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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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CQC Regulations Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} meets the highest regulatory standards in both Wales (CIW) and England (CQC) where applicable. This policy outlines how our home care business: Maintains compliance with CIW regulations in Wales. Aligns with CQC’s Fundamental Standards where applicable for services provided in England. Implements efficient processes to ensure continuity, safety, and quality across regulatory frameworks. This policy is designed to support staff, managers, and external inspectors in understanding how {{org_field_name}} ensures compliance with relevant care quality standards while maintaining efficient operational practices.

2. Scope

This policy applies to: All employees of {{org_field_name}}, including care workers, administrative staff, and managers. All service users receiving domiciliary care, ensuring compliance with CIW regulations in Wales and, where relevant, CQC regulations in England. Third-party organisations, including healthcare professionals, commissioners, and local authorities involved in regulatory oversight. This policy covers: Compliance with CIW and CQC regulations. How {{org_field_name}} meets regulatory requirements efficiently. Governance, audits, and workforce training to ensure continuous compliance.

3. Compliance with CIW and CQC Regulations

3.1 Care Inspectorate Wales (CIW) Regulatory Framework

In Wales, {{org_field_name}} provides its domiciliary support service in accordance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and statutory guidance issued by the Welsh Ministers under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016.

{{org_field_name}} must provide the regulated service with sufficient care, competence and skill and in accordance with the Statement of Purpose for the service. The Statement of Purpose must accurately describe the regulated service and must be kept under review and revised where appropriate. Where a revision requires prior notification, the required persons, including Care Inspectorate Wales, must be notified within the statutory timescale.

{{org_field_name}} maintains effective arrangements for monitoring, reviewing and improving the quality and safety of the care and support provided. These arrangements include consideration of the views of individuals receiving the service, their representatives where appropriate, service commissioners and staff, together with information obtained from complaints, safeguarding matters, incidents, notifications, audits and regulatory inspections.

The service must be provided in a way that protects, promotes and maintains individuals’ safety and well-being and supports them to achieve their personal outcomes. Care and support must be provided in accordance with each individual’s personal plan and in a manner that respects their rights, dignity, privacy, independence, communication needs, language needs and relevant protected characteristics.

{{org_field_name}} maintains the policies and procedures required by the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and ensures that they are kept up to date, are consistent with the Statement of Purpose and are followed in practice.

The Responsible Individual must fulfil the statutory duties applying to that role, including oversight of the management of the service, engagement with individuals and staff, monitoring of the service, reporting to the service provider, oversight of records and notifications, monitoring and reviewing the quality of care and support and ensuring that the service complies with the applicable regulatory requirements.

{{org_field_name}} and the Responsible Individual will act openly and transparently with individuals receiving care and support and their representatives in accordance with the statutory duty of candour.

3.2 CQC Regulatory Framework (For Services in England)

If {{org_field_name}} operates in England, we must also comply with CQC’s Fundamental Standards, which include: Person-centred care – Service users must receive care tailored to their individual needs. Dignity and respect – People must be treated with dignity, kindness, and respect. Consent – Care must only be provided with the individual’s informed consent. Safety – Services must be safe, effectively managed, and free from harm. Safeguarding from abuse – Policies must be in place to protect vulnerable individuals. Food and drink – Nutrition and hydration needs must be met. Premises and equipment – Any equipment used must be safe and well-maintained. Complaints – A clear process must be in place to handle complaints effectively. Good governance – Providers must maintain robust systems to monitor care quality. Fit and proper persons – Staff must undergo DBS checks and suitability assessments.

For services operating in England, {{org_field_name}}: Conducts self-assessments against CQC’s Key Lines of Enquiry (KLOEs). Ensures care planning meets both CIW and CQC person-centred care standards. Implements a uniform approach to risk assessment, medication management, and safeguarding across jurisdictions.

4. Efficient Compliance Management Across Regulatory Frameworks

4.1 Workforce Training and Development

To ensure staff understand the requirements of both CIW and CQC, {{org_field_name}} provides: Annual training updates on CIW and CQC compliance requirements. Safeguarding training aligned with Welsh Social Care Standards and CQC’s guidelines. Medication administration training, ensuring safe handling of medicines in compliance with both regulatory bodies.

