CQC Notifications Audit - Care Homes

Evidence to check

• • Current CQC notifications policy or procedure is available and reviewed
• • Policy lists common statutory notification types relevant to care homes
• • Policy identifies the responsible person and deputy arrangements
• • Policy explains internal escalation, submission method, evidence retention and follow-up requirements

Evidence to check

• • Named registered manager, provider representative or nominated responsible person is documented
• • Deputy cover is identified for leave, weekends and out-of-hours incidents
• • Responsible person understands statutory notification requirements
• • There is evidence of oversight of notification logs, quality checks and late or missed notifications

Evidence to check

• • Staff can explain that different reporting routes may apply to the same incident
• • Managers understand when CQC notification is required in addition to safeguarding or commissioner reporting
• • Incident forms prompt consideration of multiple reporting duties
• • Training or guidance clarifies the different external notification routes

Evidence to check

• • Incident reporting procedure includes notification escalation triggers
• • Staff know who to contact immediately after serious incidents
• • Out-of-hours escalation route is documented and understood
• • Incident records show prompt escalation to manager or provider lead

Evidence to check

• • Governance minutes include CQC notification themes, timeliness and learning
• • Notifications are reviewed alongside incidents, safeguarding, complaints and risk register themes
• • Actions have owners and timescales
• • Repeat themes lead to service improvement actions

Evidence to check

• • Notification audits are completed at a defined frequency
• • Audits compare submitted notifications with incident files, safeguarding records and care notes
• • Quality gaps are identified and corrected
• • Learning is shared with managers and relevant staff

Evidence to check

• • Trigger checklist is available in the office, incident pack or digital system
• • Checklist includes deaths, serious injury, abuse, police involvement, DoLS, service interruption and key person changes
• • Checklist is reviewed when guidance or provider procedure changes
• • Staff know where to find it

Evidence to check

• • Staff can identify common triggers such as death, serious injury, abuse allegation, police involvement, DoLS-related events and service disruption
• • Staff understand their role is to report and escalate, not decide in isolation
• • Knowledge checks include night, weekend, agency and senior staff
• • Knowledge gaps are addressed through briefing or training

Evidence to check

• • Death records are reviewed for expected or unexpected death status
• • Screening considers safeguarding concerns, coroner involvement, police involvement, incidents and DoLS status
• • Notification decision and rationale are recorded
• • Family, GP, coroner, safeguarding and CQC reporting actions are cross-referenced where relevant

Evidence to check

• • Serious injuries such as fractures, head injuries, burns, pressure damage, hospital admissions or significant deterioration are reviewed
• • Incident investigation records document whether CQC notification was required
• • Clinical details are updated when confirmed
• • Rationale for notifying or not notifying is clear

Evidence to check

• • Allegations or incidents of abuse, neglect, exploitation or serious harm are screened for CQC notification
• • Peer-on-peer incidents are included where relevant
• • Safeguarding referral and CQC notification decisions are cross-referenced
• • Protective actions are recorded

Evidence to check

• • Incidents involving restraint or restriction are reviewed for injury, safeguarding, police involvement or unlawful restriction
• • MCA and DoLS implications are considered
• • Use of restraint is recorded factually
• • CQC notification decision is documented where relevant

Evidence to check

• • Police involvement is recorded in incident logs
• • Events such as suspected crime, missing person, assault, unexplained injury or safeguarding concern are screened
• • CQC notification is submitted where required
• • Police reference numbers and outcomes are recorded where available

Evidence to check

• • DoLS authorisations, urgent authorisations, conditions and expiry dates are tracked
• • DoLS notification requirements are included in the notification procedure
• • Any unauthorised deprivation or breach of conditions is escalated
• • Records use the current care home DoLS framework and do not assume Liberty Protection Safeguards are in force

Evidence to check

• • Events such as loss of utilities, heating failure, evacuation, major staffing crisis, building failure, cyber incident or outbreak disruption are screened
• • Impact on residents is recorded
• • Mitigation and business continuity actions are documented
• • CQC notification decision is recorded

Evidence to check

• • Medication incidents are reviewed for serious harm, hospitalisation, life-threatening error or systemic failure
• • Drug, dose, route, error type and resident impact are documented
• • Safeguarding, duty of candour and commissioner reporting are considered
• • CQC notification decision is recorded

Evidence to check

• • Pressure damage incidents are reviewed for avoidability, severity, safeguarding and serious harm
• • Tissue viability advice and clinical assessment are recorded
• • CQC notification and safeguarding decisions are aligned with local expectations and provider policy
• • Rationale is documented

