CQC quality statements and the 5 key questions: the evidence inspectors ask for

CQC assesses every care home against five key questions: is it safe, effective, caring, responsive and well-led. Under the single assessment framework each key question is broken into quality statements, thirty-four in all, and each statement is scored on evidence drawn from six categories. This guide takes each key question in turn, explains what its quality statements really ask, and sets out the evidence a registered manager should be able to produce for each without notice.

The short answer

The five key questions have not changed, but the key lines of enquiry that used to sit under them have been replaced by quality statements written as commitments in the first person, such as we learn from safety events. Inspectors score each statement from one to four using evidence from people's experience, staff and leaders, partners, observation, processes and outcomes. Your job is to know which statements are weakest in your home and to have specific, current evidence for each. The rest of this article is a map of that evidence, key question by key question.

At a glance: the five key questions and where evidence comes from

Before working through each statement, it helps to see the shape of the whole framework: how many statements sit under each key question, which evidence categories carry most weight for a care home, and which records the inspector will ask to see first.

From KLOEs to quality statements: what actually changed

Many managers still think in terms of KLOEs, the key lines of enquiry that CQC used until the single assessment framework replaced them. Searches for CQC KLOEs remain common for that reason. The key lines of enquiry were questions the inspector asked, numbered S1 to W8 and so on, with prompts underneath. Quality statements replace them with commitments phrased from the provider's point of view, which are meant to describe what good looks like rather than what the inspector should check.

The practical differences are three. First, evidence is gathered continuously, not only during a visit, so your notifications, feedback and data feed the picture all year. Second, each statement is scored numerically, which makes the rating more transparent and means a single weak statement can be seen pulling a key question down. Third, the same statements apply across all service types, so a care home is assessed on the same words as a hospital, with guidance on what they mean in adult social care. If you built your audit tools around KLOEs, most of the content still applies; the headings need updating and a few new areas, particularly equity and workforce wellbeing, need adding.

How the 34 quality statements are scored

Each quality statement is given a score from one to four: one means significant shortfalls, two means shortfalls, three means good, and four means exceptional. The scores for the statements under a key question are added and converted into a percentage, and that percentage gives the key question rating. Roughly, below a quarter is Inadequate, up to about two-thirds is Requires Improvement, up to around nine-tenths is Good, and above that is Outstanding. The five key question ratings then combine into the overall rating using rules that stop a service being rated Good overall while one key question is Inadequate.

What this means for a manager is that the rating is built from the bottom up. A home with excellent care but a weak statement on safe and effective staffing and another on medicines optimisation can find its safe rating at Requires Improvement while everything else is Good. Knowing your likely score for each statement, and being honest about it, is the most useful self-assessment you can do. CQC does not always assess every statement at every visit, so a rating can change on the basis of a handful of statements.

The six evidence categories and what they look like in a care home

Every statement is scored using some or all of six evidence categories. People's experience is what residents, relatives and advocates say and what CQC receives through its feedback channels. Feedback from staff and leaders is what your team tells the inspector, in interviews and through surveys. Feedback from partners is what the GP, district nurse, commissioner, safeguarding team and pharmacist say about you. Observation is what the inspector sees on the day. Processes are your policies, records, audits and systems. Outcomes are what actually happened to people: weights, falls, pressure damage, hospital admissions, complaints resolved.

The strongest evidence is when all six agree. If the care plan says a resident is supported to walk daily, the daily notes show it, the physiotherapist confirms it, the resident says so, the inspector sees it happen, and the falls record shows a reduction, that statement scores well. If the process evidence is good but people's experience contradicts it, the process evidence counts for little. Build your evidence around this triangulation rather than around documents alone.

Safe: learning culture and safe systems

The first two safe quality statements are about learning from safety events and about safe systems, pathways and transitions. For the learning culture statement inspectors want to see that incidents are reported, reviewed, and lead to change, and that staff feel able to report without blame. Evidence is an incident log with root cause analysis where appropriate, a record of learning shared at team meetings, trend analysis by resident and by time of day, and staff who can describe an incident that changed practice.

Safe systems and transitions cover admissions, hospital transfers and discharges, and the handover of information between services. Evidence is a pre-admission assessment, a hospital passport or transfer document for every resident, records of what came back from hospital and how the care plan changed, and communication with the GP and district nurse. A home that can show a resident's hospital passport was updated the day their medicines changed is showing this statement working.

