

CQC Single Assessment Framework reference. For governance purposes only.

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