Section 4: Action plan for centre

The QR will use the following prompts to determine if a ‘yes’ or ‘no’ should be applied for each criteria. If the QR selects ‘No an action will be added to the action plan in section 4 of the report.

Each criteria has a level of risk applied to it which is indicted below by colour:

When ‘No’ is selected against a criteria i.e. the criteria was not achieved, the applicable risk status will be applied, the overall centre risk status will be the highest risk score applied.

When all criteria are awarded a ‘yes’ the centre overall risk status will be ‘low risk’. 

Example 1

Centre scores 'no' for

3.1 Red

3.3 Amber

3.5 Green

The overall centre risk status will be high as they've scored 'no' for a red criteria. 

Example 2

Centre scores 'no' for

3.3 Amber

3.5 Green

The overall centre risk status will be medium as they've scored 'no' for an amber criteria.

Example 3

Centre scores 'no' for

3.5 Green

The overall centre risk status will be low as they've scored 'no' for a green criteria.

Where ‘no’ has been selected for any of the criteria in section 3 or where a previous action (from an AMR, EQA review or approval report) has not been fully actioned in section 2, this will generate an action within the action plan section of the report.

The QR will set clear actions based on the criteria that was not achieved. Our aim is for the centre to read any actions and understand exactly what they need to do before the next review. Most reviews will take place annually, however, if there is a need for actions to be checked prior to the next annual review (high risk status) an interim review will be required.

All actions will be attributed to a specific owner and be given a reasonable and clear timescale for completion.

Recommendations will not be included in this section of the report. Any recommendations will be included in the body of the report. The QR will review these recommendations during the next review, however, as they are recommendations, they will not be set as mandated actions.

The QR will discuss the set action plan with the centre prior to submitting the report, allowing opportunity to ask any questions linked to the given actions. They will indicate in this section that the action plan has been discussed and who with. If it has not been discussed detail will be added to section 6 of the report to confirm actions have not been discussed with the centre prior to submission of the report.