Survelix CQC Compliance Resource
Governance and Quality Assurance Framework
Monthly governance calendar, audit schedule, QA meeting agenda, and quality improvement tracker
About this framework
Failures in governance are the most common root cause behind Inadequate overall CQC ratings. Inspectors look for evidence of a functioning quality assurance system: audits that are completed and acted upon, meetings that produce actionable minutes, and a culture of continuous improvement. This framework provides the operational structure. Authored by Cheta Ikemsinachi Ogbuzuru.
Complete this schedule at the beginning of each year. Assign a named lead for each audit. Track completion monthly. Inspectors will expect to see a complete 12-month audit record. Gaps or incomplete audits are a direct finding against Regulation 17.
| Audit | Frequency | Audit Lead | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Medicines Management | Monthly | |||||||||||||
| MAR Chart Review (sample) | Monthly | |||||||||||||
| Care Plan Quality | Monthly (x5) | |||||||||||||
| Infection Prevention & Control | Monthly | |||||||||||||
| Health & Safety | Monthly | |||||||||||||
| Environmental Safety | Monthly | |||||||||||||
| Safeguarding Records | Monthly | |||||||||||||
| Accidents and Incidents | Monthly | |||||||||||||
| Complaints Register | Monthly | |||||||||||||
| Staffing and Dependency | Monthly | |||||||||||||
| Training Compliance | Monthly | |||||||||||||
| Supervision Records | Quarterly | |||||||||||||
| Service User Satisfaction | Quarterly | |||||||||||||
| Staff Satisfaction | Quarterly | |||||||||||||
| Care Plan Full Review | Annual or PRN | |||||||||||||
| DoLS and MCA Audit | Quarterly | |||||||||||||
| Nutrition and Hydration | Monthly | |||||||||||||
| Pressure Ulcer Prevention | Monthly | |||||||||||||
| Mock CQC Inspection | Annual |
Every governance activity in this calendar must be evidenced with a signed and dated record. Inspectors review these records to determine whether governance is functional or ceremonial.
This agenda ensures every governance meeting covers the required areas. Minutes must name the attendees, record the key discussion points, and list actions with named leads and dates. Minutes filed without actions are not evidence of governance.
| # | Agenda Item | Lead | Key Questions to Address | Actions Arising |
|---|---|---|---|---|
| 1 | Welcome and Apologies | RM / Chair | Who is present? Who has sent apologies? Quorum confirmed? | |
| 2 | Previous Meeting Actions Review | RM | Which actions are complete? Which are outstanding and why? Have outcomes improved? | |
| 3 | Accidents and Incidents Review | RM / Snr Lead | How many incidents this month? Any serious or notifiable events? What themes are emerging? What learning has been shared? | |
| 4 | Complaints and Compliments | RM | How many complaints received? Are all within timescale? What is the outcome? What changes have been made? | |
| 5 | Audit Results Review | Audit Leads | What did each completed audit find? What were the scores? Are there recurring failures? What improvement is evidenced from last month? | |
| 6 | Medicines Report | Medicines Lead | Any MAR errors, storage failures, CD discrepancies, or near misses? What actions have been taken? | |
| 7 | Safeguarding Update | Safeguarding Lead | Any new concerns raised? Referrals made? Any ongoing investigations? Are all DOLS authorisations current? | |
| 8 | Staffing and Training Update | RM / HR | Current vacancies and agency use. Training compliance percentage. Any staff with expired mandatory training working shifts? | |
| 9 | Service User Wellbeing Update | Key Workers / Snr Carers | Any individuals with declining health, unexplained weight loss, or withdrawal from activities? What is the response? | |
| 10 | Regulatory and Policy Updates | RM | Any new CQC guidance, regulation changes, or policy reviews due? What action is needed? | |
| 11 | Quality Improvement Projects | RM / Project Leads | Progress update on current improvement projects. Evidence of measurable change? | |
| 12 | Date of Next Meeting and Actions Summary | RM / Chair | Confirm all actions, named leads, and target dates. Confirm next meeting date. |
Every identified quality gap should be entered here and tracked to completion. CQC inspectors review quality improvement evidence to determine whether governance is producing measurable change or simply generating paperwork.
| Ref | Date Identified | Source (Audit / Inspection / Complaint) | Issue Description | Improvement Actions | Lead | Target Date | Status |
|---|---|---|---|---|---|---|---|
| QI-001 | |||||||
| QI-002 | |||||||
| QI-003 | |||||||
| QI-004 | |||||||
| QI-005 | |||||||
| QI-006 | |||||||
| QI-007 | |||||||
| QI-008 | |||||||
| QI-009 | |||||||
| QI-010 |
Status codes: O = Open, IP = In Progress, C = Complete, E = Escalated