Survelix CQC Compliance Resource
CQC Evidence Portfolio Builder
A complete reference guide for gathering, organising, and presenting CQC inspection evidence across all 34 quality statements
Author: Cheta Ikemsinachi Ogbuzuru
Published via survelix.co
Version: 27 May 2026
All 5 Domains
About this guide
This guide is built from direct analysis of CQC Requires Improvement and Inadequate inspection reports published between 2021 and 2024. It identifies exactly what evidence inspectors look for under each quality statement, what evidence fails, and the most common gaps that cause providers to miss Good. Authored by Cheta Ikemsinachi Ogbuzuru.
Part 1: What CQC Inspectors Actually Look For
The most common evidence failure in Requires Improvement reports
Inspectors do not primarily assess policies. They assess outcomes. A policy that says "we will do X" is not evidence that X happens. Evidence must show that the practice described is occurring regularly, consistently, and traceably. The most common reason providers fail to move from Requires Improvement to Good is not the absence of documents. It is the presence of documents that do not reflect actual practice, are out of date, or cannot be cross-referenced to individual service users.
| Evidence Type | What it Must Show | Common Failure | What Good Looks Like |
|---|---|---|---|
| Training records | That every staff member has completed required training and it is current | Records are out of date; expired training not identified before inspection; no evidence that expired staff were stood down | Training matrix current within 7 days of inspection; expired courses flagged in advance; agency staff training verified |
| Care plans | That each service user has an individual, person-centred plan reflecting current needs | Generic plans copied between service users; plans not updated after hospital admissions or incidents; no evidence of service user involvement | Plans reviewed and signed by service user within last 3 months; review triggered by any change in need; language is personal and specific |
| Incident records | That incidents are identified, investigated, and used for learning | Incidents recorded but not investigated; no learning shared with staff; similar incidents recurring | Root cause analysis completed; learning recorded; staff briefing note referencing the incident on file |
| Audit reports | That quality checks are completed and improvements are made | Audit forms completed but no actions taken; same findings recurring month after month; no improvement trend | Actions completed within agreed timescales; follow-up audit shows improvement; results presented at governance meeting |
| Supervision records | That staff receive regular, documented supervision covering practice and wellbeing | Records show only date and topic; no evidence of two-way discussion; gaps of 4+ months between sessions | Records show specific discussion points, agreed actions, and staff response; completion within policy timescales |
| Risk assessments | That risks are identified, proportionate, reviewed, and actioned | Assessments not reviewed after incidents; risk level unchanged despite deteriorating condition; no management plan attached | Assessment reviewed within 48 hours of any incident; management plan attached and staff aware of it |
| Medicines records | That medicines are managed safely, accurately, and transparently | Gaps in MAR charts; no PRN protocols; CD discrepancies unexplained; expired medicines in cabinet | Zero unexplained MAR gaps; PRN protocols in place and referenced; CD balance checked and signed at every handover |
Part 2: Evidence Reference Map - All 34 Quality Statements
Use this map to locate and organise your evidence before inspection. For each quality statement, tick whether evidence is available and current. Note where evidence is held. Assign a gap rating: Green (fully evidenced), Amber (partially evidenced), Red (gap or missing).
