Andrewjons Limited: CQC Quality Statements

ANDREWJONS LIMITED
CQC QUALITY STATEMENTS
Title: A FRAMEWORK FOR MEETING QUALITY STATEMENTS
1.0 Scope
1.1 The cross-reference of policies, procedures and other documents with the
requirements of the CQC Quality Statements.
2.0 Aims and Values
2.1 To ensure that Cared 4 policies, procedures and other documents include the
requirements of CQC Quality Statements and I Statements.
3.0 Contents
CQC Quality Statements and I Statements.
4.0 Referenced Documents
CQC Quality Statements.

I Statements.
5.0 Responsibilities
The manager.
Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

Page 1 of 35
© Bettal Quality Consultancy - Domiciliary Care April 24
ANDREWJONS LIMITED

Key Question: Safe
Safe 1: Learning Culture
We have a proactive and positive culture of safety based on openness and honesty, in which
concerns about safety are listened to, safety events are investigated and reported thoroughly,
and lessons are learned to continually identify and embed good practices.
Regulated regulations CQC Compliance evidence can be found in:

Health and Social Care Act 2008 (Regulated QP-86 Positive and Proactive Care
Activities) Addresses the Quality Statement and regulated
2014: regulation.
Regulation 12: Safe care and treatment
Regulation 16: Receiving and acting on
complaints
Regulation 17: Good governance
Regulation 20: Duty of candour
I Statements Compliance Source of evidence

1. I feel safe and am supported to understand and QP-07 Health and Safety
manage any risks QP-76 Risk Management Policy.
QP-107 Lessons Learnt Policy
2. I can get information and advice about my DC-157 Record of Information Given to Service
health, care and support and how I can be as well Users
as possible – physically, mentally and SD-20 Supporting Service Users to Maintain Good
emotionally. Health
Processes Compliance Source of evidence

1. Duty of candour QP-55 Positive Culture
QP-56 Duty of Candour Policy
QP-86 Positive and Proactive Care
2. Evidence of Learning QP-64 Putting Care Governance into Practice

QP-93 Quality Assurance Policy
QP-107 Lessons Learned
3. Incident, near misses and events records DC-001 Accident Incident Near Miss Report Form
DC-095 Accident Incident Near Miss Report Log

Page 2 of 35
ANDREWJONS LIMITED

Key Question: Safe
Safe: 2 - Safe Systems, Pathways and Transitions
We work with people and our partners to establish and maintain safe systems of care, in
which safety is managed, monitored and assured. We ensure continuity of care, including
when people move between different services.

Health and Social Care Act 2008 (Regulated MA-18 Working in co-operation with other
Activities) providers.
2014: Addresses the Quality Statement and regulated
Regulation 9: Person-centred care regulation.

1. I know what to do and who I can contact when SD-20 Supporting Service Users to Maintain Good
I realise that things might be at risk of going Health
wrong or my health condition may be worsening. DC-053 Service Users Information Folder
DC-157 Record of Information Given to Service
Users.
2. When I move between services, settings DC-054 Person Centred Care Plan
or areas, there is a plan for what happens MA-18 Working in co-operation with other
next and who will do what, and all the providers.
practical arrangements are in place.

1. People’s care records or clinical records All care or clinical records are up to date
2. Records of referral, transfer and All care or clinical records are updated when
transition of care transferring information to another service
Other requirements Compliance Source of evidence

Continuity of care QP-86 Positive and Proactive Care
QP-92 Hospital Admission and Discharge Policy
DC-054 Person Centred Care Plan
SD-04 Communication between Home Care Staff
Safe Systems of Care QP-07 Health and Safety
QP-64 Putting Care Governance into Practice
QP-76 Risk Management Policy

Page 3 of 35
ANDREWJONS LIMITED

Key Question: Safe
Safe 3: – Safeguarding
We work with people to understand what being safe means to them as well as with our partners on
the best way to achieve this. We concentrate on improving people’s lives while protecting their right
to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.
We make sure we share concerns quickly and appropriately.

Health and Social Care Act 2008 (Regulated QP-61 Safeguarding
Activities) 2014: Addresses the Quality Statement and regulated
Regulation 10: Dignity and respect
Regulation 11: Consent
Regulation 13: Safeguarding service users from
abuse and improper treatment
Regulation 20: Duty of candour
1. I feel safe and am supported to QP-76 Risk Management Policy.
understand and manage any risks. QP-61 Safeguarding
DC-054 Person Centred Care Plan
SD-01 Assessment Planning and Reviews

1. DoLS and Court of Protection (POA) QP-10 Service User’s Charter of Rights
records QP-18 Mental Capacity Act 2005 Code of Practice
QP-21 Privacy, Dignity and Human Rights
QP-34 Service Users Consent
QP-51 Deprivation of liberty
DC-084 Record of Power of Attorney
DC-092 Mental Capacity Assessment Form
DC-167 DOLS Court of Protection form
2. Mental Capacity Act records and training QP-18 Mental Capacity Act 2005 Code of Practice
3. People’s care records or clinical records People’s care records or clinical records
are up to date.
3. Safeguarding policy, records and training. QP-61 Safeguarding

DC-062 Staff Training Record
DC-114 Staff Training Matrix
DC-154 Record of Actions Taken Following a
Safeguarding
We have up-to-date records of safeguarding incidents
and actions taken.

