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.