Safe: safeguarding and involving people in managing risk

The safeguarding statement asks whether people are protected from abuse, neglect, discrimination and unlawful restriction, and whether staff understand and act on their responsibilities. Evidence is a safeguarding log reconciled with local authority referrals and CQC notifications, training records, staff who can describe what they would do and who they could go to outside the home, and restraint or restriction records that show least restrictive practice with review. In learning disability and mental health homes, DoLS records and any restrictive practice register are examined closely.

Involving people in managing risk is about positive risk-taking: risk assessments that are done with the person, that respect their choices, and that balance safety against freedom. Evidence is risk assessments that record the person's view, best interests decisions where they lack capacity, and care plans that let people do things others might consider risky, with the mitigation written down. Scored, versioned risk assessments with the person's involvement recorded make this statement easy to evidence.

Safe: environments, staffing, infection control and medicines

The remaining four safe statements are safe environments, safe and effective staffing, infection prevention and control, and medicines optimisation. Safe environments is evidenced by premises certificates, equipment servicing, fire safety records and an environment that suits the people living there. Safe and effective staffing is evidenced by a dependency tool, a rota that matches it, recruitment files, a training matrix, competency checks and supervision. Infection prevention and control is evidenced by audits, cleaning schedules, hand hygiene observations and outbreak plans.

Medicines optimisation is the statement that most often drops the safe rating in care homes. Evidence is complete MAR charts, stock that reconciles, controlled drug records with witnesses, PRN protocols, covert medicine decisions with capacity assessments and pharmacist input, medicines reviews with the GP, and audits with findings and actions. Where an eMAR is used, the missed and late dose reports and the audit trail are the evidence; where paper is used, the monthly audit and the manager's sign-off are. Either way, inspectors will follow individual residents from prescription to cupboard.

Effective: assessing needs and evidence-based care

The first two effective statements are about assessing needs and about delivering evidence-based care and treatment. Assessing needs means every resident has a full, current assessment covering physical, mental, social and communication needs, protected characteristics, and preferences, and that the care plan flows from it. Evidence is the assessment itself, the plan, reviews at set intervals and after change, and involvement of the person and family. Generic plans copied between residents score badly here.

Evidence-based care means practice follows recognised guidance: NICE guidelines on medicines, pressure ulcer prevention, nutrition and falls, IDDSI for swallowing, MUST or an equivalent for nutrition, Waterlow or similar for skin. Evidence is the tools in use, staff who can explain why, and outcomes that show the tools are working: weights stable, pressure damage rare and managed, falls reviewed and reduced. A home should be able to name the guidance behind its main care practices when asked.

Effective: working together, healthier lives, outcomes and consent

How staff, teams and services work together is evidenced by records of GP rounds, district nurse visits, referrals to dietitians, speech and language therapists, mental health teams and learning disability teams, and by what those partners say about you. Supporting people to live healthier lives is evidenced by annual health checks (particularly for people with a learning disability), dental and optician appointments, screening invitations acted on, and support to stay active and eat well. Monitoring and improving outcomes is evidenced by tracking weights, falls, skin, hospital admissions and wellbeing and acting on trends.

Consent to care and treatment is the Mental Capacity Act statement. Evidence is decision-specific capacity assessments, best interests decisions involving the right people, DoLS applications where needed with conditions met, lasting power of attorney documents on file, and staff who can explain the five principles of the Act in their own words. Consent from relatives without legal authority, and blanket capacity statements, are the failures inspectors find most.

Caring: kindness, dignity and treating people as individuals

Caring is judged mainly by observation and by what people tell the inspector, which is why it is the key question most homes rate best on and also the one most exposed if culture is poor. The kindness, compassion and dignity statement is evidenced by how staff speak to and about residents, whether personal care is private and explained, whether people are dressed as they wish, and what residents and relatives say. The treating people as individuals statement is evidenced by care plans that describe the person's history, culture, faith, relationships and preferences, and by staff who know those things without looking them up.

Written evidence supports observation rather than replacing it. Daily notes that record a resident's mood, choices and reactions show individual attention; notes that say all care given do not. Compliments, thank-you cards and survey results count, as does evidence that a concern about attitude was acted on.