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ANDREWJONS LIMITED

Key Question: Safe
Safe 4: - Involving People to Manage Risks
We work with people to understand and manage risks by thinking holistically so that care meets
their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Health and Social Care Act 2008 (Regulated QP-76 Risk Management Policy
Regulation 11: Need for consent

1. I feel safe and am supported to understand and DC-020 General Risk Assessment Form
manage any risks. DC-157 Record of Information Given to Service
Users
2. I know what to do and who I can contact when DC-054 Person Centred Care Plan
I realise that things might be at risk of going DC-157 Record of Information Given to Service
wrong or my health condition may be worsening. Users
3. If my treatment, including medication, has to QP-46 Medication Management
change, I know why and am involved in the DC-054 Person Centred Care Plan
decision. SD-01 Assessment Planning and Reviews
4. When I move between services, settings or DC-054 Person Centred Care Plan
areas, there is a plan for what happens next and MA-18 Working in co-operation with other providers
who will do what, and all the practical
arrangements are in place.
5. I have considerate support delivered by DC-054 Person Centred Care Plan
competent people.
6. I can get information and advice about my SD-01 Assessment Planning and Reviews
health, care and support and how I can be as well
as possible – physically, mentally and
emotionally.

1. Arrangements to: respond to QP-20 First Aid
emergencies, Identify people in need of QP-59 Home Care Emergency Situations
urgent medical treatment QP-76 Risk Management Policy
PCT-11 Safety in the Service User’s Home
SD-18 Risk Management
2. DoLS and Court of Protection (POA) records DoLS and Court of Protection (POA) records
3. People’s care records or clinical records People's care and clinical records are up to date.
4. Records of restrictive practices QP-33 Managing Challenging Behaviour (Restraint)
DC-169 Record of Restrictive Practice

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ANDREWJONS LIMITED

Key Question: Safe
Safe 5: - Safe Environments
We detect and control potential risks in the care environment and make sure that the
equipment, facilities and technology support the delivery of safe care.

Health and Social Care Act 2008 (Regulated QP-26 Environmental Policy
Activities) Addresses the Quality Statement
2014:
Regulation 12 Safe care and treatment
Regulation 15: Premises and equipment
1. I feel safe and am supported to understand and QP-76 Risk Management Policy
manage any risks. DC-020 General Risk Assessment Form
Users
MA-14 Managing Staffing Levels and Staff Rotas

1. Business continuity plans (including in QP-26 Environment policy
response to extreme weather events) DC-097 Crisis Management and Service Continuity
Plan
DC-145 Business Continuity Plan
DC-163 Extreme Weather Risk Assessment (Staff)
DC-164 Extreme Weather Risk Assessment (Service
User)
2. Environmental risk assessment QP-26 Environment policy
3. Equipment maintenance and calibration records QP-109 Premises and Equipment

DC-031 Maintenance of Equipment Record
DC-105 List of Equipment used in the home
DC-170 Food Temperature Record
MA-19 Safety Availability and Suitability of
Equipment
MA-20 Cleaning and Decontamination of Equipment
4. Health and safety risk assessments QP-07 Health and Safety

QP-05 Fire Safety Service Users Home
QP-89 Fire Risk Assessment Policy
5. Infection prevention and control audit and MA-03 Infection control
action plans

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ANDREWJONS LIMITED

Key Question: Safe
Safe 6: - Safe and Effective Staffing
We make sure there are enough qualified, skilled and experienced people, who receive effective
support, supervision and development and work together effectively to provide safe care that meets
people’s individual needs.

Health and Social Care Act 2008 (Regulated MA-14 Managing Staffing Levels and Staff Rotas
Activities) Addresses the Quality Statement
2014:
Regulation 18: Staffing
Regulation 19: Fit and proper persons employed
1. I feel safe and am supported to understand QP-76 Risk Management Policy
and manage any risks. DC-020 General Risk Assessment Form
DC-157 Record of Information Given to Service Users
2. I know what to do and who I can contact DC-053 Service User’s Information Folder - Contents
when I realise that things might be at risk of DC-157 Record of Information Given to Service Users
going wrong or my health condition may be
worsening.
change, I know why and am involved in the DC-054 Person Centred Care Plan
decision. SD-01 Assessment Planning and Reviews
4. I have considerate support delivered by DC-062 Staff Training Records

competent people. DC-114 Staff Training Matrix
DC-122 Staff Competency of Administration of
Medicines
5. I can get information and advice about my SD-01 Assessment Planning and Reviews
health, care and support and how I can be as Staff Training
well as possible – physically, mentally and
emotionally.

