Policies are essential — but they don’t prove you’re delivering safe, effective, well-led care. Under the CQC’s Assessment Framework, inspectors are looking for evidence in practice across the five key questions: Safe, Effective, Caring, Responsive, Well-led. Your documents only count if they’re current, embedded, and demonstrably used to deliver outcomes for people.
What recent reports are telling providers
Across 2024–25 inspection reports, a clear pattern emerges: providers had the right policies on paper but couldn’t evidence consistent implementation.
- Policies inaccurate or not followed. A GP practice was told governance needed improvement because “some policies were inaccurate or not being followed,” and learning from incidents/complaints wasn’t used to drive improvement.
- Policies not kept up to date. A care home had “a number of policies and procedures that had not been reviewed for a significant time,” creating risk that current practice wasn’t implemented — and audits didn’t drive action.
- Staff unfamiliar with key safeguards. At another service, policies existed for MCA/DoLS, but staff didn’t know who had DoLS authorisations — a gap between documentation and day-to-day care.
- The Safeguarding policy was not consistently followed. Inspectors found staff had not always followed safeguarding policies and procedures, contributing to multiple regulatory breaches.
These findings align with CQC’s focus on real-world impact against quality statements, not just the presence of documents.
Regulations that turn policies into evidence
- Regulation 17 (Good governance): You must operate effective systems and processes, with scrutiny at board level, to assess, monitor and improve quality and reduce risks — not just store policies on a shelf. Care Quality Commission
- Regulation 12 (Safe care and treatment): Providers must assess risks, ensure staff competence, and prevent avoidable harm — evidenced by practice, records, and outcomes. Care Quality Commission
- Regulation 13 (Safeguarding): You must protect people from abuse and improper treatment; implementation, reporting, and response matter more than a policy template. Care Quality Commission
- Regulation 18 (Staffing): You need enough suitably trained, supervised staff — with induction, ongoing training, supervision and appraisal you can evidence. Care Quality Commission
What “good” looks like to CQC
Under the Assessment Framework, the five key questions are unchanged — but quality statements require you to show how people experience care and how you learn and improve. Inspectors triangulate records, observation, and interviews to test whether your policies are lived, not laminated. Map your evidence to the key questions and relevant quality statements.
From paperwork to proof: a quick self-check
Use this as a monthly governance huddle guide (and capture it in your Reg 17 evidence pack):
- Policy currency & alignment
- Reviewed in the last 12 months (or sooner if national guidance changes)?
- Cross-checked against actual workflows, templates, and clinical systems?
- Competence & staffing (Reg 18)
- Induction completed? Role-specific training up to date?
- Supervision/appraisal cycle evidenced with actions closed?
- Risk & safety (Reg 12)
- Risk assessments completed, monitored, and linked to care plans where appropriate?
- Incident/significant event learning shared and embedded (with re-audit)?
- Safeguarding (Reg 13)
- Staff can describe the process, thresholds, and who to escalate to — and you can show recent cases, decisions, and outcomes.
- Audit-to-action-to-impact (Reg 17)
- Audit schedule delivered on time; actions assigned, dated, and verified by re-audit.
- Board/partners sighted on themes, with improvement plans tracked to closure.
- Evidence pack for each quality statement
- 3–5 high-quality, current examples per statement (policy extract + training + audit + record sample + patient/staff feedback + outcome measures)
Practical examples of “evidence beyond policy”
- Medicines safety: MAR sampling + cold-chain logs + near-miss trends + last re-audit outcome, not just a medicines policy
- Consent/MCA/DoLS: Capacity assessments in notes + best-interest decisions + staff spot-checks on who has DoLS in place
- Complaints & incidents: Datix/SEA log with themes → actions → re-audit and evidence that learning changed practice.
If you rely on documents alone, you risk breaches under Regulations 12, 13, 17 and 18 — exactly the gaps inspectors are writing about now. Move from policy ownership to evidence of implementation and impact across the five key questions.
If you want a quick, honest baseline against the quality statements — with a mapped audit-to-action plan — contact BAXCQC. We’ll turn your policies into robust, inspection-ready evidence that stands up on the day. You can also utilise our online complete CQC audit for your service.
Contact us today to ensure your new service is compliant, confident, and inspection-ready from the very beginning.