4.2 Quality Assurance, Monitoring and Review

{{org_field_name}} maintains effective systems for monitoring, reviewing and improving the quality and safety of the care and support provided by the service.

Quality assurance arrangements include, as applicable:

• audits of personal plans, care records and risk assessments;
• reviews of incidents, accidents and near misses;
• analysis of safeguarding matters;
• analysis of complaints and concerns;
• analysis of whistleblowing matters;
• monitoring of medication-related incidents and errors;
• workforce competency and training records;
• staffing levels, continuity of care and service delivery;
• CIW inspection findings, ratings and regulatory actions;
• records of statutory notifications;
• Responsible Individual monitoring reports; and
• feedback from individuals receiving care and support.

The service provider will seek and take account of the views of:

• individuals receiving care and support;
• representatives of individuals, unless this is inappropriate or inconsistent with an individual’s well-being;
• service commissioners; and
• staff.

Information obtained through these arrangements will be analysed and used to identify risks, trends, areas requiring improvement and actions necessary to improve the quality and safety of the service.

The Responsible Individual must put suitable arrangements in place to ensure that the quality of care and support is reviewed as often as required and at least every six months. The review must include consideration of feedback from individuals and others, together with aggregated information relating to incidents, notifiable incidents, safeguarding matters, whistleblowing, concerns and complaints, action taken in response to complaints and the accuracy and completeness of required records.

Following each statutory quality-of-care review, the Responsible Individual will prepare the report required by Regulation 80, where applicable. The report will include an assessment of the standard of care and support provided and recommendations for improving the service. The service provider will have regard to the findings and recommendations of the report when determining actions required to improve the service.

Actions arising from audits, quality reviews, complaints, incidents, safeguarding matters, inspections or other monitoring activity will be recorded, allocated to an appropriate person, monitored to completion and reviewed to establish whether the required improvement has been achieved.

4.3 Governance and Leadership

The service provider, Responsible Individual and Registered Manager have distinct responsibilities under the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. {{org_field_name}} will maintain a clear governance structure so that those responsibilities are understood and discharged effectively.

The Responsible Individual will maintain effective oversight of the management, quality, safety and regulatory compliance of the domiciliary support service.

For the domiciliary support service, the Responsible Individual must meet with members of staff providing the regulated service and with individuals receiving the regulated service at, from or in relation to each place for which the Responsible Individual is designated. The frequency of those meetings will be determined having regard to the Statement of Purpose but must be at least once every three months.

Responsible Individual monitoring activity will be documented. Records will include, where relevant:

• the date of the monitoring activity;
• details of discussions with staff;
• details of discussions with individuals receiving the service and, where appropriate, their representatives;
• records, complaints, incidents or other information reviewed;
• concerns identified;
• improvements required; and
• actions taken or required following the monitoring activity.

Where the service provider is not an individual, the Responsible Individual will report to the service provider on the adequacy of the resources available to provide the service at least quarterly.

The Responsible Individual will report without delay to the service provider any concern about the management or provision of the service, any significant change to the way in which the service is managed or provided, or any concern that the service is not being provided in accordance with its Statement of Purpose.

The Responsible Individual will ensure suitable arrangements are in place to obtain the views of individuals receiving the service, their representatives where appropriate, service commissioners and staff about the quality of care and support provided and how the service can be improved.

The Responsible Individual will ensure that the provider’s policies and procedures are kept up to date, that effective systems are maintained for records, incidents, complaints and statutory notifications, and that the requirements of the provider’s whistleblowing arrangements and statutory duty of candour are being met.

The Statement of Purpose will be kept under review and revised when required. Where a proposed revision is subject to statutory notification requirements, the service provider will notify CIW and any other persons required by the Regulations within the applicable timescale.

4.4 Domiciliary Support Service – Scheduling, Travel Time and Care Time

For every domiciliary care worker providing care and support as part of the regulated domiciliary support service, {{org_field_name}} will prepare a schedule of visits and provide the worker with a copy of the schedule relevant to them.