Caring: independence, immediate needs and workforce wellbeing

Independence, choice and control asks whether people are supported to do as much for themselves as they can and to make decisions about their day. Evidence is plans that record what the person can do and how staff support rather than replace that ability, activities and community access chosen by the person, and, in learning disability services, easy-read plans and communication tools that let people direct their own support. Responding to people's immediate needs is about call bells answered, distress noticed and pain managed; evidence is call bell response records, pain assessments and observation.

Workforce wellbeing and enablement is new to many managers. It asks whether staff are supported, listened to and able to do their jobs well. Evidence is supervision that covers wellbeing, staff survey results, action on concerns, reasonable adjustments made, and staff who say they feel valued. A home with high turnover and no record of asking staff why will score poorly here even if care is good.

Responsive: person-centred care, continuity and information

The responsive key question is about whether services are organised around people. The person-centred care statement is evidenced by plans built with the person, reviewed when their needs change, and reflected in daily practice. Care provision, integration and continuity is evidenced by consistent staffing for people who need it, smooth transitions, and joint working with health and social care partners. Providing information is evidenced by information in formats people can use: easy read, large print, pictures, translated material, and a service user guide that people have actually seen.

For learning disability and autism services, the Right support, right care, right culture guidance shapes how these statements are read. Inspectors look for evidence that the person's choices drive the service, that the home is not organised around staff convenience, and that people have real lives in the community. Person-centred plans with easy-read versions and health action plans are the working evidence.

Responsive: listening, equity and planning for the future

Listening to and involving people is evidenced by resident and relative meetings, surveys, complaints handled well, and changes made because someone asked. Equity in access and equity in experiences and outcomes are two statements that ask whether people with protected characteristics, communication needs or particular vulnerabilities get the same quality of care and the same results as everyone else. Evidence is monitoring by group where numbers allow, adjustments made for individuals, advocacy involved, and staff who can give examples.

Planning for the future covers advance care planning, end of life wishes, and decisions about resuscitation. Evidence is advance care plans discussed and recorded with the person and family, ReSPECT or DNACPR forms completed properly and reviewed, anticipatory medicines arranged in time, and records of end of life care that show comfort, dignity and family involvement. Homes that avoid these conversations until a crisis score badly.

Well-led: culture, leadership and speaking up

CQC well led is where the registered manager is assessed most directly. Shared direction and culture is evidenced by a clear statement of what the home is for, values that staff can describe, and a culture that inspectors can feel on the floor. Capable, compassionate and inclusive leaders is evidenced by a registered manager who knows the service, is visible, and is supported by the provider; by deputy and senior roles that work; and by staff who say leaders are approachable. Freedom to speak up is evidenced by a whistleblowing policy staff know, a record of concerns raised and acted on, and a manager who can give an example of learning from a concern.

Inspectors will ask staff whether they would feel safe raising a concern and what happened last time someone did. They will ask the manager what keeps them awake at night. A manager who answers with specifics is showing well-led evidence in the most direct form there is.

Well-led: workforce equality, governance and sustainability

Workforce equality, diversity and inclusion is evidenced by recruitment and promotion that is fair, adjustments made for staff, action on discrimination, and staff from all backgrounds who say they are treated equally. Governance, management and sustainability is the statement that carries Regulation 17: an audit schedule, results, action plans, records that are accurate and contemporaneous, risk registers, business continuity, and financial sustainability. Evidence is the governance file, the manager's ability to explain it, and outcomes that show governance working, such as a fall in medicines errors after an audit found them.

Environmental sustainability is a new statement asking what the service does to reduce its environmental impact. For a care home the evidence is modest but real: energy and waste measures, food waste, transport, and a plan. Inspectors do not expect a carbon strategy from a twenty-bed home, but they do expect an answer.

Well-led: partnerships, learning and improvement

Partnerships and communities asks whether the home works well with the local authority, the integrated care board, health services, voluntary groups and the community. Evidence is regular contact with commissioners, involvement in local forums, community activities, and partners who speak well of the service. Learning, improvement and innovation asks whether the home learns from incidents, complaints, audits and feedback and improves as a result, and whether it tries new things.

The evidence is the improvement plan, examples of change with dates and results, learning shared with staff, and involvement in quality initiatives. Manager review of handovers and incidents, with a note of what was checked and what changed, is the sort of everyday evidence that scores well here. Digital compliance dashboards that show trends make the improvement story easier to tell, but the story has to be true.

