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All providers of health and adult social care in England must be registered to deliver patient care with the regulator the Care Quality Commission (CQC) in compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2012 and the Care Quality Commission (Registration) Regulations 2009.

Once registered with the CQC, all providers of health and adult social care in England must continue to deliver and evidence their compliance with the CQC’s Essential Standards of Quality and Safety. It is all staffs’ responsibility to continually deliver these essential standards of patient care. This compliance will be checked by the CQC using both planned (themed) and unannounced inspections. (Please refer to the above Policy)

The Trust’s governance structure for ensuring compliance with the CQC essential standards is set out in the Quality, Safety and Risk Management Strategy (2012-2017). The process is supported by an internal assurance framework (collation of on-going evidence against individual outcomes) which is devolved and managed at Divisional level, by leads, through the web-based software system HealthAssure. The Head of Accreditation & Regulation coordinates the process, supports staff and provides training for leads and appropriate staff.



This policy is designed as a framework to support Divisional teams and Outcome owners in undertaking robust self-assessments of the extent to which their clinical division is compliant with each of the 16 essential standards.



This policy is intended to support all Trust staff involved in supporting and undertaking quarterly self-assessments of compliance with the CQC’s 16 essential standards. It also provides guidance around types of evidence which can be utilised to demonstrate compliance with the standards.


Policy Details

Download: PDF version
Compiled by: Head of Accreditation and Regulation
Ratified by: IGAC
Date Ratified: June 2013
Date Issued: June 2013
Review Date: June 2016
Target Audience: All staff
Contact name: Head of Accreditation and Regulation


See also:

  • Quality Safety and Risk Management Strategy (2012-2017).
  • Policy for Managing and Responding to External Agency Visits, Inspections and Accreditations