The schedule will clearly distinguish between:

• time allocated for each care visit;
• time allocated for travel between scheduled visits; and
• time allocated for rest breaks, where applicable.

Travel time between scheduled visits will be sufficient having regard to the distance between locations and other factors that could reasonably affect travelling time, including traffic conditions and parking availability.

The time allocated to each visit must be sufficient to enable the individual’s care and support to be provided in accordance with their personal plan.

A visit will not be scheduled for less than 30 minutes unless one of the statutory conditions permitting a shorter visit is met. Where a visit of less than 30 minutes takes place under an applicable statutory exception, {{org_field_name}} will maintain sufficient records to demonstrate why the exception applied.

{{org_field_name}} will maintain records of the time spent by each domiciliary care worker on:

• travel between scheduled visits;
• care visits; and
• rest breaks.

Scheduling arrangements will take account of the geographical location of individuals, required or preferred visit times, staffing levels, continuity of care and sufficient travel time so that workers are able to provide the care and support described in individuals’ personal plans without routinely shortening visits.

4.5 Domiciliary Care Workers on Non-Guaranteed Hours Contracts

Where a domiciliary care worker is employed under a non-guaranteed hours contract and the statutory conditions in Regulation 42 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, are met, {{org_field_name}} will offer that worker the choice of alternative contractual arrangements in accordance with Regulation 42.

This includes offering the applicable contractual options where the worker has completed the qualifying period, has worked regular hours during the relevant preceding period, there is a continuing requirement for those hours and the worker has performed satisfactorily.

Where a domiciliary care worker elects to remain on a non-guaranteed hours contract, the contractual arrangement will be reviewed again following the further qualifying period required by Regulation 42.

{{org_field_name}} will maintain an appropriate record of the contractual discussion, the options offered and the worker’s decision.

5. Managing Inspections and Regulatory Engagement

5.1 CIW Inspections and Inspection Ratings – Wales

CIW may inspect the regulated service in accordance with its statutory inspection functions and applicable Code of Practice. {{org_field_name}}, the Responsible Individual and the Registered Manager will cooperate with CIW and provide inspectors with access to records, information, staff and other evidence that CIW is legally entitled to inspect or request.

Following an inspection of a domiciliary support service, CIW may award and publish ratings in accordance with the Regulated Services (Inspection Ratings) (Wales) Regulations 2025.

{{org_field_name}} will comply with all statutory requirements relating to the display of its most recently published CIW inspection ratings.

Where {{org_field_name}} has a website, the most recent CIW inspection ratings for each applicable regulated service must be displayed on the website in accordance with the statutory requirements.

For a domiciliary support service, the prescribed ratings sign will also be displayed in each office at or from which the relevant service operates where the office is accessible to members of the public. A ratings sign is not required to be displayed at a domiciliary support service office that is inaccessible to members of the public or where the service is provided from a person’s private home.

Where display at the service premises is required, the most recent ratings will be displayed without delay following publication by CIW, using the required format and in a legible and conspicuous position accessible to individuals receiving the service and visitors.

The service is not required to display inspection ratings in the private homes of individuals who receive domiciliary care and support.

Where {{org_field_name}} believes an inspection report or rating is based on factual inaccuracy or incomplete evidence, any challenge or appeal will be made through the applicable CIW procedure and within the required timescale.

5.2 Statutory Notifications to Care Inspectorate Wales

{{org_field_name}} will maintain effective arrangements to ensure that all events requiring notification to Care Inspectorate Wales are identified and notified within the timescale and in the form required by legislation and CIW.

The service provider will make the notifications required under Regulation 60 and Schedule 3 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Unless a different timescale is specified by legislation, notifications will be made without delay, in writing and using the method or form required by CIW.

Events requiring notification include those specified in the Regulations and may include, where applicable:

• revisions to the Statement of Purpose;
• specified changes concerning the service provider or its management or control;
• specified absences or changes concerning the Responsible Individual;
• abuse or allegations of abuse involving the service provider, staff or volunteers;
• allegations of misconduct by staff;
• serious accidents or injuries;
• specified pressure damage;
• outbreaks of infectious disease;
• incidents reported to the police;
• events that prevent, or could prevent, the service from continuing to be provided safely; and
• other events specifically prescribed within Schedule 3.

