Inspection Pack
Every document, policy, risk assessment, and evidence page an inspector may request — organised by CQC domain, one click to open or download. Present this page to the inspector on a tablet or laptop.
🚨 Before the Inspector Arrives🛡️ Safe📊 Effective💜 Caring🔄 Responsive⭐ Well-Led📚 Complete Policy Library (27 Policies)⚠️ Risk Assessments and Audit Tools
How to Use This Page
Open this page on a laptop or tablet at the start of the inspection. Share the screen with the inspector. Each section corresponds to a CQC key question. Tap any item to download the document or open the evidence page. Items marked URGENT require manual CQC portal action before the inspection begins.
88
Documents in pack
34
CQC evidence pages
27
Approved policies
12
Risk assessments
34
Quality statements covered
5
CQC domains
Before presenting to inspector: Confirm governance meeting minutes are signed and physically on site · Confirm Staff Compliance Register is current · Confirm Statement of Purpose on CQC Provider Portal is updated (provider name + email) · Confirm incident/near-miss/complaints registers are printed and available.
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Before the Inspector Arrives
Check these first. These items verify the inspection can proceed without administrative issues.
4 items
🔗
CQC Provider Portal — verify Statement of Purpose URGENT
Confirm: provider name = BCSZ Ltd t/a The Vesey Private Hospital · email = reception@thevesey.co.uk
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RM CQC Interview Preparation Guide
TVH-RM-INT-001 · 8 likely questions with model answers · pre-inspection checklist
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CQC Readiness Action Plan
TVH-AP-CQC-001 · 12 themes · current RAG status and completion evidence
🛡️
Safe
All 8 Safe quality statements evidenced. CQC inspectors will focus heavily on this domain for private clinics.
15 items
CQC Evidence Pages:
📌
Incident Register
Log all incidents from opening · date, classification, actions taken · nil-to-report monthly
📌 Maintain in governance file — present physical copy on site
📌
Near-Miss Log
Separate from incidents · demonstrates open safety culture
📌 Part of weekly safety huddle documentation
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Emergency Equipment Check Log
TVH-OPS-LOG-001 · weekly · signed by staff · kept next to equipment
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NHS GP Information Sharing SOP
TVH-SOP-CLI-001 · 2-working-day standard · method documented per record
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Incident Reporting Policy
TVH-POL-SAF-002 · 48hr review · root cause analysis · no-blame culture
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Safeguarding Quick Reference Card
TVH-SAF-QRC-001 · Birmingham MASH 0121 303 1888 · in every clinical room
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Medicines Management Policy
TVH-POL-MED-001 · Human Medicines Regulations 2012 (as amended 2023)
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Staff Compliance Register
TVH-HR-REG-001 · DBS dates · registration numbers · expiry dates for all staff
📊
Effective
All 6 Effective quality statements. Focus: evidence-based practice, clinical audit, and NHS GP information sharing.
8 items
CQC Evidence Pages:
📄
Clinical Audit Template + Completed Audits
TVH-AUD-TMPL-001 · completed cycle: audit → action → re-audit · in governance file
📊
Patient Outcome Measures Tracker
TVH-OUT-003 · sequential blood test results · monthly aggregate · population-level improvement data
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Minimum Clinical Records Dataset Standard
TVH-SOP-CLI-002 · 10 mandatory fields · quarterly audit
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Mental Capacity Act and Best Interests Policy
TVH-POL-CLI-003 · two-stage test · LPA · Best Interests decisions documented
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Referral Management Policy
TVH-POL-CLI-002 · 2WW same-day action · discharge letter 2 working days
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Training and Development Policy
TVH-POL-HR-002 · Skills for Care framework · individual CPD plans
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Mandatory Training Matrix
TVH-Training-Matrix · completion status · expiry dates · per staff member
💜
Caring
All 5 Caring quality statements. Doctify 4.87/5 from 350+ reviews is direct evidence. Show the feedback loop.
6 items
CQC Evidence Pages:
📄
Monthly Patient Feedback Summary
TVH-GOV-FBK-001 · NPS score · Doctify · Trustpilot · actions taken in response
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Complaints Register
TVH-COM-REG-001 · every complaint logged · acknowledgement dates · learning documented
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Complaints Policy and Procedure
TVH-POL-COM-001 · NHS Complaints Regulations 2009 · CQC Regulation 16
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Staff Vision and Values Briefing
TVH-OUT-004 · signed by all staff · filed in HR record · Outstanding Well-Led evidence
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Staff Supervision Policy
TVH-POL-HR-004 · CQC Regulation 18 · supervision records maintained
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Equality, Diversity and Human Rights Policy
TVH-POL-HR-003 · Equality Act 2010 · Human Rights Act 1998
🔄
Responsive
All 7 Responsive quality statements. Subscription model, 7-day access, and same-day blood results are structural advantages.
4 items
CQC Evidence Pages:
📊
Innovation and Improvement Register
TVH-OUT-005 · WhatsApp channel, subscription model, 7-day access logged as innovations
⭐
Well-Led
All 8 Well-Led quality statements. Governance meeting minutes are the most critical evidence — present all signed copies.
13 items
CQC Evidence Pages:
📄
Governance Meeting Minutes (all signed)
TVH-GOV-MIN-001 · all meetings from May 2026 · physically signed · retained in governance file
📌 Present physical signed originals on site
📌
Risk Register
Maintain current version in governance file · RAG status · monthly review
📌 Present current signed version in governance file on site
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Disciplinary and Grievance Policy
TVH-POL-HR-005 · Employment Rights Act 1996 · ACAS Code 2024
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Environmental Policy
TVH-POL-ENV-001 · Environment Act 2021 · sustainability agenda item at governance meetings
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Pathway to Outstanding — Staff Guide
TVH-OUT-001 · 46 steps · all domains · progress tracker
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Policy Awareness Confirmation (all staff signed)
TVH-HR-PAC-001 · signed by every staff member · filed in HR records
📌 Ensure signed copy for every staff member on file
📚
Complete Policy Library (27 Policies)
All 27 approved policies. Approved 24/04/2026 by Ben Royal, Registered Manager. Next review 24/04/2027.
26 items
⚠️
Risk Assessments and Audit Tools
12 risk assessments and audit tools. All approved 01/04/2026. All rebranded to The Vesey.
12 items