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Evidence System Guides

There is a lot to go through to be fully CQC ready, and this guidance will show you the fastest way to get your Evidence System organised and ready for any inspection.

Yes, it is this easy!

  1. Familiarise yourself with the system
  2. Get your Registered Manager and Assistants to look through this.
  3. Get everyone to refer to this whenever they work on setting up or updating the evidence.
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Basic principles of the Evidence System

Our objectives

These are objectives with the Evidence Folder

  1. Help focus on important issues, and rehearse for an inspection
  2. Have something at your fingertips at an inspection
  3. Present evidence in a professional format to the Inspector

You will find inspectors either singing the praises or totally ignoring the evidence folder, every inspector is different and work to a different formula.

Most clients say that having all this ready prepares them in record time, to a higher degree, and gives them enormous confidence about their preparedness and achievements.

Keep it minimalist

The Evidence Folder is meant to be your "Executive Summary" and it is important to keep it brief and concise.
Treat it as your 30-minute presentation to show how well organised you are. So, exercise care not to clog it up with detailed paperwork, that can be filed elsewhere.

The type of documents the file should contain are logs and summaries that give an overview of the evidence and activities. Supporting paperwork should be kept in separate folders and only produced if requested.

By keeping the file clean and minimalist, it will be easier to navigate; easier to work with; easier to do a presentation with. Looking for a document buried in a thick pile can be counterproductive especially if you can't find something when under pressure.

It is usually better to have a well thought out log of the checks and reviews you have done rather than the actual documents. With this in front of you, you can start a conversation rather than worrying if everything is there, which will make your approach defensive

Examples of what should NOT be in the file:-

    1. Your actual Policies (Have a list showing it was reviewed)
    2. Staff appraisals
    3. Complaints (Show a log with review and outcomes)

Tatty file

Multi-site Operations

Branches and multiple sites should adopt a common standard, frameworks and processes.

The Evidence System is intended to standardise frameworks and establish a common understanding of aims and processes.

  • A good approach is to work on the setup in a team setting
  • Team meetings can be useful, else use conference calls if distance is an issue
  • Work from one common set of documents to avoid ending up with differing frameworks and understanding.
  • Team settings should ensure that there are no differences or deviations from the common standard
  • A major advantage is that it presents a good opportunity to identify, discuss and correct misconceptions.
Who can do the setup

The person who manages all core CQC matters should lead the setup and liaise with the Registered Manager or Nominated Individual.

  • GP and Dental Practices: Typically this will be a Practice Manager reporting to a Registered Manager
  • Adult Care: Typically there will be a Registered Manager reporting to a Nominated Individual

There is no hard and fast rule, we have on occassion trained admin staff to set up a large portion of the file, then pass it over to their Manager for completion.
The Evidence System doubles as a great learning tool for anyone who uses it, and a team effort spreads the loads and gets the work done.

Initial Setup: A Step-by-Step guide to setting up the Evidence Folder

The 3 Components

Ensure your team can differentiate these 3 main components and what they are used for

Three Components

The Governance Pack fast-tracks completion. It takes 30 minutes to implement and saves two weeks worth of work for you.

If you didn't buy this as part of your package, you should get it now

Get the Governance Pack

Day 1: Governance Pack - Before you start

Whatever you do, DO NOT FILE THE GOVERNANCE PACK. As with most things, you will hope to come back to it later but will never find the time.
70% of clients who file it straight away, still haven't used this pack 3 months later.

This is how you can conduct your first review quickly:-

  1. Set aside 30 minutes to do this
  2. Do not worry if you spot gaps, this is our first read, you can come back to fix things later in your own time
  3. Use the included an Action List for things that you spot as not yet done

The idea is to get through the first review without breaking the rythm by stopping for missing items. Then you can prioritise important issues and plan out how best to tackle the missing items.

Governance Pack - First Review

Start the First Review

  1. You can do this alongside your Registered Manager and team members or on your own
  2. Read each page of the Governance Framework, which should take an average of 2 minutes or less per page
  3. If you are confident that you are compliant with at least 60% of the page content, sign and date it
  4. For any gaps that you need to cover, add this to the "Action list" supplied

Registered Manager and your team

  1. If you did this on your own, take the signed pack to the RM
  2. Get them to read and sign as "approved"

File the Governance Pack

  1. File the signed Framework pages under the correct section in the Folder, everything is numbered so it should be easy
  2. At the same time, tick this item off the main yellow index to show this has been done

What you will have achieved

  1. Demonstrate that you have a Governance Framework
  2. Demonstrate that you are working as a team
  3. Demonstrate how this adds to Well-Led and Effective criteria

Governance Pack - Continuous Reviews

Governance Pack - Continuous Reviews

Now we can schedule regular reviews and complete any items that were left as outstanding in our own time.