The Responsible Individual will ensure that notifications for which the Responsible Individual is personally responsible are made in accordance with Regulation 84 and Schedule 4. These include applicable notifications concerning the appointment, absence, return, replacement or cessation of the Registered Manager.

The Responsible Individual will maintain oversight of systems for recording incidents, complaints and matters requiring statutory notification.

A record will be maintained of notifications submitted to CIW, including the event, date identified, date notified, person making the notification, information provided and any subsequent correspondence or action required.

5.3 Annual Return

{{org_field_name}} will comply with the annual return requirements under section 10 of the Regulation and Inspection of Social Care (Wales) Act 2016, as amended by the Health and Social Care (Wales) Act 2025, and the Regulated Services (Annual Returns) (Wales) Regulations 2017, as amended.

Following the end of each financial year during which {{org_field_name}} is registered as a service provider, {{org_field_name}} will complete and submit its annual return to Care Inspectorate Wales through CIW Online within the prescribed submission period.

The annual return must be submitted to CIW by 26 May each year unless a different statutory deadline applies.

Following submission, {{org_field_name}} will obtain the publication copy made available through its CIW Online account and publish the required annual return on {{org_field_name}}’s own website no later than 30 June each year, unless legislation prescribes a different date.

The transaction copy generated for the provider’s own records will not be used as the publication copy.

Before publication, {{org_field_name}} will ensure that the published return does not contain information whose disclosure is prohibited by law and will comply with applicable data protection requirements.

{{org_field_name}} will make a copy of its published annual return available to any person who requests one.

The Responsible Individual will ensure that the statement of compliance required for the annual return is prepared in accordance with Regulation 81 and will have regard to the most recent quality-of-care review when preparing that statement.

Information contained within the annual return must be accurate and reflect the position of the provider and regulated service for the relevant reporting period.

5.4 CQC Inspections (England, if applicable)

CQC ratings are monitored, and action plans are implemented to address any identified areas for improvement. Regular mock inspections are carried out to prepare staff for CQC reviews.

5.5 Continuous Improvement in Compliance

{{org_field_name}} will continuously monitor the effectiveness, quality and regulatory compliance of the service and will take appropriate action where improvement is required.

Staff are expected and supported to report concerns about quality, safety, safeguarding, regulatory compliance or poor practice through the appropriate management, safeguarding, incident-reporting or whistleblowing arrangements.

Learning arising from incidents, accidents, complaints, safeguarding matters, whistleblowing concerns, audits, Responsible Individual monitoring, quality-of-care reviews and CIW inspections will be considered and, where necessary, used to improve the service.

Policies and procedures will be kept up to date and will be reviewed whenever required as a result of changes to legislation, statutory guidance, the Statement of Purpose, regulatory requirements, identified risks or learning from the operation of the service. The scheduled annual policy review will not prevent an earlier review or amendment where this is required.

6. Related Policies

This policy should be read alongside: Statement of Purpose Policy (DCW05). Safe Care and Treatment Policy (DCW11). Governance and Compliance Policy (DCW04). Staff Supervision, Training, and Development Policy (DCW27). Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13).

7. Policy Review

This policy will be formally reviewed at least annually and will be reviewed and amended sooner where required because of:

• changes to legislation or regulations;
• amendments to statutory guidance;
• changes to CIW requirements;
• changes to the Statement of Purpose;
• CIW inspection findings or enforcement action;
• findings from the quality-of-care review;
• significant incidents, safeguarding matters, complaints or identified regulatory risks; or
• changes to the operation or management of the regulated service that affect the content of this policy.

The Responsible Individual will ensure suitable arrangements are in place to keep this policy up to date having regard to the Statement of Purpose.

Where changes are made, relevant staff will be informed and, where necessary, provided with appropriate instruction or training to ensure that the revised requirements are implemented in practice.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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