1. Appraisal and supervision records DC-060 Staff Supervision Record
DC-061 Staff Supervision Schedule and Planner
PP-05 Staff supervision and appraisal
DC-SSF Staff Supervision File
2. Recruitment records QP-79 Recruitment of Staff
DC-041 Recruitment Monitoring Form
DC-166 Staff Vacancy and Turnover Rate
PP-01 Recruitment of staff
3. Staffing and staff skill mix records MA-14 Managing Staffing Levels and Staff Rotas
4. Training in communication with people with a We have up-to-date records where training.
learning disability and autistic people in communication with people with a learning
disability and autistic people has been provided

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ANDREWJONS LIMITED

Key Question: Safe
Safe 7: - Infection Prevention and Control
We assess and manage the risk of infection. We detect and control the risk of it spreading
and share any concerns with appropriate agencies promptly.

Health and Social Care Act 2008 (Regulated QP-38 Infection Control and Decontamination
Activities) 2014: Addresses the Quality Statement

1. I feel safe and am supported to understand and DC-157 Record of Information Given to Service
manage any risks. Users
QP-32 Providing Information on Infection Control
QP-38 Infection Control and Decontamination

1. Infection prevention and control policy QP-15 Communicable Infectious Disease (MRSA)
QP-32 Providing Information on Infection Control
QP-87 Infection Control During a Pandemic
QP-90 Donning and doffing PPE
DC-024 Infection Control Monitoring Form
DC-044 Report of Infectious or Communicable
Disease Form
DC-155 Record of Actions Taken Following an
Infection Outbreak
MA-03 Infection Prevention Control
MA-16 Care Quality Commission Statutory
Notifications
Minimising the risk of infection at the services As above where applicable.

(shared lives only)

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ANDREWJONS LIMITED

Key Question: Safe
Safe 8: - Medicines Optimisation
We make sure that medicines and treatments are safe and meet people’s needs, capacities and
preferences by enabling them to be involved in planning, including when changes happen.

Health and Social Care Act 2008 (Regulated QP-46 Medication Management
Activities)
2014: Regulation 12 Safe care and treatment
Regulated Activities Regulations 2014

1. I feel safe and am supported to understand and QP-07 Health and Safety
manage any risks. QP-46 Medication Management
Users
2. I know what to do and who I can contact when I QP-46 Medication Management
realise that things might be at risk of going wrong or DC-157 Record of Information Given to Service
my health condition may be worsening. Users

change, I know why and am involved in the decision DC-123 Consent for Medication
4. I have considerate support delivered by competent QP-46 Medication Management
people. DC-062 Staff Training Record
DC-122 Staff Competency of Administration of
Medicines

1. Administering and dispensing medicines QP-46 Medication Management
DC-147 Medication Administration Record
2. Medicines Reviews QP-46 Medication Management
3. Medicines audits and action plans DC-040 Record of Staff Authorised to Administer
Medication
DC-085 Medication Supervision Record
DC-124 Service Users Medication Audit
DC-128 Audit of On-Site Medication
4. PRN protocols QP-46 Medication Management
5. People’s care records or clinical records People’s care records or clinical records are up to date.

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ANDREWJONS LIMITED

Key Question: Effective
Effective 1: Assessing Needs
We maximise the effectiveness of people’s care and treatment by assessing and reviewing their
health, care, wellbeing and communication needs with them.
.
Health and Social Care Act 2008 (Regulated SD-01 Assessment Planning and Reviews

1. I can get information and advice about my DC-054 Person Centred Care Plan
health, care and support and how I can be as well DC-072 Home Care Assessment Planning and
as possible – physically, mentally and Information Pack Contents
emotionally. SD-01 Assessment Planning and Reviews
SD-20 Supporting Service Users to Maintain Good
Health
2. I have care and support that is co-ordinated, and DC-054 Person Centred Care Plan
everyone works well together and with me. DC-055 Satisfaction Survey Questionnaire
. SD-20 Supporting Service Users to Maintain Good
Health
3. I have care and support that enables me to live QP-21 Privacy Dignity and Human Rights
as I want to, seeing me as a unique person with DC-054 Person Centred Care Plan
skills, strengths and goals.
4. I am empowered to get the care, support and SD-01 Assessment Planning and Reviews
treatment that I need and want. SD-20 Supporting Service Users to Maintain Good
Health

1. Assessments and records of meeting needs QP-40 Equality Diversity and Inclusion
under the Equality Act 2010
2. Assessments and or best interest decisions QP-18 Mental Capacity Act 2005 Code of Practice
under the MCA Policy
DC-092 Mental Capacity Assessment Form
APPENDIX: Good practice in assessing Mental
Capacity
3. Clinical tools to assess pain and monitor risk QP-70 Pain Management
DC-165 Abbey Pain Scale
are up to date.