Safe
Safe Domain | Ref | Quality Statement | Evidence to Locate | Where Held | Status | Gap / Action |
|---|---|---|---|---|---|
| S1.1 | Learning culture | Incident register, learning logs, staff briefing records, de-brief meeting minutes | |||
| S1.2 | Safe systems, pathways and transitions | Hospital admission/discharge records, handover documents, care pathway records | |||
| S1.3 | Safeguarding | Safeguarding training records, referral logs, risk assessments, local authority correspondence | |||
| S1.4 | Involving people to manage risks | Risk assessment sign-offs, care plan consent records, best interest meeting notes | |||
| S1.5 | Safe environments | Environmental risk assessments, equipment service records, H&S walk-round reports | |||
| S1.6 | Safe and effective staffing | Training matrix, competency assessments, rota records with CVE compliance status | |||
| S1.7 | Infection prevention and control | IPC audit reports, PPE stock records, outbreak management records | |||
| S1.8 | Medicines optimisation | MAR chart audits, medicines audit reports, CD register, PRN protocols |
Effective
Effective Domain | Ref | Quality Statement | Evidence to Locate | Where Held | Status | Gap / Action |
|---|---|---|---|---|---|
| E2.1 | Assessing needs | Pre-admission assessments, MUST screening, falls risk tools, care plan initial assessments | |||
| E2.2 | Delivering evidence-based care | Clinical guidelines referenced in care plans, specialist referral records, NICE pathway evidence | |||
| E2.3 | How staff, teams and services work together | MDT meeting minutes, referral records, discharge summaries, inter-agency communication logs | |||
| E2.4 | Supporting people to live healthier lives | Health promotion records, GP correspondence, NHS health check records | |||
| E2.5 | Monitoring and improving outcomes | Outcome measurement records, weight monitoring charts, QA reports with trend data | |||
| E2.6 | Consent to care and treatment | Consent forms, capacity assessments, best interest decisions, DoLS authorisations |
Caring
Caring Domain | Ref | Quality Statement | Evidence to Locate | Where Held | Status | Gap / Action |
|---|---|---|---|---|---|
| C3.1 | Kindness, compassion and dignity | Satisfaction surveys, compliments register, spot checks, staff training on dignity | |||
| C3.2 | Treating people as individuals | Person-centred care plans, cultural needs documentation, life history records | |||
| C3.3 | Independence, choice and control | Outcome records showing choices made, activity records, independence goal reviews | |||
| C3.4 | Responding to people's immediate needs | Care notes showing response times, call bell response audits, escalation records | |||
| C3.5 | Workforce wellbeing and enablement | Staff survey results, supervision records, wellbeing initiatives, sickness/absence data |
Responsive
Responsive Domain | Ref | Quality Statement | Evidence to Locate | Where Held | Status | Gap / Action |
|---|---|---|---|---|---|
| R4.1 | Person-centred care | Care plan reviews with service user involvement, advocacy records, choice documentation | |||
| R4.2 | Care provision, integration and continuity | Transition records, discharge planning documentation, continuity of carer evidence | |||
| R4.3 | Timely access to care | Appointment tracking records, waiting time data, referral to treatment records | |||
| R4.4 | Listening to and involving people | Resident/family meetings minutes, satisfaction survey results, involvement records | |||
| R4.5 | Equity in access, outcomes and experience | Equality monitoring data, accessible information records, interpreter records |
Well-led
Well-led Domain | Ref | Quality Statement | Evidence to Locate | Where Held | Status | Gap / Action |
|---|---|---|---|---|---|
| W5.1 | Shared direction and culture | Staff handbook, induction records, team meeting minutes, values documentation | |||
| W5.2 | Capable, compassionate and inclusive leaders | RM registration, CPD records, leadership training, 360 feedback | |||
| W5.3 | Freedom to speak up | Whistleblowing policy, speaking up records, staff survey on culture, HR grievance records | |||
| W5.4 | Workforce equality, diversity and inclusion | EDI policy, workforce diversity data, staff EDI training records | |||
| W5.5 | Governance, management and sustainability | Audit schedule and results, QA meeting minutes, quality improvement tracker, Reg 17 report | |||
| W5.6 | Partnerships and communities | External partnership records, community engagement logs, integration meeting minutes | |||
| W5.7 | Learning, improvement and innovation | Lesson learned logs, quality improvement outcomes, pilot initiative records | |||
| W5.8 | Environmental sustainability | Environmental policy, energy/waste management records |
Part 3: Inspection Preparation Timeline
| When | Action | Lead Person | Done | Date |
