QRV evidence requirements

As a part of the Quality Review Visit (QRV), the QRV Lead will look at a large volume of data. It would be helpful if the information listed below could be prepared in advance so that this is readily available, electronically or as a paper copy, on the day of the QRV.

Please also ensure that you have reviewed your previous QRV Actions, as this will be used to inform your upcoming review.

Below is not an exhaustive list and we may ask for additional or different evidence during the visit. Not all evidence listed here will be reviewed on the day dependant on if other evidence has been able to answer the relevant standard within the report.

If you have any queries, please email the Quality & Compliance Team (CQCTeam@merseycare.nhs.uk) who will pass this information on to the relevant QRV Lead.

  • Please provide the last 12 months (or date of last QRV) of Radar reports and evidence that these are discussed at team huddles/ meetings and actions cascaded to the team, including trend and theme analysis, lessons learnt and any changes in practice
  • Details of any Rapid Reviews and learning from these (or other PSIRF tool kit methodology) and completed reviews that have been signed off
  • Evidence that external Safety events are shared with the team. Can still be Mersey Care based such as 7-minute briefings, good catches, QPAs
  • Evidence of Duty of Candour compliance report available from Risk Governance/Patient Safety team (You may need to approach your senior leadership team, Risk and Governance Team or Patient Safety Team for this)
  • BiT/ performance data including compliance that will be needed in an overall team percentage including, mandatory training, role specific training, safeguarding training, data awareness/IG training, infection control training, suicide training, MHA/MCA/DOLS training, Medicines management training, equality and diversity training, Patient Safety Training, clinical supervision, and PACE
  • Any Training Needs Analysis you keep of role specific training for the service.
  • Evidence that reflective practice sessions take place
  • Provide evidence of how your team safeguards service users by following Trust polices, giving examples
  • Evidence of adherence to IPC guidelines (including audits undertaken)
  • A PLACE report if appropriate (inpatient services only)
  • Although you may not have direct responsibility to complete estate reports, as a team you need to demonstrate that you have access to and awareness of the Fire Risk Assessment, Fire Alarm testing, Workplace Inspections and Cleaning Schedules (if the files are not kept on the premises, please locate this information)
  • Fire Risk assessment https://yourspace.merseycare.nhs.uk/application/files/9216/2193/6109/sa08-v5-fire-safety-up-4-mar-2021-review-jan-2023.pdf
  • Work Place Inspection (WPI) https://yourspace.merseycare.nhs.uk/application/files/1016/2193/6107/hs5-workplace-inspections-v4-up-21-jan-19-rev-dec-21.pdf
  • ESRA if appropriate and any action plans (inpatient services only)
  • PGDs if used by the service
  • Evidence of Non- Medical Prescribing updates and supervision
  • Evidence of prescribing audits
  • Evidence of appropriate clinical content/ record keeping audit
  • Evidence of safer staffing, recruitment plans and escalation processes
  • Evidence of local induction for all staff including bank staff and new starters
  • Evidence of caseload management relevant to your area of practice
  • Safety huddle/ shift handover documentation and audit
  • Evidence of appropriate escalation of the deteriorating patient
  • Staff noticeboards are available with relevant Trust information
  • Evidence of risk assessments for individual patients/ service users and for the service as appropriate

  • Evidence of a holistic patient assessments underpinned by evidence-based guidance and pathways
  • Evidence of FRAT and MUST compliance where appropriate
  • Evidence of patient activity programmes (mental health services only)
  • Patient information Leaflets and other patient information literature used by team and that is available/ accessible in different formats
  • A record of audits for the last year, including cascading results to the team, improvement plans, any changes made and plans for re-audit (local and national audit and benchmarking)
  • Evidence of outcome measurement monitoring processes
  • There is evidence that a MHA monitoring visit has taken place

  • Evidence of patient feedback: FFTs/ patient surveys/ radar compliments/ patient forums
  • Privacy audit compliance (if relevant to the service)

  • Notes and minutes are available of team meetings, including an action log
  • Evidence of MDT meetings, care plans and care pathways with clear evidence of patient/ carer involvement
  • Team building/ team development/ team canvas/ work supported by OE