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ANDREWJONS LIMITED

Effective 2: Delivering evidence-based care and treatment
We plan and deliver people’s care and treatment with them, including what is important and
matters to them and in line with legislation and current evidence-based good practice and
standards.

Health and Social Care Act 2008 (Regulated QP-123 Evidence-Based Practice Policy Addresses
Activities) 2014: the Quality Statement and regulated regulation.
Regulation 9: Person-centred care
Regulation 14: Meeting nutritional and hydration
needs
Health
QP-123 Evidence-Based Practice Policy
Health
CI-08 Satisfaction surveys
as I want to, seeing me as a unique person with DC-054 Person Centred Care Plan
skills, strengths and goals.

are up to date.
2. Quality Improvement Activity QP-93 Quality Assurance Policy

DC-156 Record of Information Given to Staff Form
CI-03 Management Review of the Quality System
CI-05 Internal Audits of the Quality System
Other CQC Requirements

People’s nutrition and hydration needs are met in QP-14 Nutrition and Hydration
line with current guidance. DC-087 Nutritional Intake Chart

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ANDREWJONS LIMITED

Effective 3: How staff, teams and services work together
We work effectively across teams and services to support people, making sure they only
need to tell their story once by sharing their assessment of needs when they move between
different services.

Health
. SD-20 Supporting Service Users to Maintain Good
Health

1. Information sharing and transfer of records MA-18 Working in co-operation with other providers
across or between services
2. Multidisciplinary team meeting records Record of Multidisciplinary Team Meetings
are up to date.

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ANDREWJONS LIMITED

Effective 4: Supporting People to Live Healthier Lives
We support people to manage their health and wellbeing so they can maximise their independence,
choice and control. We support them to live healthier lives and where possible, reduce their future
needs for care and support.

Health and Social Care Act 2008 (Regulated SD-20 Supporting Service Users to Maintain Good
Activities) 2014: Health
Regulation 9: Person-centred care Addresses the Quality Statement and regulated
Regulation 10: Dignity and respect regulation.

Health
2. I have care and support that is co-ordinated, and QP-106 Person Centred Care Planning Policy
everyone works well together and with me. DC-054 Person Centred Care Plan
DC-055 Satisfaction Survey Questionnaire
as I want to, seeing me as a unique person with QP-106 Person Centred Care Planning Policy
skills, strengths and goals. DC-054 Person Centred Care Plan

are up to date.

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ANDREWJONS LIMITED

Effective 5: Monitoring and improving outcomes
We routinely monitor people’s care and treatment to continuously improve it. We ensure that
outcomes are positive and consistent, and that they meet both clinical expectations and the
expectations of people themselves.


as I want to, seeing me as a unique person with QP-106 Person Centred Care Planning Policy
skills, strengths and goals. DC-054 Person Centred Care Plan

are up to date.
2. Provider led audits and action plans DC-025 Internal Audit Schedule
DC-026 Internal Quality Audit Report Form

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ANDREWJONS LIMITED

Effective 6: Consent to care and treatment
We tell people about their rights around consent and respect these when we deliver person-centred
care and treatment.
Health and Social Care Act 2008 (Regulated QP-34 Service Users consent

1. Best interest meetings, evidence of power of DC-084 Power of Attorney Form
attorney DC-168 Record of Best Interest Meetings
2. Capacity assessments and DNACPR decision QP-18 Mental Capacity Act 2005 Code of Practice
records Policy APPENDIX: Good practice in assessing
Mental Capacity
QP-54 Do not attempt resuscitation
DC-171 DNACPR Decision Records
3. Consent policy DC-110 Consent to Care and Treatment
are up to date.

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ANDREWJONS LIMITED
Key Question: Caring

Caring 1: Kindness, compassion and dignity
We always treat people with kindness, empathy and compassion and we respect their privacy and
dignity. We treat colleagues from other organisations with kindness and respect.
.
Health and Social Care Act 2008 (Regulated QP-21 Privacy, Dignity and Human Rights

1. I am treated with respect and dignity. QP-10 Service User’s Charter of Rights
Care Governance
QP-21 Privacy, Dignity and Human
QP-31 Communicating with Service Users
QP-36 Valuing and Supporting Staff
QP-59 Home Care Emergency Situations
QP-70 Pain Management
DC-109 Emergency Numbers Form
QP-64 Putting Care Governance into Practice

None None

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ANDREWJONS LIMITED

Caring 2: Treating people as individuals
We treat people as individuals and make sure their care, support and treatment meets their needs and
preferences, taking account of their strengths, abilities, aspirations, culture and unique backgrounds
and protected characteristics.

