CQC Action Plans: There's More to Improvement Than Completing a List

My website host recently offered to draft a blog for me about developing CQC action plans. I thought I'd have a look at what it came up with, and I have to say, by the time I'd finished reading it, I was thoroughly frustrated!

It wasn't that the information was wrong, although there were a few things I would question. It was the way it presented improvement planning as a relatively straightforward exercise. Identify the problem, allocate responsibility, set a deadline, deliver some training, update a policy and monitor progress. Apparently, that's all there is to it!

It was repetitive, full of generic advice and made the usual assumptions that more training, another audit or an updated policy would somehow resolve the concerns identified. It also suggested that following these steps would help providers exceed regulatory expectations, which is quite a claim when you haven't established whether any of the actions have actually improved care.

Having spent many years working with services to address quality and governance concerns, I wish it were that simple. An effective action plan requires a proper understanding of what has gone wrong, why it has happened and what needs to change to prevent it happening again. That isn't always immediately apparent from an inspection report, an audit or an incident investigation, and it's often where the most important work needs to take place.

Understanding What Needs to Improve

Before developing an action plan, it's worth spending time reviewing the findings and the evidence behind them. An inspection report may identify several concerns which appear unrelated but, when examined together, suggest a wider problem with how the service is managed or how care is delivered.

For example, concerns about medicines management, incomplete care records and inconsistent risk assessments might initially result in three separate sets of actions. However, further review could identify common issues involving staff supervision, management oversight, systems or working practices. Treating each finding in isolation risks creating additional work without addressing the underlying causes.

This doesn't mean delaying action where there are immediate risks to people's safety. Those risks need to be addressed promptly, while the provider undertakes a more detailed review of the concerns and develops longer-term improvements.

Developing Actions That Address the Problem

One of the things I frequently see in improvement plans is an overreliance on training as the proposed solution. Training is important, and there will be occasions when additional learning is necessary, but it shouldn't automatically be the response to every concern.

If staff aren't following a procedure, we need to understand whether they know what is expected, whether the procedure is practical, whether they have the necessary resources and whether management arrangements are supporting them to deliver care safely. An action to provide refresher training may be appropriate, but it may only address one part of the problem. Actions should be specific, proportionate to the risk and realistic about what can be achieved. Each should have an identified person responsible for delivery, a clear timescale and an agreed method of establishing whether the intended improvement has been achieved.

Monitoring Progress and Establishing Effectiveness

There is nothing particularly difficult about recording that a policy has been reviewed, training has been completed or a new process has been introduced. The more challenging part is establishing whether those activities have resulted in better practice.

If an action has been introduced to reduce medication omissions, for example, reviewing training records alone won't tell us whether the improvement has been successful. We need to examine medicines administration records, incident patterns, staff practice and the effectiveness of management oversight.

Depending on the concern, this may involve observations, discussions with staff and people receiving care, review of records, targeted audits or analysis of incidents and complaints.

It's also important to allow sufficient time to establish whether improvements are being maintained. A single satisfactory audit immediately after an intervention may provide some reassurance, but it doesn't necessarily demonstrate sustained improvement.

Keeping the Plan Manageable

Improvement plans can become unnecessarily complicated, particularly when several people contribute to them or when every finding generates multiple actions.

I've seen plans containing extensive lists of tasks, many of which overlap, with little indication of which actions are most important or how progress is being evaluated.

A useful action plan should enable managers to understand what needs to happen, who is responsible and what progress is being made. It should also help senior leaders identify where additional support, resources or intervention may be required.

Where a provider operates multiple services, there may also be opportunities to identify common concerns and introduce improvements across the organisation rather than expecting each service to resolve similar issues independently.

Maintaining Oversight

An action plan needs regular review, but the frequency and level of oversight should reflect the nature and seriousness of the concerns.

High-risk actions may require immediate escalation and frequent monitoring, while longer-term improvements may be reviewed through established governance meetings.

Managers should be able to explain not only which actions have been completed, but also what evidence supports their assessment of progress and whether any concerns remain outstanding. Where an action hasn't achieved the intended result, the response should be to reconsider the approach rather than simply extending the deadline or recording another task as complete.

Making Improvement Part of Everyday Practice

Although this article focuses on CQC action plans, the same principles apply to improvement work arising from internal audits, complaints, safeguarding concerns, incidents and other quality reviews. A service shouldn't need to wait for an inspection to identify areas requiring attention, and improvement planning should be part of its normal governance arrangements.

Of course, where CQC has taken regulatory action or formally required a response, providers must ensure they understand and meet the specific requirements and timescales involved.

As for the blog my website host originally drafted, I suppose it did achieve something. It reminded me how easily complex improvement work can be reduced to a list of generic tasks, particularly when the person writing about it has never had to implement any of them.

I'll give it credit for providing the inspiration, even if I couldn't bring myself to publish what it wrote.