Humberside LMCs CQC

Self-Assessment form

Please answer the following questions as honestly/openly as possible. We want to ensure that the sessions meet the needs of those attending so we need to have a clear idea of your current needs as a Practice Manager or CQC Lead and for your practice overall. Your individual response will only be used to inform the content of the webinars and will not be shared on an individual basis with Humberside LMCs, CQC or any other organisation

Name *

First

Last

Practice *

Practice Website / URL *

Date of last inspection *

Most recent rating *

How do you, other managers and partners at your practice feel if/when your CQC inspection date is announced? *

It's not something we love but we feel confident we are in a good position, without a huge amount of work, to be ready for an inspection whenever it is announced	A bit anxious - we know we will get everything ready to be in a good position once the inspection starts but we know it will be quite a lot of work leading up to the inspection date	Quite stressed - we will have a lot to find/arrange/create and I'm not looking forward to the date as there will be a huge amount to do and I think we will struggle to get it all done	Extremely stressed - We are not at all ready for an inspection and the amount of work will be overwhelming to get us in a position for an inspection
It's not something we love but we feel confident we are in a good position, without a huge amount of work, to be ready for an inspection whenever it is announcedItem #1 It's not something we love but we feel confident we are in a good position, without a huge amount of work, to be ready for an inspection whenever it is announced	A bit anxious - we know we will get everything ready to be in a good position once the inspection starts but we know it will be quite a lot of work leading up to the inspection dateItem #1 A bit anxious - we know we will get everything ready to be in a good position once the inspection starts but we know it will be quite a lot of work leading up to the inspection date	Quite stressed - we will have a lot to find/arrange/create and I'm not looking forward to the date as there will be a huge amount to do and I think we will struggle to get it all doneItem #1 Quite stressed - we will have a lot to find/arrange/create and I'm not looking forward to the date as there will be a huge amount to do and I think we will struggle to get it all done	Extremely stressed - We are not at all ready for an inspection and the amount of work will be overwhelming to get us in a position for an inspectionItem #1 Extremely stressed - We are not at all ready for an inspection and the amount of work will be overwhelming to get us in a position for an inspection

Do you / senior management / partnership team have clear accountability and ownership for all areas of CQC compliance? (including medicines management, training, safeguarding, IPC, Health and Safety, Finance, Governance, IT, Compliance (CQC), Patient services and complaints) *

Yes absolutely. Roles and accountability is very clear and the leadership team work well together to oversee the CQC areas not only when an inspection is announced but all year round	Yes to some extent - we do make sure everything is covered but this is usually only a focus when the inspection date is announced	Hmm - its all left to one person to oversee and there is little joint ownership for CQC compliance across the leadership team/partners	This does feel like a gap at the moment
Yes absolutely. Roles and accountability is very clear and the leadership team work well together to oversee the CQC areas not only when an inspection is announced but all year roundItem #1 Yes absolutely. Roles and accountability is very clear and the leadership team work well together to oversee the CQC areas not only when an inspection is announced but all year round	Yes to some extent - we do make sure everything is covered but this is usually only a focus when the inspection date is announcedItem #1 Yes to some extent - we do make sure everything is covered but this is usually only a focus when the inspection date is announced	Hmm - its all left to one person to oversee and there is little joint ownership for CQC compliance across the leadership team/partnersItem #1 Hmm - its all left to one person to oversee and there is little joint ownership for CQC compliance across the leadership team/partners	This does feel like a gap at the momentItem #1 This does feel like a gap at the moment

How well do you think your CLINICAL staff understand the requirements and expectations CQC will be assessing and inspecting? *

Outstanding understanding of the requirements and expectations of CQC	Good understanding of the requirements and expectations of CQC	Understanding of the requirements and expectations of CQC requires improvement	Inadequate understanding of the requirements and expectations of CQC
Outstanding understanding of the requirements and expectations of CQCItem #1 Outstanding understanding of the requirements and expectations of CQC	Good understanding of the requirements and expectations of CQCItem #1 Good understanding of the requirements and expectations of CQC	Understanding of the requirements and expectations of CQC requires improvementItem #1 Understanding of the requirements and expectations of CQC requires improvement	Inadequate understanding of the requirements and expectations of CQCItem #1 Inadequate understanding of the requirements and expectations of CQC

