Policies Based System

How to make policies work in CQC

Everyone starts with policies as this is the easiest to understand.
Yes, you do need policies but this is only the first step in your compliance.

What you need to do:

  1. Review the policies
  2. Customise them for your practice where appropriate
  3. Get staff to read and understand key policies
  4. Test staff knowledge
  5. Keep a record of staff training/reading of policies
  6. Keep these up to date, and keep staff informed

How providers use policies

Policy centric systems are labour intensive, and a typical manager would have to spend 3 months solid just to review the hundreds contained in the package.

In reality, most providers only read and maintain only some key policies, but will take comfort in having hundreds of these as an insurance against the CQC asking for something random.

Typical purchase cost vs. Typical operational costs

Typical purchase cost

If you just want a package of policies in Word or PDF format to download and print for your file, a small investment of £275 +VAT gives you “over 600 draft policies, procedures, protocols, letters, forms and template documents”

Online systems that allow you to track and log staff activity can range around £1,000 per annum. One system gets you 1,000+ pages of guidance for £1,395 per annum (£116.25 pm).

Typical operational costs

Surveys indicate a typical time cost of £15,000 in management time and similar in staff time to maintain paper policies and keeping paper based usage evidence and logs.

Online systems are more efficient for staff but offer relatively little savings in management time as someone still has to read through and disseminate.

A significant part of the problem is that publishers have got into the frame of providing every policy for every occasion, even down to what to do with guide dogs, largely to justify value. Whilst this may appeal as a “comprehensive” package, it is in fact counter-productive as the provider will have to expend valuable time culling this.

It's not about policies

Many managers are rushing to buy new policies and protocols described as CQC compliant, and genuinely believe that buying these will automatically make them compliant with CQC. In fact, all that you need are competent policies, which most practices already have anyway.

Question: Is 'CQC' all about policies and protocols?

What the BMA says:

"We believe that most providers will already be compliant with the essential standards" and "CQC registration should not involve the development of large numbers of new policies and protocols."

Extracts from the BMA CQC Registration guidance for GPs.

What the CQC says:

"Absolutely not. We are much less interested in policies and protocols than in knowing what care is like for your patients, whether staff know what to do about things like child protection, and so on. Good practices shouldn’t need to do anything they aren’t already doing."

Professor David Haslam, National Clinical Adviser to the Care Quality Commission

The focus of CQC inspections is the experiences people have when they receive care and the impact the care has on their health and wellbeing. CQC make their judgements against the regulations, and the judgements they make are informed by these experiences. This is why inspectors spend a lot of their time on an inspection talking to patients, their families and their carers. They’ll check their findings in a number of ways, for example by looking at records or speaking with staff, to reach their judgements.

"We won’t normally spend a great deal of time reading policy or procedure documents, unless we need to look at them to substantiate other evidence or what staff or patients have told us about their experiences."

General Advice about Policies

If you chose the route of a polcies based system, focus on key policies and get them right.

A typical provider with less than 50 full time equivalent staff does not need more than 30-40 standard policies. For example, a common sense approach to safety will cover most unusual situations, and it is better to invest time in developing staff and instilling a common sense approach, than overwhelming them with paperwork to cover every eventuality.


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