CQC Compliance for GP Practices: What ‘Safe and Effective Staffing’ Really Means

As those working in primary care will be familiar with, the first rule of house when it comes to CQC compliance is not to assume that we know what the CQC means by ‘safe and effective staffing’. This is what the CQC understands it to mean, and what providers will be inspected against:

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development. They work together effectively to provide safe care that meets people’s individual needs.

The CQC further breaks this down into the following topics:

• There are robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, are suitably experienced, competent and able to carry out their role.
• Recruitment, disciplinary and capability processes are fair and are reviewed to ensure there is no disadvantage based on any specific protected equality characteristic.
• There are appropriate staffing levels and skill mix to make sure people receive consistently safe, good quality care that meets their needs.
• Staff receive training appropriate and relevant to their role.
• Staff receive the support they need to deliver safe care. This includes supervision, appraisal and support to develop, improve services and where needed, professional revalidation.
• Staff at all levels have opportunities to learn, and poor performance is managed appropriately.

Let’s look at these in more detail. 

Safe recruitment

It is imperative to safely ‘recruit’ all workers in an organisation – temporary staff, volunteers and contractors would therefore be covered by this requirement. Providers will often state how keen they are to have a concrete ‘list’ of what is required in this regard, and this recruitment checklist and FAQs is a useful document to refer to, although the CQC stops short of producing its own exhaustive list. 

This document comments on certain scenarios such as what if an employee hasn’t got any reason for an employment gap, how long to keep recruitment documents for, and whether to retrospectively ‘safely recruit’ members of staff who have been employed for decades before the CQC even existed. 

CQC inspectors may ask to see evidence of the practice’s recruitment and selection processes. This can include job descriptions, person specifications, advertisements, interview records, references, right-to-work checks, professional registration checks where relevant and evidence of appropriate background checks.

Staffing levels and skill mix

A useful starting point here is to map the entire workforce against the services and business functions that are provided. Consideration needs to be given to which staff members are responsible for each important process, who provides cover during absence, what supervision is required, and what would happen if demand increased unexpectedly. This should include clinical and non-clinical functions, since problems in reception, administration, document handling or workflow management can also affect patient safety.

The chaperone function must be remembered when determining minimum staffing levels, as should the avoidance of ‘lone working’.

Staffing levels and skill mix must then be reviewed regularly and adapted to respond to the changing circumstances of the service. Risks such as reliance on a single individual for a specialist function, gaps in safeguarding expertise, insufficient supervision for newly appointed staff, inadequate cover for annual leave or sickness, or clinical sessions that routinely exceed a safe workload should be regularly discussed (and minuted) and mitigated where possible.

Training, supervision and appraisal

Providers should maintain a workforce training matrix, supported with evidence of individual training records or portfolios. The matrix should show the training considered necessary for each role (the CQC does not provide one universal mandatory training list for GP practice staff), date of completion, renewal arrangements where applicable and any outstanding actions.

Training should be prioritised according to risk. For example, safeguarding, basic life support, infection prevention and control, information governance, complaints, incident reporting and equality and diversity training would likely be tackled first. 

The provider should also consider how learning is shared and be able to demonstrate documented examples of where learning has led to action rather than simply recording that an event took place.

Competence of staff must be assessed, not assumed, even if they have excellent qualifications. To that end, the provider should identify the competencies required for each role and record how they have been confirmed. Depending on the role, this may include observed practice, discussion with a supervisor, completion of relevant training, review of documentation or evidence of professional development.

All staff should receive a tailored induction, including temporary staff who should receive one proportionate to their duties.It should help the individual understand how the service is run, what is expected of them and how to raise concerns. It should also cover relevant practice policies and procedures, and explain the individual’s limits of competence and who they should approach for advice. The induction must be recorded as taking place so that evidence can be provided when requested.

One role of appraisal is to review the training, learning and development needs of individual staff members, but it should also be used to discuss workload… 

Workload management

A practice may have a full rota and still have ‘unsafe staffing’ i.e. be operating unsafely if clinicians and other staff are routinely overloaded with the clinical and the often less visible administrative work. 

The BMA’s safe working guidance recommends no more than 25 patient contacts per GP per day and supports 15-minute appointments, with no more than three hours of a session spent consulting to allow time for documentation and other clinical tasks. These recommendations are intended to support safe, high-quality care and should be considered in the context of patient complexity and the wider responsibilities of the individual clinician. The CQC may well enquire as to a practice’s adherence to this guidance. 

In summary, safe and effective staffing is ultimately about aligning people, competence, supervision and workload with the needs of patients in a workforce system that has the governance behind it to demonstrate such.