How well do you think your NON-CLINICAL staff understand the requirements and expectations CQC will be assessing and inspecting? *

Outstanding understanding of the requirements and expectations of CQC	Good understanding of the requirements and expectations of CQC	Understanding of the requirements and expectations of CQC requires improvement	Inadequate understanding of the requirements and expectations of CQC
Outstanding understanding of the requirements and expectations of CQCItem #1 Outstanding understanding of the requirements and expectations of CQC	Good understanding of the requirements and expectations of CQCItem #1 Good understanding of the requirements and expectations of CQC	Understanding of the requirements and expectations of CQC requires improvementItem #1 Understanding of the requirements and expectations of CQC requires improvement	Inadequate understanding of the requirements and expectations of CQCItem #1 Inadequate understanding of the requirements and expectations of CQC

Do you have a CQC annual plan for your practice? *

Yes - we have an annual plan that covers all the key activities and actions we need to track and complete to be CQC ready as much as we can be all year round	We create a CQC action plan when the date is announced to make sure everything is ready when the inspection date comes round	We don't have a CQC plan
Yes - we have an annual plan that covers all the key activities and actions we need to track and complete to be CQC ready as much as we can be all year roundItem #1 Yes - we have an annual plan that covers all the key activities and actions we need to track and complete to be CQC ready as much as we can be all year round	We create a CQC action plan when the date is announced to make sure everything is ready when the inspection date comes roundItem #1 We create a CQC action plan when the date is announced to make sure everything is ready when the inspection date comes round	We don't have a CQC planItem #1 We don't have a CQC plan

Do you have processes in place to maintain your CQC requirements all year round? *

Yes - we have robust processes in place followed year-round that I know mean we are on track to deliver against all CQC requirements	Yes - we have some processes in place but I think there is still more we could do to ensure year-round requirements are met	We don't have processes in place that are followed year-round and it tends to feel like a scramble when the inspection is announced
Yes - we have robust processes in place followed year-round that I know mean we are on track to deliver against all CQC requirementsItem #1 Yes - we have robust processes in place followed year-round that I know mean we are on track to deliver against all CQC requirements	Yes - we have some processes in place but I think there is still more we could do to ensure year-round requirements are metItem #1 Yes - we have some processes in place but I think there is still more we could do to ensure year-round requirements are met	We don't have processes in place that are followed year-round and it tends to feel like a scramble when the inspection is announcedItem #1 We don't have processes in place that are followed year-round and it tends to feel like a scramble when the inspection is announced

Do you consider the practice has robust processes for CQC documentation management and audits? *

Yes completely - we know where to find all documents and capture all audit and related information required by CQC	Yes to some extent - we have a number of robust processes that are usually followed and can usually find all the information we need to access	We sometimes struggle to locate files and sometimes our processes are a bit flawed or aren't followed which causes gaps in documentation	Not at all - this is an area that I think needs a fair bit of work to improve at the practice
Yes completely - we know where to find all documents and capture all audit and related information required by CQCItem #1 Yes completely - we know where to find all documents and capture all audit and related information required by CQC	Yes to some extent - we have a number of robust processes that are usually followed and can usually find all the information we need to accessItem #1 Yes to some extent - we have a number of robust processes that are usually followed and can usually find all the information we need to access	We sometimes struggle to locate files and sometimes our processes are a bit flawed or aren't followed which causes gaps in documentationItem #1 We sometimes struggle to locate files and sometimes our processes are a bit flawed or aren't followed which causes gaps in documentation	Not at all - this is an area that I think needs a fair bit of work to improve at the practiceItem #1 Not at all - this is an area that I think needs a fair bit of work to improve at the practice

How confident are you that the CQC documentation and audits have been reviewed within the required timescales? *

Very confident	Confident	Fairly confident	Not confident at all
Very confidentItem #1 Very confident	ConfidentItem #1 Confident	Fairly confidentItem #1 Fairly confident	Not confident at allItem #1 Not confident at all

Does your practice have an auditable system for document management, evidence and audits around CQC requirements? (Covering complaints, SEAs, near misses, team feedback, stakeholder feedback (ICS/CQC), patient feedback) *

