The checklist below outlines examples of the information and evidence that inspectors are likely to request and review during their visit. Achieving as many “Yes” responses as possible will demonstrate compliance and preparedness. Where a “No” response is identified, appropriate corrective action should be taken promptly to address the gap prior to the next inspection.

All supporting documentation should be maintained in clearly labelled folders, organised in line with the relevant CQC regulations to which they relate. Documents should be up to date, easily accessible, and logically filed to enable prompt retrieval during the inspection. This will help ensure that interviews and evidence reviews proceed smoothly and will demonstrate an organised, well-governed service.

The General Risk Assessment is a formal document used to identify, evaluate, and manage potential risks that may impact patients, staff, visitors, and the overall operation of the service. It ensures that hazards within the workplace and clinical environment are systematically assessed and that appropriate control measures are implemented to minimise the likelihood of harm.

This assessment considers a wide range of risks, including environmental hazards, clinical and non-clinical activities, equipment use, infection prevention and control, fire safety, lone working, security, and health and safety compliance. Each identified risk is reviewed to determine its likelihood and potential impact, and a risk rating is assigned accordingly.

Where risks are identified, proportionate control measures are documented, along with any additional actions required to further reduce risk. Responsibilities for implementing actions are clearly assigned, and timescales for completion are specified. The assessment is reviewed regularly, or sooner if there are significant changes to the premises, workforce, services provided, legislation, or following an incident.

The General Risk Assessment supports compliance with CQC regulations, health and safety legislation, and governance requirements. It demonstrates the organisation’s proactive approach to maintaining a safe, well-led, and effective service.

The Infection Prevention and Control (IPC) Internal Audit is a structured review process undertaken to assess the organisation’s compliance with current infection control standards, national guidance, and regulatory requirements. The purpose of the audit is to ensure that effective systems are in place to prevent, identify, and manage the risk of infection to patients, staff, and visitors.

The audit evaluates key areas including hand hygiene compliance, use of personal protective equipment (PPE), cleaning schedules and environmental cleanliness, waste management, sharps safety, decontamination of equipment, specimen handling, vaccination status of staff (where applicable), and adherence to relevant policies and procedures. It also reviews staff training records, availability of IPC resources, and evidence of risk assessments.

Findings from the audit are documented, with areas of good practice highlighted and any identified gaps clearly recorded. Where improvements are required, an action plan is developed outlining corrective measures, responsible individuals, and timescales for completion. Progress against actions is monitored to ensure continuous improvement.

The IPC Internal Audit is conducted at regular intervals and following any significant incidents or outbreaks. It provides assurance to leadership and regulators, including the Care Quality Commission (CQC), that the service maintains a safe, clean, and compliant clinical environment.

The Clinical Governance and Quality Assurance Policy outlines the framework through which the organisation ensures the delivery of safe, effective, caring, responsive, and well-led services. It sets out the systems and processes in place to monitor, evaluate, and continuously improve the quality of care provided to patients.

This policy defines the responsibilities of clinical and non-clinical staff in maintaining high standards of professional practice, patient safety, and regulatory compliance. It incorporates key elements of clinical governance, including risk management, incident reporting and learning, safeguarding, infection prevention and control, audit and service evaluation, staff training and appraisal, complaints management, patient feedback, and adherence to evidence-based guidelines.

The policy details how performance is measured through regular audits, data monitoring, peer review, and quality improvement initiatives. It also explains how learning from incidents, complaints, significant events, and external inspections is embedded into practice to drive continuous improvement.

Clear lines of accountability are established to ensure effective oversight by senior leadership, with regular governance meetings held to review performance, risks, and action plans. The policy supports compliance with Care Quality Commission (CQC) regulations and other relevant statutory and professional standards, demonstrating the organisation’s commitment to delivering high-quality, patient-centred care.