Health and Social Care Act 2008 (Regulated QP-21 Privacy, Dignity and Human Rights
Regulation 14: Meeting nutritional and hydration
needs

2. I have care and support that enables me to live QP-106 Person Centred Care Planning Policy
as I want to, seeing me as a unique person with
skills, strengths and personal goals.
3. I am supported to manage my health in a way SD-20 Supporting Service Users to Maintain Good
that makes sense to me. Health
4. I am in control of planning my care and SD-01 Assessment Planning and Reviews

support. If I need help with this, people who know
and care about me are involved.
5. I can keep in touch and meet up with people DC-171 Record of Keeping Contact with family and
who are important to me, including family, friends Friends
and people who share my interests, identity and SD-09 Assisting Service Users with external
culture. activities

1.People’s care records or clinical records People’s care records or clinical records are up to
date.

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ANDREWJONS LIMITED

Caring 3: Independence, choice and control
We promote people’s independence, so they know their rights and have choice and control over their
own care, treatment and wellbeing.

Health and Social Care Act 2008 (Regulated QP-106 Person Centred Care Planning Policy
2. I have care and support that enables me to live QP-106 Person Centred Care Planning Policy

support. If I need help with this, people who know QP-106 Person Centred Care Planning Policy
5. I can keep in touch and meet up with people DC-171 Record of Keeping Contact with family and
who are important to me, including family, friends Friends
and people who share my interests, identity and
culture.

1.People’s care records or clinical records People’s care records or clinical records are up to
date.

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ANDREWJONS LIMITED

Caring 4: Responding to people’s immediate needs
We listen to and understand people’s needs, views and wishes. We respond to these in that moment
and will act to minimise any discomfort, concern or distress.

Health and Social Care Act 2008 (Regulated QP-126 Responding to People’s Immediate Needs
Activities) 2014:
Regulation 9: Person-centred care QP-106 Person Centred Care Planning Policy
Regulation 10: Dignity and respect Addresses the Quality Statement and regulated
Regulation 11: Need for consent regulation.
complaints

QP-126 Responding to People’s Immediate Needs

None None

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ANDREWJONS LIMITED

Caring 5: Workforce wellbeing and enablement
We care about and promote the wellbeing of our staff, and we support and enable them to always
deliver person centred care.

Health and Social Care Act 2008 (Regulated QP-36 Valuing and Supporting Staff
Activities) 2014: Policy
Regulation 9: Person-centred care Addresses the Quality Statement and regulated
Regulation 12: Safe care and treatment regulation.

1. I have care and support that enables me to live QP-40 Equality and Diversity

support. If I need help with this, people who know

1. Mechanisms to monitor, improve and promote QP-07 Health and Safety
staff safety and wellbeing QP-23 Lone Working
DC-131Employee Satisfaction
DC-156 Record of Information Given to Staff
PP-04 Staff training and development
PP-06 Staff meetings
PP-05 Staff Supervision and Appraisal
2. Staff management policies QP-36 Valuing and Supporting Staff

PP-03 Staff induction and probation
PP-05 Staff supervision and appraisal
PP-07 Staff grievance procedure
PP 08 Disciplinary procedure
3. Staff sickness, vacancy and turnover rates QP-35 Staff Sickness and Attendance
DC-096 Return to Work Interview Form
DC-166 Staff Vacancy and Turnover Rate

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ANDREWJONS LIMITED

Key Question: Responsive
Responsive 1: Person-centred care
We make sure people are at the centre of their care and treatment choices and we decide, in
partnership with them, how to respond to any relevant changes in their needs.

Health and Social Care Act 2008 (Regulated QP-106 Person Centred Care Planning Policy
Activities) Addresses the Quality Statement and regulated
2014: regulation.

2. I am in control of planning my care and DC-072 Home Care Assessment Planning and
support. If I need help with this, people who know Information Pack Contents
and care about me are involved. DC-157 Record of Information Given to Service
Users
3. I am supported to plan ahead for important QP-43 End of Life Care Plan
changes in my life that I can anticipate. DC-054 Person Centred Care Plan
4. I know how to access my health and care DC-110 Consent to Care and Treatment
records and decide which personal information DC-123 Consent for Medication
can be shared with other people, including my DC-157 Record of Information Given to Service
family, and care staff. Users
.
are up to date.
2. Arrangements for ensuring continuity of care SD-17 Crisis Management and Service Continuity

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ANDREWJONS LIMITED

Responsive 2: Care provision, integration, and continuity
We understand the diverse health and care needs of people and our local communities, so
care is joined-up, flexible and supports choice and continuity.

