CQC Action Plans Explained

Following the Trust’s Care Quality Commission (CQC) inspection in November 2016 and the reports published on 30 March 2017, the Trust has put a robust quality assurance system in place to ensure oversight on progress against actions given by the CQC.

There are 39 things that the Trust ‘Must do’ and 48 things that it ‘Should do’.

After the reports were published by the CQC on 30 March 2017, an action plan was created for each ‘core service’ report, as well as one for the entire Trust’s Provider report. The action plans were completed with the teams and their managers with details of the action taken since the inspection in November 2016. Actions were given assigned leads and estimated completion dates.

A monthly meeting called the ‘CQC Performance and Oversight Task And Finish Group’ started in June 2017. The teams are asked to update their action plans before the meeting each month as well as attend the meeting to discuss when actions are completed and any barriers in progressing the actions. So far there have been three meetings. The Trust aspires to have most of the actions completed by November 2017 (one year on from inspection) and will take stock at this point.

To ensure quality and that actions are truly embedded, a process called Care Standards Peer Inspections or ‘CSPIs’ was introduced. When an action is completed, a CSPI visit is requested by the team. The action is tested independently in practice, usually by visiting the service and speaking with staff and service users. Only after this point can the action be signed off as completed.

The Executive Directors Group (EDG), who have oversight of the CQC action plans on a quarterly basis felt that the Trust needed to be transparent in what action is being taken to improve services and therefore decided that the action plans would be published on the Trust website on a quarterly basis. This is not required by the CQC, however the Trust wants to be held to account about what it is doing to improve its services.  Click here to view the individual action plans.

All of the Executive Directors are ‘champions’ for one of the five CQC domains which means that they are accountable for the progress against the actions.

The progress of the action plans is also shared with the CQC every month when they visit the Trust for an engagement meeting.

Please note: Primary Medical Services and Adult Social Care Services are being monitored through a similar process through action planning and updates to CQC. The action plans will be published shortly.

Please email CQCsupport@shsc.nhs.uk if you have any questions related to any of the action plans or their content.


The action plans are working documents used by professionals and are owned by the services. They have been altered to take out staff names and a glossary / jargon buster has been added. As some of the content is quite lengthy complex and not necessarily easy to read, a summary or overview has been produced showing highlights and challenges.

Some tips for reading the full action plans:

  • They contain a lot of information in clinical language- A ‘Glossary and Jargon-buster’ has been included to assist with reading the actions.
  • There is a summary on page 1 which shows the current status and the previous months progress.
  • Each action has been given a number/code- Musts start with M, Shoulds with S. Musts are listed first in the report, Shoulds are second.
  • The ‘initial update’ contains all the action taken form the inspection up until May 2017, then a monthly update is provided per action.
  • The section highlighted in Grey is the most up to date information i.e. July 2017 Update.
  • The CQC domain that the action relates to (Safe, Effective, Caring, Responsive, Well-led) is listed by the action number.