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In healthcare, CQC compliance isn’t just about ticking boxes—it’s about safeguarding patients, staff, and your organisation’s reputation. Yet even well-intentioned providers can find that their compliance systems aren’t delivering what the Care Quality Commission (CQC) expects.
Under Regulation 17 (Good Governance), providers must have “systems and processes that ensure compliance with the fundamental standards.” If those systems aren’t robust, the risks to quality, safety, and reputation can be significant.
Below, we highlight seven warning signs that your compliance framework may not be working—and how to put it right.
1. You’re Reacting, Not Reviewing
If audits only happen after something goes wrong, you’re missing the point of governance. CQC expects proactive monitoring—regular internal reviews, action logs, and evidence of improvement over time.
Fix it: Implement scheduled governance reviews and trend analysis to spot risks early. BAXCQC compliance software baseline assessment can help identify weak points before inspectors do.
2. Staff Aren’t Clear on Their Roles
When team members are uncertain about who’s responsible for what, compliance quickly unravels. Regulation 17 expects “clear lines of accountability.”
Fix it: Define and document responsibilities in your governance framework. Regular team briefings and a shared compliance dashboard can make this visible to all.
3. Policies Are Out of Date or Generic
Outdated, templated, or irrelevant policies are a red flag during any inspection. The CQC looks for evidence that policies reflect your services, not someone else’s.
Fix it: Review all policies annually and ensure they align with your scope of registration, staffing model, and service type.
4. Audit Outcomes Aren’t Leading to Action
Many providers audit regularly but fail to translate findings into meaningful change. The CQC wants to see a “cycle of continuous improvement.”
Fix it: Link each audit to a measurable action plan, assign ownership, and review progress at board or governance meetings.
5. Incident Learning Is Inconsistent
If lessons learned from incidents aren’t shared or acted on, the same issues will recur—something inspectors quickly notice.
Fix it: Embed a structured learning process: record, analyse, act, and review. Showcase examples of improvement and learning during inspections.
6. You Struggle to Evidence Compliance
Even if you’re compliant in practice, a lack of evidence can lead to lower ratings. CQC assessments depend on demonstrable proof; documents, meeting minutes, feedback, and trend data.
Fix it: Create a clear audit trail using tools like BAXCQC’s online compliance tracker to store, monitor, and evidence activity.
7. Governance Feels Like a Burden
If your governance meetings feel repetitive or unclear, it’s time to refresh your approach. Regulation 17 expects governance systems to be effective—not just bureaucratic.
Fix it: Streamline your governance processes. Focus on outcomes, not paperwork. Align meetings, risk logs, and quality reports with CQC’s five key questions and 34 quality statements.
Compliance is not a one-time task—it’s a living system. By embedding effective governance, engaging your team, and maintaining real-time evidence, you can not only meet but exceed CQC expectations.
If you’re unsure where to start or think your current systems might be falling short, we can help.
Our experts can carry out a baseline compliance assessment, deliver tailored training, or support you in creating a fully compliant governance framework aligned to Regulation 17. Contact us.