2. I am in control of planning my care and QP-106 Person Centred Care Planning Policy
support. If I need help with this, people who know DC-072 Home Care Assessment Planning and
and care about me are involved. Information Pack Contents
Users

are up to date.
2. Arrangements for ensuring continuity of care SD-17 Crisis Management and Service Continuity

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ANDREWJONS LIMITED

Responsive 3: Providing information
We provide appropriate, accurate and up-to-date information in formats that we tailor to individual
needs.

Health and Social Care Act 2008 (Regulated QP-67 Information Governance Policy
Regulation 13: Safeguarding services users from
1. I can get information and advice that is QP-67 Information Governance Policy
accurate, up to date and provided in a way that I DC-157 Record of Information Given to Service
can understand. Users
2. I am encouraged and enabled to feedback about QP-02 Comments, Suggestions and Complaints
my care in ways that work for me and I know DC-055 Satisfaction Survey Questionnaire
how it was acted on. CI-08 Satisfaction surveys
3. I know how to access my health and care QP-72 Accessible Information Policy
records and decide which personal information
can be shared with other people, including my
family, care staff, school or college.

1. arrangements to: QP-31 Communicating with Service Users
a. explain fees clearly DC-067 Terms and Conditions of the Home Care
b. identify people’s communication Service
preferences
2. Information sharing with people using services QP-67 Information Governance Policy
and those close to them QP-72 Accessible Information Policy
DC-072 Home Care Assessment Planning and
Information Pack Contents
Meeting the Accessible Information Standard QP-67 Information Governance Policy

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ANDREWJONS LIMITED

Responsive 4: Listening to and involving people
We make it easy for people to share feedback and ideas or raise complaints about their care,
treatment and support. We involve them in decisions about their care and tell them what’s
changed as a result.

Health and Social Care Act 2008 (Regulated QP-02 Comments, Suggestions and Complaints
complaints

2. I am in control of planning my care and DC-157 Record of Information Given to Service

support. If I need help with this, people who know Users
I am encouraged and enabled to feedback about DC-055 Satisfaction Survey Questionnaire

my care in ways that work for me and I know CI-08 Satisfaction surveys
how it was acted on. QP-02 Comments, Suggestions and Complaints

1. Advocacy and support service records SD-12 Advocacy
2. Collecting people’s feedback, taking action and CI-08 Satisfaction surveys

sharing learning
3. Complaints records and outcomes QP-02 Comments, Suggestions and Complaints

DC-010 Complaints Form
DC-011 Complaints Log
4. Improvement plans and audits CI-05 Internal Audits of the Quality System

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ANDREWJONS LIMITED

Responsive 5: Equity in access
We make sure that everyone can access the care, support and treatment they need when they
need it.

Health and Social Care Act 2008 (Regulated QP-40 Equality Diversity and Inclusion Addresses
Activities) 2014: the Quality Statement and regulated regulation.
Regulations 12: Safe care and treatment

support. If I need help with this, people who know DC-157 Record of Information Given to Service
and care about me are involved. Users
DC-019 Equalities Action Plan

1. People's care records or clinical records People's care records or clinical records are up to date
2. Provider led audits of processes QP-70 Implementing Care Governance

DC-025 Internal Audit Schedule

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ANDREWJONS LIMITED

Responsive 6: Equity in experiences and outcomes
We actively seek out and listen to information about people who are most likely to
experience inequality in experience or outcomes. We tailor the care, support and treatment
in response to this.

Health and Social Care Act 2008 (Regulated QP-108 Culturally Appropriate Care
17: Good governance

I have care and support that is co-ordinated, and SD-01 Assessment Planning and Reviews
everyone works well together and with me. QP-106 Person Centred Care Planning Policy
support. If I need help with this, people who know DC-157 Record of Information Given to Service
and care about me are involved. Users
3. I am encouraged and enabled to feedback about SD-01 Assessment Planning and Reviews
my care in ways that work for me and I know how QP-106 Person Centred Care Planning Policy
it was acted on. QP-02 Comments, Suggestions and Complaints

2. Improvement plans and audits QP-64 Putting Care Governance into Practice
DC-025 Internal Audit Schedule

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ANDREWJONS LIMITED

Responsive 7: Planning for the future
We support people to plan for important life changes, so they can have enough time to make
informed decisions about their future, including at the end of their life.

