CQC Notifications Audit

Is there documented evidence that learning and subsequent actions from notified incidents are reviewed to prevent reoccurrence?

What we look for: Trace a notified incident through to its conclusion. Good looks like discussion at team meetings, updated risk assessments, or policy reviews as a direct result of the incident. Fails if notifications are treated merely as a compliance tick-box with no subsequent learning loop.

Evidence: Governance Meeting Minutes, Quality Assurance Reports, Updated Care Plans/Risk Assessments

Does a cross-reference of the central incident, accident, and safeguarding logs confirm that all notifiable events have been reported to the CQC?

What we look for: Sample the last 3 months of incidents, accidents, and safeguarding concerns. Good looks like every notifiable event (e.g., serious injury, abuse allegation) has a corresponding CQC notification on file. Fails if you find events that met the threshold but were not notified.

Evidence: Accident/Incident Log, Safeguarding Tracker, CQC Notification Submissions Log

Are all incidents involving police attendance or criminal investigations related to service users or staff correctly notified?

What we look for: Check incident logs for any mention of 999/101 calls or police attendance at a service user's home. Good looks like immediate notification to CQC when police investigate an incident involving the service. Fails if police involvement is treated as an internal matter only.

Evidence: Daily Logs, On-call logs, Notification records, Local Authority safeguarding minutes

Are all deaths of people using the service appropriately notified to the CQC, regardless of the cause or location of death?

What we look for: Review the roster/discharge list for service users who have passed away. Good looks like a Notification of Death is submitted for every deceased service user where regulated activity was being provided. Fails if deaths in hospital (while still on service) are missed.

Evidence: Service User Discharge/End of Life Log, Notification of Death records, CQC Portal Receipts

Do the Registered Manager and delegated on-call senior staff accurately understand which events require a statutory CQC notification?

What we look for: Question the RM and a senior/on-call staff member on notification thresholds (e.g., pressure ulcers, police, safeguarding). Good looks like confident, accurate knowledge of the required events. Fails if on-call staff do not know what warrants an immediate notification versus local logging.

Evidence: Staff Interview notes, On-call handover records, Competency assessments

Is there a robust, up-to-date policy and procedure for CQC statutory notifications that details what, when, and how to report?

What we look for: Review the notifications policy. Good looks like a clear, accessible guide detailing all notifiable events, timelines, and the provider portal process. Fails if the policy refers to outdated legacy forms or lacks clarity on off-hours reporting.

Evidence: Notifications Policy, Incident Management Policy, Staff Handbook

Are CQC statutory notifications submitted 'without delay' according to the required regulatory timeframes?

What we look for: Compare the time of the incident to the timestamp of the CQC submission receipt. Good looks like submissions made within 24-48 hours, or immediately for serious events. Fails if notifications are routinely delayed or batched at the end of the week.

Evidence: CQC Submission Receipts, Incident Logs with timestamps, On-call records

Are notification forms accurately completed with sufficient detail while strictly preserving the anonymity of the service user?

What we look for: Read a sample of recent notifications. Good looks like clear, factual descriptions of the event and actions taken, using unique IDs rather than names. Fails if service user names or highly identifiable information are inappropriately shared in the narrative.

Evidence: Copies of submitted CQC Notifications, Service User Care Plans (for cross-referencing)