Evidence to check

• • Outbreak records include impact on residents, staffing, admissions, visiting and service continuity
• • Public health, IPC and commissioner reporting are considered
• • CQC notification decision is documented where disruption or harm is significant
• • Learning and IPC actions are recorded

Evidence to check

• • Changes to registered manager, registered provider, nominated individual or location details are tracked
• • Required notifications or applications are submitted promptly
• • Evidence of submission is retained
• • Provider governance monitors regulatory status changes

Evidence to check

• • Notification log shows incident date, awareness date and submitted date
• • Notifications are submitted without avoidable delay
• • Specific statutory timescales are met where applicable
• • Late submissions are reviewed and actioned

Evidence to check

• • Serious incident records show prompt manager awareness
• • Submission dates are close to incident or awareness date
• • Delay reasons are documented where notification was not immediate
• • Out-of-hours arrangements support prompt submission

Evidence to check

• • Deputy notifier is named and trained
• • On-call procedure includes CQC notification escalation
• • Access to CQC portal or submission process is available to authorised deputies
• • Weekend and night incidents are not delayed until routine office hours without rationale

Evidence to check

• • Incident forms are completed promptly after events
• • Managers review new incidents daily or according to risk
• • Late incident reporting is monitored
• • Staff are reminded to escalate serious incidents immediately

Evidence to check

• • Central notification log includes incident type, due date, submitted date, CQC reference number and status
• • Open actions and follow-up information are tracked
• • Responsible person is identified for each notification
• • Log is reviewed regularly

Evidence to check

• • Notifications are updated when injuries, investigation findings or safeguarding outcomes are confirmed
• • CQC requests for information are responded to promptly
• • Updates are documented and linked to the original notification
• • Final outcomes are recorded

Evidence to check

• • Late notifications are flagged in the log
• • Root cause is recorded, such as delayed incident reporting, unclear trigger, absence of manager or system issue
• • Preventative actions are agreed
• • Effectiveness is reviewed in governance

Evidence to check

• • Dates, times, location, resident details, injury details and immediate actions match incident records
• • Notification narrative is consistent with care notes and investigation records
• • Any later corrected information is updated
• • Discrepancies are investigated

Evidence to check

• • Correct resident name, date of birth, unit or placement details are used where required
• • Records are checked before submission
• • No resident is misidentified
• • Errors are corrected promptly and documented

Evidence to check

• • Narratives describe what is known, observed and recorded
• • Speculation, blame or unsupported assumptions are avoided
• • Unconfirmed details are clearly stated as suspected or awaiting confirmation
• • Language is professional and respectful

Evidence to check

• • Notification states what happened, when, where, who was involved and immediate impact
• • Immediate actions taken to protect residents are included
• • Current status and next steps are described
• • Relevant external referrals or notifications are noted

Evidence to check

• • Injuries are described clearly, such as suspected or confirmed fracture
• • Hospital, GP or clinical confirmation is added when received
• • Notification updates are submitted where appropriate
• • Care records and incident records remain consistent

Evidence to check

• • Notification describes allegation or concern factually
• • Immediate protection measures are recorded
• • Local authority, police or safeguarding team involvement is stated where applicable
• • Confidentiality and proportionality are maintained

Evidence to check

• • Medication name, dose, route, timing, error type and harm level are included where relevant
• • Immediate clinical actions and advice sought are recorded
• • Preventative actions are described
• • Duty of candour and safeguarding considerations are documented where relevant

Evidence to check

• • Police or coroner involvement is recorded accurately
• • Reference numbers are included where available
• • Information is consistent with death records, incident records and correspondence
• • Updates are made when outcomes become known

Evidence to check

• • Notification explains the nature and duration of interruption
• • Impact on residents, staffing, premises, care delivery or safety is described
• • Business continuity actions and mitigation are included
• • Resident relocation or evacuation is recorded where applicable

Evidence to check

• • Authorisation status, urgent authorisation, standard authorisation and conditions are accurately recorded
• • Any breach, expiry or unauthorised deprivation is escalated
• • Care plan restrictions align with DoLS documentation
• • Representatives or advocates are recorded where relevant

Evidence to check

• • Only necessary supporting documents are attached
• • Documents are redacted where appropriate
• • Confidentiality and data minimisation are maintained
• • Attachments are checked before submission

Evidence to check

• • Incident investigation records are completed according to seriousness and complexity
• • Root cause or contributory factors are identified where appropriate
• • Resident impact and immediate safety actions are reviewed
• • Investigation findings are linked back to notification updates where needed