Yes - we have a very easy to navigate electronic system(s) where we capture all relevant documentation	Yes to some extent - we do capture most things on a system but it is still sometimes challenging to find things or there are gaps	No - we don't use an electronic system - we use spreadsheets to track and paper documents
Yes - we have a very easy to navigate electronic system(s) where we capture all relevant documentationItem #1 Yes - we have a very easy to navigate electronic system(s) where we capture all relevant documentation	Yes to some extent - we do capture most things on a system but it is still sometimes challenging to find things or there are gapsItem #1 Yes to some extent - we do capture most things on a system but it is still sometimes challenging to find things or there are gaps	No - we don't use an electronic system - we use spreadsheets to track and paper documentsItem #1 No - we don't use an electronic system - we use spreadsheets to track and paper documents

If you were to ask your staff how confident they felt in their knowledge of a CQC area such as safeguarding, how do you think they would score themselves on the below: *

	All staff would confidently know this	Most staff would confidently know this	Some staff would confidently know this	I'm not sure many staff would be clear about this
Who are the Leads and what are their roles within the Safeguarding Area for the practice?	All staff would confidently know thisWho are the Leads and what are their roles within the Safeguarding Area for the practice? All staff would confidently know this	Most staff would confidently know thisWho are the Leads and what are their roles within the Safeguarding Area for the practice? Most staff would confidently know this	Some staff would confidently know thisWho are the Leads and what are their roles within the Safeguarding Area for the practice? Some staff would confidently know this	I'm not sure many staff would be clear about thisWho are the Leads and what are their roles within the Safeguarding Area for the practice? I'm not sure many staff would be clear about this
Do you understand and would you be able to access the processes and documentation required for Safeguarding policies and procedures for the practice?	All staff would confidently know thisDo you understand and would you be able to access the processes and documentation required for Safeguarding policies and procedures for the practice? All staff would confidently know this	Most staff would confidently know thisDo you understand and would you be able to access the processes and documentation required for Safeguarding policies and procedures for the practice? Most staff would confidently know this	Some staff would confidently know thisDo you understand and would you be able to access the processes and documentation required for Safeguarding policies and procedures for the practice? Some staff would confidently know this	I'm not sure many staff would be clear about thisDo you understand and would you be able to access the processes and documentation required for Safeguarding policies and procedures for the practice? I'm not sure many staff would be clear about this

What tool is used within the practice to manage safeguarding compliance *

Paper Folders	Spreadsheet	Patients Clinical Records	Safeguarding Meetings / Minutes	Don't know
Paper FoldersWhat tool is used within the practice to manage safeguarding compliance Paper Folders	SpreadsheetWhat tool is used within the practice to manage safeguarding compliance Spreadsheet	Patients Clinical RecordsWhat tool is used within the practice to manage safeguarding compliance Patients Clinical Records	Safeguarding Meetings / MinutesWhat tool is used within the practice to manage safeguarding compliance Safeguarding Meetings / Minutes	Don't knowWhat tool is used within the practice to manage safeguarding compliance Don't know

Please note, you can select more than one option

If you were inspected tomorrow, how would you score your practice with regards to the management with supporting evidence of the following CQC domain areas:- *

	Outstanding	Good	Requires Improvement	Inadequate
Well Led	OutstandingWell Led Outstanding	GoodWell Led Good	Requires ImprovementWell Led Requires Improvement	InadequateWell Led Inadequate
Safe	OutstandingSafe Outstanding	GoodSafe Good	Requires ImprovementSafe Requires Improvement	InadequateSafe Inadequate
Caring	OutstandingCaring Outstanding	GoodCaring Good	Requires ImprovementCaring Requires Improvement	InadequateCaring Inadequate
Responsive	OutstandingResponsive Outstanding	GoodResponsive Good	Requires ImprovementResponsive Requires Improvement	InadequateResponsive Inadequate
Effective	OutstandingEffective Outstanding	GoodEffective Good	Requires ImprovementEffective Requires Improvement	InadequateEffective Inadequate

Any other thoughts, comments or things you would like covered in the CQC webinar sessions?

Humberside CQC

Humberside LMCs CQC

Self-Assessment form

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