The immediate reaction is for managers to think they need to revise all their policies and procedures exactly to mirror the guidelines, and once you have done this, you are most of the way there. This is not helped by the fact that commercial companies push "CQC compliance systems" which are basically every policy and procedure you can think of in one comprehensive manual. This tick box approach is exactly what the CQC was intended to discourage.

To work out where to start, one has to understand basic terminology, simply so that you are able to discern why you are doing it:-

Policies - Policies are your adopted rules and intent.
Processes - A process is detailing how you will make the policies work
Evidence - The ability to prove that the methodology/compliance took place

Practices often confuse policies and procedures, and assume that creating a file with all these in it and/or getting staff to sign bits of paper acknowledging they read it is all you need to do. Let us illustrate this with a simple example to distinguish the two using fire safety.

A policy might read something like "Our policy is to maintain strict fire safety precautions and ensure all staff are aware of how to deal with ...... etc."

These are some of the processes required to put this in practice:-

  • Carrying out regular risk assessments
  • Daily safety checks to ensure safety is maintained, for example that fire doors are not inadvertently blocked
  • Regular fire drills
  • Testing alarms and fire systems on a regular basis


  • Written copies of risks assessments and actions taken
  • Daily check-list completed, signed, and reviewed
  • Log of fire drill activity
  • Log of alarm tests

Getting policies is the easiest of all; after all, all you have to do is pay someone to give you collection of manuals. Making things work in practice is the hard part and is actually 90% of the work. The easiest way of testing your systems is to go to a random member of staff and ask them to tell you what the fire policies are and what they actually do when they see a box of files obstructing the fire exit. This is what the independent inspector might be asking.