Evidence for people who cannot easily tell the inspector

People's experience is the first evidence category, and many residents in nursing, dementia, learning disability and mental health homes cannot easily give an account of their care. Inspectors know this and will use observation tools and speak to relatives, advocates and professionals. Your evidence should anticipate it. Communication passports, easy-read plans, records of how the person expresses happiness and distress, observation records over time, and advocacy involvement all show that you have found ways to hear people who do not use words.

Daily notes are the everyday version of this. A note that says the resident smiled during the music session and chose to stay for the second half is people's experience evidence; a note that says care given is not. Three-tap daily logs with mood, activity and photograph prompts turn this into a habit rather than a chore.

A procedure for building your evidence pack by key question

A well-run home does not need a special pack for inspection, but it does need to know where the evidence for each statement lives and to check it regularly. This is a procedure that takes a manager and deputy a day the first time and an hour a month after that.

1. Print the 34 quality statements and score each one honestly from one to four as you believe an inspector would today.
2. For each statement, list the two or three items of evidence in each relevant evidence category: what residents say, what staff say, what partners say, what could be observed, which records, which outcomes.
3. Pull a sample of each item and check it is current, complete and consistent with the others.
4. Mark every statement where the evidence categories disagree or where evidence is missing.
5. Write an action for each gap with an owner and a date, and add it to the improvement plan.
6. Repeat the scoring monthly and after any significant incident, complaint or staffing change.
7. Keep the current scores and the location of evidence in the first-hour pack so any senior can find them.

A checklist of evidence inspectors ask for most

These are the items that come up on nearly every care home assessment, grouped by key question.

• Safe: incident log with reviews and learning; safeguarding log; risk assessments per resident; MAR charts and medicines audits; controlled drug register; rota and dependency tool; training matrix; IPC audits; fire and equipment records.
• Effective: pre-admission assessments; care plans with reviews; MCA assessments and best interests decisions; DoLS tracker; nutrition screening and weights; GP and professional correspondence; supervision and competency records.
• Caring: daily notes that describe the person; feedback from residents and relatives; compliments; staff survey and wellbeing actions; observation on the day.
• Responsive: person-centred and easy-read plans; activity and community access records; complaints log; accessible information; advance care plans and end of life records.
• Well-led: audit schedule and results; improvement plan; team and resident meeting minutes; speak-up records; notifications log; provider oversight visits; business continuity plan.

Using the framework as a self-assessment tool

The single assessment framework is public, and the most useful thing a manager can do with it is to run it on themselves. Score each statement, gather the evidence, and then ask a colleague from another service to challenge the scores. The exercise finds gaps that audits miss, because audits check processes and the framework checks whether the processes produce experience and outcomes.

It also changes how you read your own reports. When a report says a statement scored two, you know which evidence category let it down and can fix that rather than everything. Our guide to the single assessment framework and quality statements gives the statements in full, and our guide to preparing for a CQC inspection turns the self-assessment into a monthly routine.

How the key questions connect to the regulations

Ratings and enforcement are separate. The key questions produce a rating; the regulations produce breaches. But they run in parallel, and a low score on a quality statement usually points at a regulation. Medicines optimisation and safe environments point at Regulation 12. Safeguarding points at Regulation 13. Safe and effective staffing points at Regulations 18 and 19. Consent points at Regulation 11. Governance points at Regulation 17. Learning culture and freedom to speak up point at Regulations 17 and 20.

When you find a weak statement in self-assessment, look up the matching regulation and ask whether you are in breach as well as scoring low. Our article on the CQC fundamental standards explains each regulation and the evidence that meets it. Fixing the regulatory gap usually fixes the score.

Learning disability and mental health services: the extra lens

For services supporting people with a learning disability or autistic people, and for many mental health homes, CQC applies the Right support, right care, right culture guidance alongside the quality statements. Right support means the model of care maximises choice, control and independence. Right care means care is person-centred and promotes dignity, privacy and human rights. Right culture means the values, attitudes and behaviours of leaders and staff ensure people lead confident, inclusive and empowered lives.

