Issues usually arise when a CQC action plan is approached as an individual task. And for Registered Managers, drawing up these plans can often present as a firefighting activity. However, it is usually simple shifts in approach and thorough protocol that reposition CQC action plans into an opportunity.
Often arriving with a ‘Requires Improvement’ rating following an inspection, services are given a 28-day window to prepare and submit these documents. A CQC action plan is formally requested when the regulatory findings showcase compliance breaches that pose no immediate risk to service users.
Upon receiving an action plan request, providers must respond with a detailed plan, outlining exactly how those issues will be resolved. Though the approval process presents zero tolerance for error. If the CQC are to reject a drafted action plan, issues can escalate into enforcement action, while the regulators could also cease specific operations.
The overarching purpose of this job is to allow services to address risks and move forward. And while this is a reactive task, a proactive approach is where action plans pave the way for opportunity.
The Official Process Of A CQC Action Plan
As previously mentioned, the CQC will request this when a compliance breach poses no immediate public harm. Granted a 28-day window, providers must create their own structured action plan using the template provided by the CQC. .
Led via a liaison between the Registered Manager and executive leaders, internal support is a necessity. As a baseline, an action plan will outline proposed actions to address compliance gaps and the planned timeframes. If not submitted in the allotted window, it will be recorded as a non-compliance. CQC provide an official portal for providers to submit action plans.
Approval processes are unforgiving. A common pitfall comes when goals are non-specific, vague, or exist purely on paper. Although goals must still be outlined with specific evidence and KPIs in mind. These action plans should also open healthy dialogue throughout care teams, as feedback from the bottom up should be valued.
Upon approval, implementation must be enforced immediately. Changes must be routinely audited, with evidence collection integrated throughout training records and documentation processes. Then, in writing, providers will inform the CQC that all necessary actions have been completed.
In most cases, a CQC action plan will lead to a follow-up inspection. These will usually entail a shorter, more focused visit, aiming to verify that improvement promises were acted upon.
How Is A Great CQC Action Plan Formed?
The gap between an approved CQC action plan and enforcement action is thin, making correct protocol pivotal. So simply, every action requires a named owner, with a clear timeframe, and a measurable plan.
But to ensure a smooth, proactive action plan process, providers must first see beyond the action plan as a paper task. While difficulties are posed by the paperwork, the real task lies in embedding proper practice throughout overarching governance systems and frontline care teams. But there are more measures to satisfy the regulators:
Concrete timeframes
Realistic timeframes for proposed actions should outline each proposed action. These must also indicate the phasing process, rather than suggesting the prospect of a “quick fix” approach.
Accountability Criteria
Accountability is vital throughout the healthcare sector. All proposed actions must be owned by an individual, specifically named in the CQC action plan. Details such as reporting dynamics and progress updates should be detailed, rather than vague declarations.
Evidencing and Scaling Success
Compliance starts on paper, before being evidenced by ground-level practice, but this should be evidenced in the face of scrutiny. So, each goal should be actionable. Baseline evidence, thorough documentation, and up-to-date records should underlie each improvement.
Regulation Starts At Registration
The regulators can see clearly how quality is demonstrated. Assessment is a proactive process that does not just begin once the inspectors arrive on-site. Embedded improvement cultures become immediately obvious to inspectors.
So, leaders must encourage proactive cultures sooner rather than later. Inspection activity is accelerating, while alterations to the CQC’s frameworks are set to take place over the coming months. Enforcement activities and action plans can often feel like a firefighting activity, while Registered Managers and senior leaders can feel as though they are losing control. Our external support offers a CQC-grade assessment, informed by up-to-date practices and policies that are currently being enforced by regulators.
Informed by over 30 years in healthcare, our services empower leaders by making inspection a showing of daily practice rather than a reactive activity.
Contact us today, and take control from registration to regulation.