  1. Create a plan, we suggest you use the compliance calendar in the Templates section
  2. Schedule your reviews to address the gaps you spotted
  3. Schedule Management Meetings to discuss each Governance page

The Management Review will help focus the team on issues, and other people will add their ideas and observations, which will save you having to do this on your own. You will have involved the entire team, so everyone is now briefed, and your minutes will reflect how the organisation monitors and manages their corporate governance.


Day 2: Go to Section 3 - Our Policies.

Section 3 - Our Policies.
Here you have the recommended list of 30+ main policies

  1. Tick off all the policies you already have in place, and try and schedule in the time when you will add the ones that are missing
  2. You don't have to add the missing ones if you feel they are not relevant, but this is an opportunity to have your answers ready if anyone asks about it
  3. You should keep the actual policies in a separate location/file/cabinet as you want to keep this file slim and easy to navigate
Day 3: Go to Section 4 - Our Staff

Section 4 - Our Staff
Do a quick review to add as much information as is available, and add the missing items to the Action List

Examples of how to complete things easily

  1. Training Matrix - Print out the latest matrix and add comments as to how this will be added to and monitored during the year
  2. Staff Appraisals have a log of appraisals or a note as to when they were last done, and the next ones scheduled
  3. Staff List - You must have this with a note of part-time Vs full-time
  4. Think about whatever is missing and have your answers ready e.g. "We have scheduled a review in 2 months' time" or reasons why this is not applicable
  5. In all cases, make an Action List to demonstrate that you have noted this and have a plan to address this, else it looks like you never thought of it
  6. Once again, don't worry about not having things ready, work on having valid answers to show you are on top of things. Compliance is an ongoing process.
Day 4: Our Organisation

Our Organisation

Now you can go to Section 1 and complete basic information about the Practice and management staff

  • Only file important things in this file, so if your Business Continuity Plan is many pages, all you need to have here is a note that you have this. You can always fetch it if required.
  • If things are missing or you haven't had the time, once again, just spend a minute thinking about what you would say "We do discuss Staff Sufficiency informally at meetings but now we intend to formally record this as a risk assessment..."








Evidence & Monitoring: How to maintain your compliance evidence

Downloading templates

Where are the templates ?: You are already in the right section, just look for the side menu item "Evidence System Templates"

The best way to tackle the evidence sections is by completing it section by section rather than download everything in one go.

Downloading everything in one go can be counterproductive and demotivating when it gives the impression of an overwhelming amount of work.

Whilst completing the evidence, it is also a good opportunity to think about how the data was collected, in essence a review of whether the process itself is adequate. You generally don't get the chance to do this and rushing through templates will miss this opportunity.

We have set the system to prevent a mass download of documents, and this also allows us to intervene with a quick conversation in case someone is heading in the wrong direction. If this causes difficulties in special circumstances, we are always willing to accommodate, just get touch with support.

Evidence Templates

Evidence Sections - going through the Yellow Index

  1. For most items, we will have an editable template in the Evidence System Templates section.
  2. If you think something is missing, contact us and we'll try and provide a fix or add this to the library where useful
  3. Don't forget that you can also put your own explainer note if you find that easier e.g. "Fire drills were done on 20th November 2018, we do these every 6 months"
  4. You will not get everything done in one go, but that's ok, just schedule in a review time on a regular basis to get his done.
  5. Wherever you have left a blank in the index spend a minute thinking about how you would answer that. i.e. "We do this every month, just haven't had the time to put it here, but the records are over there...."


Evidence Sections 6 to 8

Tackle the rest of the section

  1. Go to Section 6 - Safety Checks. Gather all your evidence here e.g. logs of safety checks.
  2. Go to Section 8 - Add all the key things like log/list of complaints, log of drug expiry checks etc.
  3. Go to Section 5: Do the same as above


What about historical evidence?

If you find that your recording has been inadequate in the past OR you want to record everything using new templates. this is the quickest way to get evidence in place.
Do not worry about gathering historical evidence at this point

  1. For each topic, just record the last few incidents that have happened in say the last 2 to 3 months
  2. Brief staff members how and where the record is being kept, and make sure the updating process is in place
  3. Brief staff about the importance of the subject

This will ensure that you are CQC compliant from this point forward and fully covered for future events.

Historical logs

  1. You can now go back to collate historical evidence in your own good time if this was not properly logged before.
  2. Tackle 3 months at a time, going back from the current date
  3. Stop at 12 months in time, usually anything older is of no value
  4. Exercise judgement, some things like Significant Event Audits may need going back further


Scheduled Management Reviews

You should use the Compliance Planner to schedule topics for management meetings.
By using meetings to complete and review sections, you can combine the functions of management review, monitoring, and well-led into the process of completing and updating the file.
This can now be used to give your meetings some structure and get things done at the same time

What can be reviewed:-

  1. Action points
  2. Incomplete Governance Framework items can be completed as a team
  3. Any completed sections reviewed again as a revisit and refresher
  4. Index pages for discussion of overall achievements by section

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