CQC Evidence Gap Checker

Critical gaps (21)

These Quality Statements have very little or no evidence. An assessor is likely to flag these.

• S1

  Learning culture (Safe)

  0 of 5 evidence types covered

  Suggestion: Collect incident reports with documented outcomes, staff meeting minutes showing lessons learned, and evidence of policy changes made after incidents.

• S2

  Safe staffing (Safe)

  0 of 5 evidence types covered

  Suggestion: Maintain up-to-date staffing rotas, dependency tool assessments (e.g. CHESS or similar), and records showing how staffing levels are adjusted to resident needs.

• S3

  Safeguarding (Safe)

  0 of 5 evidence types covered

  Suggestion: Keep safeguarding training records with dates and certificates, a log of safeguarding referrals, and evidence your policy is reviewed annually.

• S4

  Infection prevention and control (Safe)

  0 of 5 evidence types covered

  Suggestion: Document IPC audits with action plans, maintain PPE stock records, and keep staff IPC training certificates up to date.

• S5

  Medicines management (Safe)

  0 of 5 evidence types covered

  Suggestion: Ensure MAR charts are complete, conduct regular medicines audits, document any medication errors with follow-up actions, and keep fridge temperature logs.

• S6

  Risk assessment (Safe)

  0 of 5 evidence types covered

  Suggestion: Complete individual risk assessments (falls, pressure areas, nutrition) for each resident, maintain environmental risk assessments, and review them regularly.

• E1

  Evidence-based care (Effective)

  0 of 5 evidence types covered

  Suggestion: Reference specific NICE guidelines in care plans, document how clinical best practice is applied, and keep records of clinical reviews.

• E2

  Staff skills and training (Effective)

  0 of 5 evidence types covered

  Suggestion: Maintain a training matrix for all staff, keep supervision and appraisal records, and document induction completion for new starters.

• E3

  Nutrition and hydration (Effective)

  0 of 5 evidence types covered

  Suggestion: Complete MUST screening tools, record dietary preferences and choices, keep food and fluid charts where needed, and document weight monitoring.

• E4

  Consent and capacity (Effective)

  0 of 5 evidence types covered

  Suggestion: Document capacity assessments, keep signed consent forms, record best interest decisions with who was involved, and file any DoLS applications.

• C1

  Kindness, compassion and dignity (Caring)

  0 of 5 evidence types covered

  Suggestion: Gather resident and family testimonials, document dignity audits, and keep thank-you cards or positive feedback on file.

• C2

  Person-centred care (Caring)

  0 of 5 evidence types covered

  Suggestion: Include "This is me" or life history documents in care plans, record how residents are involved in their care planning, and document individual preferences.

• C3

  Privacy and independence (Caring)

  0 of 5 evidence types covered

  Suggestion: Document how privacy is maintained during personal care, record how independence is promoted (e.g. self-medication, mobility), and audit knock-before-entering practices.

• R1

  Personalised care plans (Responsive)

  0 of 5 evidence types covered

  Suggestion: Ensure each care plan is person-centred with named preferences, review dates are current, and residents or families have signed off on reviews.

• R2

  Complaints and feedback (Responsive)

  0 of 5 evidence types covered

  Suggestion: Keep a complaints log with response times and outcomes, document how complaints led to improvements, and record feedback from surveys.

• R3

  Activities and social engagement (Responsive)

  0 of 5 evidence types covered

  Suggestion: Maintain an activities programme with photos or attendance records, document how activities are tailored to individual interests, and gather feedback.

• R4

  End of life care (Responsive)

  0 of 5 evidence types covered

  Suggestion: Complete advance care plans and DNACPR forms where appropriate, document family involvement, and keep records of end-of-life training for staff.

• W1

  Governance and management (Well-Led)

  0 of 5 evidence types covered

  Suggestion: Maintain an audit schedule with completed audits, keep management meeting minutes with action logs, and document your quality improvement plan.

• W2

  Quality monitoring (Well-Led)

  0 of 5 evidence types covered

  Suggestion: Track key metrics (falls, infections, complaints, weight loss), benchmark against previous periods, and present data in regular governance reports.

• W3

  Learning, improvement and innovation (Well-Led)

  0 of 5 evidence types covered

  Suggestion: Document root cause analyses for serious incidents, maintain an action plan tracker showing progress, and record lessons shared with the team.

• W4

  Partnership working (Well-Led)

  0 of 5 evidence types covered

  Suggestion: Keep records of MDT meetings, document engagement with families (e.g. relatives meetings), and evidence links with GPs, pharmacists, and community groups.