CQC Registration

Application process commenced

This is the first stage of the process and includes Deputy Director of Nursing and CQC Team scoping the requirements for the application.  It includes exploring what we are expected to deliver and from where

Internal paperwork to be completed

We then begin to complete our registration under the Health and Social Care Act 2008 (as amended) application to add a location to an approved regulated activity.  This paperwork contains 6 sections as follows:

Section 1: Application details        

Section 2: Statement of Purpose 

Section 3: Locations, regulated activities and service types   

Section 4: How you will provide your service    

Section 5: Details of not meeting the regulations and action plan for a location        

Section 6: Application declaration

This must be checked and approved prior to submission.

Alongside the application, the Trust Statement of Purpose must also be updated to reflect the location and activities we wish to add.

Registration application / Statement of Purpose submitted

Both the application to add a location and statement of purpose are sent via email to CQC and we copy in our Registration colleagues at CQC to advise them of the upcoming registration submission.

All supporting documentation is uploaded onto the CQC Team SharePoint site and tagged as per process.

Documentation Request

The next stage is the documentation request which we receive once we have an allocated officer.  Mersey Care CQC Team link in daily with the officer to determine requirements as these vary depending on application.  A log is set up and naming conventions applied to allow ease of document transfer.  A straightforward application would request a minimum submission of the following documents (where applicable):

SDR - 01        "Policies of and procedures to discuss: Infection Control"

SDR - 02        Covid 19 policy/procedure

SDR - 03        Donning and doffing of PPE policy/procedure

SDR - 04        Medication Management policy policy/procedure

SDR - 05        Incident reporting policy/procedure

SDR - 06        Referral procedure policy/procedure

SDR - 07        Visitors policy policy/procedure

SDR - 08        "Certification including: Gas"

SDR - 09        Electric certification

SDR - 10        PAT testing certification

SDR - 11        Water treatment certificate and contract for ongoing Legionella testing services (if needed)

SDR - 12        Maintenance contracts for equipment

SDR - 13        Planning consent

SDR - 14        Building regs

SDR - 15        "Commissioning certificates and maintenance contracts (where relevant) for:

Central heating and boiler"

SDR - 16        Fire alarm system commissioning certificates and maintenance contracts

SDR - 17        Security alarm system commissioning certificates and maintenance contracts

SDR - 18        Extractor fans commissioning certificates and maintenance contracts

SDR - 19        Lift commissioning certificates and maintenance contracts

SDR - 20        Air conditioning commissioning certificates and maintenance contracts

SDR - 21        CCTV commissioning certificates and maintenance contracts

SDR - 22        Emergency lighting commissioning certificates and maintenance contracts

SDR - 23        Thermostatic controls for hot water commissioning certificates and maintenance contracts

SDR - 24        Any large pieces of equipment commissioning certificates and maintenance contracts

SDR - 25        Business Continuity plan

SDR - 26        A Business plan for the next 12 months

SDR - 27        Fire risk assessment

SDR - 28        Contract for the provision and maintenance of firefighting equipment

SDR - 29        Lift safety test (if needed)

SDR - 30        Environmental health and safety risk assessment

SDR - 31        Contracts for domestic and clinical waste and sharps collection

SDR - 32        Contract for cleaning, if this is outsourced

SDR - 33        Cleaning schedule and COSSH information

SDR - 34        Certificate of premises, public liability and employers liability insurance

SDR - 35        Lease or other evidence of your entitlement to use the premises

SDR - 36        Information on staffing, recruitment, supervision and training

SDR - 37        Information on the quality monitoring systems that will be in place

SDR - 38        NHS contract/SLA

SDR - 39        Audit schedules

SDR - 40        Floor plan of the location

SDR - 41        Specific risk assessments eg. Ligature risk assessment if required for detained patients.

SDR - 42        Exclusion Criteria

SDR - 43        Who will be the radiation protection supervisor? (if applicable)

SDR - 44        Regarding the local rules, will you have support from the radiation protection advisor?

SDR - 45        S17 leave"

SDR - 46        Observation protocol

SDR - 47        Mobile phone/IT access

SDR - 48        Rapid tranquilisation

SDR - 49        Restrictive practices/restraint

SDR - 50        Seclusion

This is the minimum requirement and additional information is requested as the registration progresses. We will generally submit in excess of 200 documents at this stage each of which must be checked and verified prior to submission.

This information would be requested via CQC Team from the division and / or the manager overseeing the project work at site, it requires estates input along with several other key individuals throughout the Trust depending on requests. 

All supporting documentation which is sent in is checked and tagged by CQC Team and forwarded over to Deputy Director of Nursing to check and approve.  Once approved the information is uploaded and submitted to CQC.

At this stage there is a lot of communication between CQC Inspectors / Deputy Director of Nursing and CQC Team and under the Scheme of Delegation, the Director of Inspectors provide additional scrutiny.  Also if there is an additional element, i.e. Learning Disability the information along with CQC report will be taken to a panel.

Site Visit

Following submission of the above documentation, a site visit is required at which depending on the scale of the location there will be a minimum of 2 inspectors attend.  For larger sites such as Rowan View there was:

CQC Registration Officer

CQC Inspection Officer

CQC Engagement Manager

CQC Regional Manager

CQC Expert by Experience x 2

There will also be CQC service user meetings requested along with additional meetings such as Medicines Management and Optimisation, Divisional Management and Ward management to allow CQC to understand how we will transition services safely.  We generally arrange these via teams since the start of the pandemic but there will other staff the CQC may wish to speak with and we would link in and arrange these divisionally.

Outstanding paperwork / requested information to be sent

Following on from the site visit the CQC will identify any additional supporting documentation they require.  We have to return this to them with a tight turnaround and so need to have a single point of contact within the division.

This additional supporting information includes any recommendations they have made during the site visit such as photographs to evidence that the recommendations have been completed.

Decision / Confirmed Registration

Once CQC have received all supporting documentation and are happy to approve we receive an email from our registration manager to advise us of a Notice of Decision.  This is not the formal paperwork we require but it allows us to progress with the location.

Certificate of Registration received

The final stage of registration is receipt of the Certificate of Registration.  This document is uploaded onto the CQC team SharePoint site, checked for accuracy and tagged. 

This is the end of the process.