In evidence terms this raises the bar on several statements: independence, choice and control; treating people as individuals; involving people in managing risk; safeguarding (particularly restrictive practice); and shared direction and culture. Positive behaviour support plans, ABC records that show behaviour being understood, restrictive practice registers with reduction plans, and easy-read documents that people actually use are the evidence inspectors look for. Where a home uses a records system such as Kiwi with PBS plans and easy-read versions built in, the evidence sits alongside the care plan rather than in a separate file.

Common mistakes

• Preparing evidence by document type rather than by quality statement, so nobody knows which statements are weak.
• Relying on process evidence alone when people's experience or observation would contradict it.
• Ignoring the newer statements on workforce wellbeing, equity and environmental sustainability until an inspector asks.
• Treating caring as automatic and failing to record the individual detail that shows it.
• Consent and capacity records that are generic, or signed by relatives without authority.
• Well-led evidence that consists of audits with ticks and no findings, and no examples of learning.
• Assuming every statement is assessed at every visit and being surprised when a rating changes on three of them.

What good looks like on inspection day

The inspector says they are looking at safe and well-led today, and lists the quality statements they will focus on: safeguarding, medicines optimisation, safe and effective staffing, governance, and learning and improvement. The manager opens the self-assessment, shows the current score for each and the evidence locations, and hands over the first-hour pack. For medicines, three residents are followed from prescription to cupboard and every dose is accounted for, with the home's own audit findings from last month and the actions taken. For safeguarding, the log matches the referrals and notifications, and two care workers describe what they would do and name the local authority team. For staffing, the rota matches the dependency tool and the floor, and a night carer says there are enough staff and that supervision happens. For governance, the improvement plan shows closed actions with dates and evidence, and the manager describes the two weakest statements without being asked. For learning, a team meeting minute shows an incident discussed and a change made, and the outcome data shows fewer incidents of that type since. The inspector spends the rest of the day observing care, because the evidence for the statements they came to test was already in hand.

Final conclusion

The five key questions and thirty-four quality statements are the whole of how CQC judges a care home, and they are public. A manager who scores each statement honestly, knows which evidence categories support it, and keeps that evidence current has done most of the work of any inspection before it begins. Organise by statement rather than by document, triangulate rather than rely on paperwork, and fix the weakest statements first, and the rating will reflect the care you actually give.

Frequently asked

What are the 5 CQC key questions?

Safe, effective, caring, responsive and well-led. CQC uses them for all registered services and rates each one separately before giving an overall rating. Under the single assessment framework each is broken into quality statements that are scored individually.

How many CQC quality statements are there?

There are 34 quality statements across the five key questions: eight under safe, six under effective, five under caring, seven under responsive and eight under well-led. Each is written as a first-person commitment and scored from one to four. Not every statement is assessed at every visit.

What happened to CQC KLOEs?

Key lines of enquiry were replaced by quality statements when the single assessment framework was introduced. The five key questions stayed the same, but the prompts under them became first-person commitments with numerical scoring. Audit tools built around KLOEs still cover most of the content but need their headings updated and a few new areas added.

What are the CQC evidence categories?

There are six: people's experience of health and care services, feedback from staff and leaders, feedback from partners, observation, processes, and outcomes. Each quality statement is scored using some or all of them. The strongest evidence is where all categories tell the same story.

How are CQC quality statement scores turned into a rating?

Each statement is scored one to four. The scores under a key question are added and converted to a percentage, which gives the key question rating of Inadequate, Requires Improvement, Good or Outstanding. The five key question ratings then combine into the overall rating using aggregation rules.

What evidence does CQC want for well-led in a care home?

An audit schedule with findings, an improvement plan with closed actions, records that are accurate and contemporaneous, team and resident meeting minutes, a speak-up record, a notifications log, and a manager who can explain the service's weaknesses. Staff feedback about leadership and culture carries a lot of weight. Provider oversight visits also count.

Do CQC assess all 34 quality statements at every inspection?

No. CQC can assess a selection of statements and update the score and rating for those, leaving the others as previously assessed. This means a rating can change on the basis of a few statements. Self-assessment against all 34 keeps you ready whichever ones are chosen.

Sources

• CQC: single assessment framework guidance
• CQC: quality statements for adult social care
• CQC: evidence categories and scoring guidance
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• CQC: Right support, right care, right culture
• Mental Capacity Act 2005 Code of Practice
• NICE guideline NG67 Managing medicines in care homes