Management Governance

Is there a robust system for analyzing incidents, accidents, and near misses to identify trends and implement lessons learned?

What we look for: Review the incident tracker for the last quarter. Good looks like evidence of root cause analysis and proactive changes to care delivery. Fail if incidents are logged but not analyzed for trends, or staff are unaware of lessons learned.

Evidence: Incident logs, quarterly trend analysis reports, team meeting minutes showing shared learning, updated risk assessments

Does the Registered Manager maintain an accurate training and supervision matrix with clear oversight of compliance and overdue interventions?

What we look for: Check the training matrix. Good looks like over 90% compliance with a clear plan for booking outstanding training or overdue supervisions. Fail if the matrix is out of date, inaccurate, or shows significant unaddressed gaps in mandatory training.

Evidence: Electronic training matrix, supervision schedule, booked training records, staff files

Are all safeguarding concerns accurately logged, investigated in partnership with the local authority, and submitted as CQC statutory notifications?

What we look for: Cross-reference the safeguarding log with CQC notifications. Good looks like prompt reporting (within 24-48 hours) and internal investigations running parallel to LA processes. Fail if notifications are missed, delayed, or outcomes are not recorded.

Evidence: Safeguarding log, CQC notification portal records, local authority correspondence, safeguarding policy

Are complaints and concerns effectively managed, responded to within policy timeframes, and used to drive continuous improvement?

What we look for: Sample 2 recent complaints. Good looks like empathetic, timely responses with clear outcomes and evidence of service changes where applicable. Fail if complaints are ignored, defensive responses are sent, or timeframes are breached without communication.

Evidence: Complaints log, response letters, complaints policy, quality improvement plan

Are there effective mechanisms for the management team to engage with staff, actively promoting a positive culture and 'Freedom to Speak Up'?

What we look for: Look for evidence of two-way communication. Good looks like staff surveys driving actual changes (e.g. routing adjustments, pay structure) and staff knowing who the FTSU guardian is. Fail if feedback is collected but ignored, or staff report a closed culture.

Evidence: Staff survey results, action plans from surveys, supervision records, details of the Freedom to Speak Up Guardian

Are comprehensive quality assurance audits completed on schedule, with clear, time-bound action plans that are monitored until completion?

What we look for: Sample 3 recent audits. Good looks like clear identification of shortfalls with specific actions, owners, and deadlines. Fail if audits are a tick-box exercise, actions are open without progress, or audits are missed.

Evidence: Audit schedule, completed audit tools (e.g. care plans, meds), action plans, sign-off records

Are all organisational policies and procedures up to date, aligned with current legislation (e.g., MCA, Health and Safety), and accessible to staff?

What we look for: Review the policy index and sample 3 key policies. Good looks like policies reviewed within the last year, reflecting current local guidelines, and easily accessible by field staff. Fail if policies reference outdated legislation (e.g., DoLS instead of LPS preparations, old safeguarding boards).

Evidence: Policy index, updated policies (Safeguarding, Whistleblowing), staff handbooks, digital portal access logs

Does the service have a robust, tested Business Continuity Plan (BCP) that covers severe weather, IT failure, and staffing crises?

What we look for: Check the BCP. Good looks like specific, actionable steps for domiciliary care scenarios (e.g., prioritizing highly dependent clients during snow). Fail if the BCP is a generic template, out of date, or lacks prioritized client lists.

Evidence: Business Continuity Plan, emergency contact lists, testing/drill records, risk register