CQC quality statement — Safe
Safe systems, pathways and transitions
"We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services." In MyCareCompliance, 12 mapped checks across 12 audit templates map to this quality statement.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
How we check it
Each check below is a real question from a MyCareCompliance audit template. It names the regulation it evidences, describes what an auditor looks for in good and poor practice, and lists the evidence an inspector would expect you to produce.
- 12 mapped checks under the "Safe systems, pathways and transitions" quality statement
- Evidences 2 regulations: Regulation 12 — Safe care and treatment, Regulation 19 — Fit and proper persons employed
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 12 checks
- Regulation 12 — Safe care and treatmentBusiness Continuity
Are all service users RAG-rated (Red, Amber, Green) or similarly prioritised to ensure essential care is delivered during a staffing crisis or emergency?
What we look for: Sample 5 service user files and the master emergency dependency list. You should clearly see who requires immediate, life-sustaining care (Red) vs those whose visits could be delayed or cancelled safely (Green). Fail if this is absent or not updated.
Evidence: Service user dependency lists, RAG rating matrix, Emergency scheduling plans, Care plans
- Regulation 12 — Safe care and treatmentCommissioned vs Delivered Care
Is there a robust system for monitoring, reporting, and responding to late or missed calls in real-time?
What we look for: Check how the service monitors ECM for delayed visits. Evaluate the response to a recent late/missed call. Failure to identify a missed call promptly or lacking a clear escalation process constitutes a fail.
Evidence: Missed call logs, ECM live dashboard, On-call records, Incident reports
- Regulation 12 — Safe care and treatmentContinuity of Care
Are missed, late, or truncated care calls robustly monitored, investigated, and actioned to prevent recurrence?
What we look for: Review the ECM dashboard and missed/late call logs for the past month. Look for timely management response and clear root cause analysis. A fail is ignoring alerts or failing to notify the service user of delays.
Evidence: ECM alerts, missed call logs, incident reports, duty manager handover notes, safeguarding referrals (if applicable)
- Regulation 19 — Fit and proper persons employedDriving Compliance
Does the provider maintain a robust system to track and verify the ongoing roadworthiness (MOT) and road tax status of all staff vehicles used for work?
What we look for: Check the provider's tracking matrix for MOT and Tax expiry dates. Good practice includes using the government website to verify status rather than relying on staff word. A fail is expired MOTs or unmonitored vehicle compliance.
Evidence: Gov.uk MOT/Tax check printouts, Vehicle compliance tracker, Reminder system/alerts
- Regulation 12 — Safe care and treatmentEmergency / On Call
Do on-call staff have secure, immediate access to up-to-date client care plans, risk assessments, and staff contact details?
What we look for: Test the remote access capabilities of the on-call equipment to verify live access to client and staff data. Good practice ensures secure, GDPR-compliant access to electronic care records. A fail would be on-call staff relying on outdated paper summaries or being unable to access critical risk assessments in an emergency.
Evidence: On-call mobile/laptop audit, digital system access logs, BCP access
- Regulation 12 — Safe care and treatmentFalls Management
Is there evidence that staff follow the correct immediate post-fall protocol when a person falls?
What we look for: Review 3 recent falls incidents. Check that staff checked for injury, did not move the person inappropriately, and sought medical advice (e.g., 111/999) if head injury or suspected fracture occurred. Fail if staff inappropriately lifted a service user without clearance.
Evidence: Incident reports, daily logs, post-fall checklists, call logs to 111/999
- Regulation 12 — Safe care and treatmentHospital Transitions
Are 'Hospital Grab Bags' or emergency information packs available and up to date in the person's home to support safe emergency admission?
What we look for: Sample 3-5 files of people with fluctuating health or recent admissions. Check if a hospital transfer document exists and includes baseline observations, current medicines, and communication needs. A fail is an outdated or missing pack that delays vital information sharing with paramedics.
Evidence: Hospital passports, PRSB 'About Me' documents, Medication administration records (MAR), ReSPECT/DNACPR forms
- Regulation 12 — Safe care and treatmentMissed Visits Audit
Are all missed visits logged accurately and escalated immediately in line with the provider's missed visits and emergency response policy?
What we look for: Sample 3-5 recent missed visits or late calls. Check that the office/on-call team responded immediately to ECM alerts or client calls. A fail is if visits are missed without an immediate welfare check or escalation process being followed.
Evidence: Missed visit log, On-call logs, ECM (Electronic Call Monitoring) alerts, Incident reports
- Regulation 12 — Safe care and treatmentPolicy & Procedure Audit
Does the Business Continuity plan provide actionable procedures for emergencies specific to a domiciliary care service?
What we look for: Review the Business Continuity plan for scenarios like severe weather, mass staff sickness, cyber-attacks, or office power failure. It must include a robust priority rating system for service users. A fail is a generic plan lacking prioritized lists for missed visits.
Evidence: Business continuity plan, on-call folder, IT failure procedure, severe weather plan
- Regulation 12 — Safe care and treatmentRota / Staffing Capacity
Is there a robust system to monitor and respond to missed, late, or shortened visits in real-time?
What we look for: Examine ECM alert logs and management responses for the last month. Assess if alerts for late/missed calls are investigated and actioned immediately to prevent harm. A fail is unacknowledged ECM alerts or failure to contact the person/family when delays occur.
Evidence: Electronic Call Monitoring (ECM) alerts, late/missed call logs, incident reports, daily handover notes
- Regulation 12 — Safe care and treatmentService User Reviews Audit
Where a review identifies a change in care delivery, is the care plan updated and communicated to all relevant care staff immediately?
What we look for: Verify that staff are actually working from the newly updated plan. Check handover notes or digital system alerts to ensure staff were briefed on the changes. Fails if staff are unaware of the updated needs.
Evidence: Updated care plans, Staff communication logs, Digital care planning system alerts
- Regulation 12 — Safe care and treatmentSkin Integrity
Is there clear evidence in daily logs and repositioning charts that repositioning and skin checks are completed as prescribed?
What we look for: Review daily logs for consistency. Good looks like repositioning recorded at exact prescribed intervals with notes on skin condition. A fail is gaps in recording or simply writing 'turned' without specifying position or skin checks.
Evidence: Daily care notes, Repositioning charts, Fluid/turn charts
Other Safe quality statements
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