|---|---|---|---|---|
| 8 Weeks Before | Run full pre-inspection readiness assessment using the Survelix CQC Readiness Checklist | |||
| 8 Weeks Before | Identify all NC and PC items. Create a prioritised action plan with target dates | |||
| 8 Weeks Before | Check training compliance. Identify any expired training and book renewals immediately | |||
| 6 Weeks Before | Complete a full audit of all 5 mandatory monthly audits (medicines, IPC, care planning, H&S, safeguarding) | |||
| 6 Weeks Before | Review all serious incidents from the last 6 months. Confirm learning records are complete and accessible | |||
| 4 Weeks Before | Ensure care plans for all service users are reviewed, updated, and signed within the last 3 months | |||
| 4 Weeks Before | Brief team leads on the 5 CQC domains. Each lead responsible for their domain evidence | |||
| 3 Weeks Before | Compile evidence by quality statement using this portfolio builder as a guide | |||
| 3 Weeks Before | Conduct a mock inspection using a colleague or peer as the inspector | |||
| 2 Weeks Before | Address all gaps identified in mock inspection. File all outstanding audits and action plans | |||
| 2 Weeks Before | Verify all staff have been briefed on their individual compliance status | |||
| 1 Week Before | Final evidence check: all 34 quality statements. Any amber or red items escalated to RM | |||
| Day Before | Ensure all evidence is indexed and retrievable. Brief staff on inspection day procedures | |||
| Inspection Day | Provide inspector with your evidence portfolio index. Be transparent about any known gaps and the actions taken |
Part 4: Top 10 Pitfalls from Inadequate and Requires Improvement Reports
These pitfalls appear repeatedly across inspection reports. Addressing all 10 will substantially reduce your risk of a Requires Improvement rating.
| # | Pitfall | How It Appears in Reports | How to Prevent It |
|---|---|---|---|
| 1 | MAR chart gaps | Inspectors found unexplained omissions in medicines administration records spanning multiple days | Audit MAR charts weekly. Any gap without a documented omission code must be investigated immediately |
| 2 | Generic care plans | "Care plans did not reflect the individual needs of people using the service and appeared to have been copied from previous plans" | Audit 5 care plans monthly using the Survelix care plan quality checker. Review language for personal specificity |
| 3 | Expired staff training | "Staff were found to be working with service users while their mandatory training had lapsed" | Check training compliance before every rota sign-off. Non-compliant staff must not be scheduled without documented risk assessment |
| 4 | Audit without action | "The provider completed monthly audits but there was no evidence that actions were taken or that quality had improved" | Every audit must have a signed action plan. Actions reviewed at governance meeting. Repeat audit confirms improvement |
| 5 | DoLS not applied for | "Several people were being deprived of their liberty without a Deprivation of Liberty Safeguards authorisation in place" | Complete DoLS eligibility screening on admission. Review DoLS status at every care plan review and any change in restrictions |
| 6 | PRN medicines without protocols | "As required medicines were administered without a written protocol to guide staff on when and how to use them" | Ensure every PRN medicine has a written protocol. Audit PRN administration records monthly. Protocol must be signed by GP |
| 7 | Incidents not notified to CQC | "The registered manager was not aware that several events required notification to CQC under Regulation 18" | Maintain a notifications log. Review Regulation 18 notification requirements with all senior staff. Notify within required timeframes |
| 8 | Supervision gaps | "Several staff had not received supervision for more than 6 months. Records did not evidence meaningful discussion" | Supervision due dates tracked in HR system. Overdue supervisions highlighted at governance meeting. Records must reflect actual discussion |
| 9 | Inconsistent care notes | "Care notes did not reflect the care described in the care plan. There was no evidence of person-centred recording" | Care notes training included in induction and annual update. Sample of notes reviewed monthly for quality |
| 10 | No evidence of learning | "Despite multiple incidents of a similar nature, the provider could not demonstrate that learning had been shared or implemented" | After every serious incident: produce a written learning brief, share at team meeting, record staff attendance, file with incident record |
Authored by: Cheta Ikemsinachi Ogbuzuru
Published via Survelix (survelix.co) for Custoris Ltd
Based on analysis of CQC Inspection Reports 2021-2024. References: CQC Single Assessment Framework; HSCA Regulated Activities Regulations 2014