Health and Social Care Act 2008 (Regulated QP-43 End of Life Care Plan

1. I can get information and advice that is QP-72 Accessible Information Policy
accurate, up to date and provided in a way that I
can understand.
2. I am in control of planning my care and QP-43 End of Life Care Plan

support. If I need help with this, people who know QP-64 Putting Care Governance into Practice
3. I am supported to plan ahead for important QP-117 Advance Care Planning

changes in my life that I can anticipate.
1. DNACPR and ReSPECT decisions QP-54 Do Not Attempt Cardiopulmonary
Resuscitation
QP-43 End of Life Care Plan
2. End of life care planning QP-43 End of Life Care Plan

DC-084 Power of Attorney Form

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ANDREWJONS LIMITED
Key Question: Well Led

Well Led 1: Shared direction and culture
We have a shared vision, strategy and culture. This is based on transparency, equity, equality and
human rights, diversity and inclusion, engagement, and understanding challenges and the needs of
people and our communities in order to meet these.

Health and Social Care Act 2008 (Regulated QP-64 Putting Care Governance into Practice
Activities) Regulations 2014: Addresses the Quality Statement and regulated

None None

1. Business plans DC-116 Business Plan
2. Equality, diversity, and inclusion policy QP-40 Equality Diversity and Inclusion
3. Monitoring service objectives QP-64 Putting Care Governance into Practice

QP-93 Quality Assurance Policy
DC-003 Annual Management Review Form
CI 01 A Framework for Quality – meeting Quality
Statements
CI-06 Routine monitoring of quality and corrective
action of the Quality System
4. Vision, aims and strategy DC-063 Statement of Purpose
5. Whistleblowing QP-65 Whistle Blowing Policy


Page 28 of 35
ANDREWJONS LIMITED

Well Led 2: Capable, compassionate and inclusive leaders
We have inclusive leaders at all levels who understand the context in which we deliver care,
treatment and support and embody the culture and values of their workforce and organisation. They
have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity,
openness and honesty.

Health and Social Care Act 2008 (Regulated QP-62 Fit and Proper Person Policy
Regulation 4: Requirements where the service regulation.
provider is an individual or a partnership
Regulation 5: Fit and proper persons directors
Regulation 6: Requirement where the service
provider is a body other than a partnership
Regulation 7: Requirements relating to registered
managers
Regulation 19: Fit and proper persons employed
Registration regulations 2009:
Regulation 14: Notice of absence
Regulation 15: Notice of changes
None None

1. Evidence of compliance with schedule 3 and QP-62 Fit and Proper Person Policy
Fit and Proper Person Requirements QP-74 Fit and Proper Persons Test
PP 02 Checking the Authenticity of qualifications
2. leadership development and training QP-22 Staff Training

PP 04 Staff training and development
3. Recruitment and induction records QP-55 Positive Culture

QP-79 Recruitment of Staff Policy
DC-023 Induction Checklist
DC-041 Recruitment Monitoring Form
PP 01 Recruitment of staff
PP 03 Staff induction and probation

Page 29 of 35
ANDREWJONS LIMITED

Well Led 3: Freedom to speak up
We foster a positive culture where people feel that they can speak up and that their voice will be
heard.

Health and Social Care Act 2008 (Regulated QP-55 Positive Culture
None None

1.Mechanisms for seeking and responding to staff QP-36 Valuing and Supporting Staff
feedback QP-55 Positive Culture
DC-083 Staff Meetings Attendance Form
2. Whistleblowing records QP-65 Whistle Blowing Policy


Page 30 of 35
ANDREWJONS LIMITED

Well Led 4: Workforce equality, diversity and inclusion
We value diversity in our workforce. We work towards an inclusive and fair culture by improving
equality and equity for people who work for us.

Health and Social Care Act 2008 (Regulated QP-36 Valuing and Supporting Staff
Regulation 17: Good governance regulation.
None None

1. Equality, diversity and inclusion policies and QP-40 Equality Diversity and Inclusion
training QP-22 Staff Training
MA-04 Equal opportunities
2. Flexible working arrangements, reasonable QP-68 Use of Technology

adjustments and staff use of assistive technology QP-127 Remote and Hybrid Working Policy
3. Records of any incidents towards staff QP-107 Lessons Learnt Policy

DC-001 Accident / Incident Report Form
DC-095 Accident/ Incident/ Near Miss Report Log
MA 02 Accident / incident reporting
4. Workforce or EDI strategy and associated CI 02 Equalities action plan

objectives and action plans

Page 31 of 35
ANDREWJONS LIMITED

Well Led 5: Governance, Management and Sustainability
We have clear responsibilities, roles, systems of accountability and good governance. We use these
to manage and deliver good quality, sustainable care, treatment and support. We act on the best
information about risk, performance and outcomes, and we share this securely with others when
appropriate.