Evidence to check

• • Action plans address causes such as falls patterns, medication system issues, staffing gaps, equipment failure or training needs
• • Actions are SMART with owners and deadlines
• • Progress is monitored through governance
• • Effectiveness is reviewed after implementation

Evidence to check

• • Team meetings, supervision, handovers or training records show learning shared
• • Learning is anonymised where appropriate
• • Staff understand what changed as a result
• • Learning is embedded into policy, care plans or practice

Evidence to check

• • Investigation results, safeguarding outcomes or confirmed clinical updates are submitted where needed
• • Updates are linked to original notification reference
• • CQC correspondence is retained
• • Final status is recorded in the notification log

Evidence to check

• • Records show openness, apology, explanation and actions to prevent recurrence
• • Relevant person or representative is informed promptly
• • Written follow-up is provided where required
• • Duty of candour records are cross-referenced with incident and notification files

Evidence to check

• • Commissioner, local authority, ICB, safeguarding, coroner, police or public health notifications are recorded where applicable
• • Notification dates and contacts are documented
• • External reporting requirements are not confused with CQC notification requirements
• • Follow-up correspondence is retained

Evidence to check

• • Training or briefing records are available for managers, deputies and senior staff
• • Leaders know how to access the CQC portal or approved submission route
• • Training includes examples and decision-making scenarios
• • Refresher training is provided after guidance or system changes

Evidence to check

• • Sampled staff can describe serious events requiring escalation
• • Staff know who to contact immediately
• • Night, weekend and agency staff are included in awareness checks
• • Knowledge gaps are addressed through immediate briefing

Evidence to check

• • Flowcharts, trigger lists, examples or digital prompts are available
• • Tools are clear, current and accessible
• • Managers use tools when reviewing incidents
• • Tools are updated after audit learning

Evidence to check

• • Refresher briefings or updates are documented
• • Relevant staff receive updates promptly
• • Changes are reflected in procedures and checklists
• • Staff understanding is checked after updates

Evidence to check

• • Manager, deputy or provider review is completed before submission where time allows
• • Checks include accuracy, completeness, tone, confidentiality and consistency with records
• • Urgent notifications are not delayed unnecessarily for review
• • Quality feedback is given to notifiers

Evidence to check

• • Log includes incident type, resident, date and time of event, awareness date, submitted date and time, notifier, CQC reference number and status
• • Updates and follow-up actions are recorded
• • Log is secure and accessible to authorised people
• • Log is reviewed regularly

Evidence to check

• • Submitted notification copies are stored securely
• • Copies are linked to incident files
• • CQC reference numbers are retained
• • Records can be retrieved promptly for audit

Evidence to check

• • Regular reconciliation is completed
• • Cross-check covers deaths, serious injuries, safeguarding, police involvement, DoLS and service interruptions
• • Missed or questionable events are reviewed
• • Findings are recorded and acted on

Evidence to check

• • Sample audits review accuracy, completeness, timeliness and learning
• • Audit compares notification, incident form, care notes, safeguarding record and investigation file
• • Audit findings are documented
• • Actions from audit are tracked

Evidence to check

• • Only necessary personal information is included
• • Sensitive third-party information is handled carefully
• • Access to notification records is restricted
• • Submissions use secure approved routes

Evidence to check

• • Recent notification records are available
• • Submission dates and CQC reference numbers are visible
• • Records align with the central notification log
• • Any absence of notifications is supported by reconciliation evidence

Evidence to check

• • Incident logs are cross-checked against notification log
• • Deaths, serious injuries, safeguarding, police involvement and service interruptions are reviewed
• • Potential missed notifications are investigated
• • Reconciliation outcomes are signed off by a manager

Evidence to check

• • Manager can describe use of policy, trigger checklist and professional judgement
• • Manager can explain escalation to provider, safeguarding, commissioner or CQC as needed
• • Manager understands timescale expectations
• • Manager can give recent examples of decision-making

Evidence to check

• • Notification updates are visible in the log
• • Updates include confirmed diagnosis, investigation findings, safeguarding outcome or action plan progress
• • CQC correspondence is retained
• • Original and updated records remain consistent

Evidence to check

• • Audit includes staff questioning, log review, incident file sampling and reconciliation
• • Audit checks decision-making, timeliness, quality of narrative and learning
• • Findings are escalated through governance
• • Actions reduce the risk of missed, late or poor-quality notifications

Evidence to check

• • Notification themes inform the Quality Improvement Plan, risk register, training plan and supervision topics
• • Repeat notifiable events are analysed for systemic causes
• • Senior leaders monitor trends and unresolved risks
• • The service can evidence learning and sustained improvement after notifiable events