This blog is based on a more detailed guidance document which can be found on researchgate.net.

There is a real art to getting CQC action planning right and communicating improvement back to the CQC. This often has a huge impact on CQC’s overall judgements and ratings.

Unfortunately, it is all too common for organisations to get lost in their action plans and fail to either make improvements or communicate them

Like any CQC inspector, I’ve written and peer-reviewed many CQC reports, as well as monitored CQC action plans created by organisations. Unfortunately, it is all too common for organisations to get lost in their action plans and fail to either make improvements or communicate them. This was always a source of frustration for me, especially seeing the wasted time, resource and effort that went into a process that completely missed the mark. I’ve also found that assurance around CQC actions is commonly focussed upward in an organisation, often in incomprehensible formats, completely overlooking those that need to know and explain the information to inspectors the most; the frontline staff.

One of the main reasons I decided to start consulting was that I wanted to support organisations to avoid these traps and offer guidance through the process. I’ve picked up the following tips through my time at CQC as well as managing this process successfully in multiple NHS trusts.

Action planning is key to improving quality and I thought it might be useful to post to the Q community who will likely have quality assurance or regulatory roles or will work closely with colleagues who may find this useful.

1. Being prepared

• Start action planning and making improvements immediately after the inspection. Don’t wait until the CQC report is published.
• Get early buy-in from action leads, corporate teams (especially comms teams) and the board. Agree actions and expectations together from the start to foster ownership. Get everyone together in one room at the start.

2. Creating a useful and usable CQC action plan template

• Simplicity is key. It’s very easy to get bogged down in the action plans as time goes by to the point where the actual point is completely lost. Limit the number of measurables in the action plan. Avoid countless ratings and scales. Get board sign off on this.
• Copy and paste the must/should wording across from the CQC reports. Don’t be tempted to change or shorten the wording as the essence can easily be lost. Join overlapping actions together but be careful not to lose the essence of any specifics.

3. Completing the action plan

• The ‘actions to complete the must/should’ are key to overall success. They need to actually resolve the issue that is being raised in the must/should. They should tell the chronological story of what needs to be done.

Actions should be written by or together with the action leads; often when actions are inherited, they are not understood.

• Follow these three key principles when writing actions:
  A. Reviewing, deciding on and implementing the change to the process
  B. Informing/reminding/communicating/training staff of a change or process
  C. Auditing/testing that process: ongoing audits, evidence of discussion in meeting minutes or introducing spot checks. A good rule of thumb is three months’ worth of checks/audits with improved outcomes to see that a process is embedded.
• Actions should be written by, or together with, the action leads; often actions that are inherited, are not understood.
• Avoid refusing to accept or nit-picking at certain CQC actions, and avoid writing what is already in place as the solution to an action.
• Set realistic deadlines; it’s a red flag when all the deadlines in an action plan are all clustered at the end of the same month.
• Some musts/shoulds can seem impossible to ever achieve. The best way to approach these is to agree some realistic milestones to work toward improving.

4. Good governance and assurance processes

• Use existing governance structures and meetings to manage this process where possible. Having said that, where there are a considerable amount or complex CQC actions, setting up a dedicated and regular ‘CQC action plan update meeting’ is essential to discuss the detail and provide updates.
• Establish an executive assurance group or process to ensure that ‘completed actions’ are signed off as they are completed.

Evidence should be concise and signed off as part of the executive assurance process.

• Evidence is essential to show actions have been completed. Evidence should be concise and signed off as part of the executive assurance process.
• Establish a check of ‘completed actions’ at the point of service. This could be done as spot check, peer review or part of existing assurance processes.

5. Running the CQC action plan update meeting

• The meeting should be the opportunity for the action leads to provide narrative around their updates on actions, any barriers to completion and expected delays. The chair’s role is vital; it’s easy to get bogged down in the detail and as time goes on the chair will need to keep focus on the original actions and hold action leads to account.
• Keep a record of each ongoing update so the journey can be tracked, and discuss each action one by one until completed. Action leads should send a deputy or provide a written update on each action in advance if they cannot attend in person.
• Going beyond action deadlines is inevitable. Don’t take this as failure; review and set a new deadline at the meeting, ensuring the narrative is clear to justify this and the exec and CQC are informed. Ensure any actions that are approaching their deadline are highlighted at least a month in advance so that these can be prioritised.

6. Ongoing update of CQC action plans: keeping momentum

• Don’t be tempted to add updates to the action plans outside of the set update, even if there are significant changes. This causes headaches with version control.
• Deciding on/discussing the completeness rating can take up a lot of time and distract from progress. Think about what works best and stick to it.
• Cross learning: although its good practice to implement the learning from one CQC action across other areas, this can really dilute the specific work that needs to be done in one area. Leave this until the action is completed in the area that it was given, then share the learning.

7. Communication

• Inform your CQC inspector of this process and share the action plans with them on a regular basis. This is essential for ensuring inspectors understand your progress so they don’t have to figure it out at inspection.
• Transparency is key; share the action plan far and wide. Ensure its accessible to as many staff as possible.
• Create a ‘top things to know about quality and safety’ information sheet/poster to communicate to staff what the themes of the CQC actions are, as well as reminder of new processes.
• Create a ‘CQC said, We did’ easy to read poster/information sheet for staff, visitors or patients which clearly communicates improvements, as well as what the actual impact/outcome is.

The key measure of success would be, if you handed the CQC action plan to an inspector, would it be immediately clear what the improvements were and the impact on quality of care? When inspectors ask staff and patients, would they say the same?

Want to find out more? You can read the guidance in full on researchgate.net.