Health and Social Care Act 2008 (Regulated QP-64 Putting Care Governance into Practice
Regulation 12: Safe care and treatment regulation.
Registration regulations 2009:
Regulation 14: Notice of absence
Regulation 15: Notice of changes
Regulation 16: Notification of death of service
user
Regulation 18: Notification of other incidents
Regulation 22A: Form of notifications to the
Commission
None None

1.Business continuity plans and risk register DC-034 Non-conformance Report Register
DC-097 Crisis Management and Service Continuity
Plan
DC-145 Business Continuity Plan
SD 17 Crisis Management and service continuity
2. Governance arrangements and organisational QP-64 Putting Care Governance into Practice
structure (roles and responsibilities) DC-116 Business Plan (Organisational Structure)
3. Information security, data protection and GDPR QP-44 Data Protection
arrangements QP-67 Information Governance
QP-72 Accessible Information Policy
2. Quality management, systems and reporting QP-93 Quality Assurance Policy

CI 01 A Framework for Quality – Meeting Quality
Statements
5. Workforce planning MA-14 Managing staffing levels and staff rotas
PP 04 Staff training and development

Page 32 of 35
ANDREWJONS LIMITED

Well Led 6: Partnership and communities
We understand our duty to collaborate and work in partnership, so our services work seamlessly for
people. We share information and learning with partners and collaborate for improvement.

Health and Social Care Act 2008 (Regulated MA-18 Working in co-operation with other providers.
None None

1.Examples of sharing learning and best practice QP-115 Lessons Learnt Policy
2.Records of collaboration MA-18 Working in co-operation with other providers.
3.Trusted Assessors/Discharge to Assess schemes QP-99 Hospital Admission and Discharge Policy

Page 33 of 35
ANDREWJONS LIMITED
Well Led 7: Learning, improvement and innovation

We focus on continuous learning, innovation and improvement across our organisation and the local
system. We encourage creative ways of delivering equality of experience, outcome and quality of
life for people. We actively contribute to safe, effective practice and research.

Health and Social Care Act 2008 (Regulated QP-107 Lessons Learnt Policy.
Regulation 16: Receiving and acting on complaints regulation.
None None

1.Embedding learning and making improvements QP-02 Comments, Suggestions and Complaints
QP-22 Staff Training
DC-37 Proposed Change to Quality Procedure
2.Engagement in innovation initiatives QP-67 Information Governance

CI 01 A Framework for Quality – meeting CQC
Quality Statements

Page 34 of 35
ANDREWJONS LIMITED

Well Led 8: Environmental sustainability – sustainable
development
We understand any negative impact of our activities on the environment and we strive to make a
positive contribution in reducing it and support people to do the same.

Health and Social Care Act 2008 (Regulated QP-26 Environmental Policy
None cited regulation.

None None

1.Green and carbon reduction plans and policies QP-26 Environmental Policy
MA 11 Purchasing of goods and services
C4-ASF Approved Suppliers File
2. Processes for recycling QP-64 Putting Care Governance into Practice

CI 01 A Framework for Quality – meeting CQC
Quality Statements
3.Staff training in environmental sustainability QP-22 Staff Training

DC-062 Staff Training Record

Page 35 of 35

Andrewjons Limited: CQC Quality Statements

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ANDREWJONS LIMITED

CQC QUALITY STATEMENTS

Title: A FRAMEWORK FOR MEETING QUALITY STATEMENTS

2.0 Aims and Values

CQC Quality Statements and I Statements.

4.0 Referenced Documents

CQC Quality Statements.

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

I Statements Compliance Source of evidence

Processes Compliance Source of evidence

2. Evidence of Learning QP-64 Putting Care Governance into Practice

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

I Statements Compliance Source of evidence

Processes Compliance Source of evidence

Other requirements Compliance Source of evidence

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

Processes Compliance Source of evidence

3. Safeguarding policy, records and training. QP-61 Safeguarding

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

I Statements Compliance Source of evidence

Processes Compliance Source of evidence

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

Processes Compliance Source of evidence

2. Environmental risk assessment QP-26 Environment policy

3. Equipment maintenance and calibration records QP-109 Premises and Equipment

4. Health and safety risk assessments QP-07 Health and Safety

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

4. I have considerate support delivered by DC-062 Staff Training Records

Processes Compliance Source of evidence

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

I Statements Compliance Source of evidence

Processes Compliance Source of evidence

Minimising the risk of infection at the services As above where applicable.

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

I Statements Compliance Source of evidence

3. If my treatment, including medication, has to QP-46 Medication Management

Processes Compliance Source of evidence

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

I Statements Compliance Source of evidence

Processes Compliance Source of evidence

Issue No: 1 Rev: 1 Issue Date: 14/03/24 Approved by: ……………………..……

CQC QUALITY STATEMENTS

Regulated regulations CQC Compliance evidence can be found in:

Processes Compliance Source of evidence

2. Quality Improvement Activity QP-93 Quality Assurance Policy

Other CQC Requirements