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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 outline how {{org_field_name}} meets and maintains compliance with the fundamental standards set out by the Care Quality Commission (CQC) under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It sets out the expectations and responsibilities of all staff to ensure that our service delivers care that is safe, effective, caring, responsive, and well-led. This policy also reinforces our commitment to transparency, continuous improvement, and providing the highest quality of service to the people we support.

2. Scope

This policy applies to all employees, managers, volunteers, agency staff, and contractors working within or on behalf of {{org_field_name}}. It also informs the approach taken by the Registered Manager, Nominated Individual, and Company Directors in overseeing the delivery of regulated activities. This policy underpins the framework for how we operate, support compliance, prepare for inspections, and respond to regulatory changes.

3. Related Policies

This policy must be read in conjunction with:

• CH04 – Good Governance Policy
• CH05 – Statement of Purpose Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH17 – Infection Prevention and Control Policy
• CH25 – Notification of Other Incidents Policy
• CH35 – Duty of Candour Policy
• CH26 – Recruitment, Selection and Retention Policy
• CH27 – Staff Supervision, Training and Development Policy

4. Policy Details

4.1 Understanding the Fundamental Standards

All staff must understand and comply with the CQC Fundamental Standards and all other requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that apply to their role and to the regulated activities carried on by {{org_field_name}}.

The requirements relevant to the delivery of care include:

• Regulation 9 – Person-centred care;
• Regulation 9A – Visiting and accompanying in care homes, hospitals and hospices;
• Regulation 10 – Dignity and respect;
• Regulation 11 – Need for consent;
• Regulation 12 – Safe care and treatment;
• Regulation 13 – Safeguarding service users from abuse and improper treatment;
• Regulation 14 – Meeting nutritional and hydration needs;
• Regulation 15 – Premises and equipment;
• Regulation 16 – Receiving and acting on complaints;
• Regulation 17 – Good governance;
• Regulation 18 – Staffing;
• Regulation 19 – Fit and proper persons employed;
• Regulation 20 – Duty of candour; and
• Regulation 20A – Requirement as to display of performance assessments.

Where applicable to the legal form and registration of {{org_field_name}}, the organisation must also comply with Regulations 4 to 8 concerning the fitness and responsibilities of providers, directors and registered managers.

These requirements must be reflected in the operation of the service, staff induction, training, supervision, competency assessment, governance and quality assurance arrangements. Staff must understand the regulatory requirements relevant to their duties and how their practice contributes to the provision of safe, effective, caring, responsive and well-led services.

4.2 Governance and Leadership Responsibilities

{{org_field_name}}, as the registered provider, retains legal responsibility for ensuring that regulated activities are carried on in accordance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Quality Commission (Registration) Regulations 2009, the conditions of registration imposed by the Care Quality Commission and other applicable legislation.

The Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, is responsible for the day-to-day management of the regulated activities for which they are registered and for ensuring that the service is managed in accordance with the conditions of registration and applicable regulatory requirements.

The Nominated Individual, {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}}, where required by the organisation’s registration, is responsible for supervising the management of the regulated activities on behalf of the provider and for acting as the principal point of contact between the provider organisation and the Care Quality Commission in relation to the provider’s registration.

Where Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 applies to {{org_field_name}}, the provider must ensure that directors and persons performing functions equivalent to those of a director satisfy the applicable fit and proper person requirements and that appropriate checks and records are maintained.

The Registered Provider, Registered Manager, Nominated Individual and relevant directors or senior leaders must ensure that effective governance systems are maintained to assess, monitor and improve the quality and safety of services, assess and mitigate risks, maintain required records and ensure that statutory notifications, information and correspondence required by the Care Quality Commission are accurate and submitted within the required timescales.

Quality assurance findings must be reviewed by the appropriate responsible persons and action must be taken where improvements are required.

4.3 Policy and Procedure Framework

Our operational procedures are directly mapped to the relevant CQC regulations, and we maintain a comprehensive suite of policies aligned with each regulation. These policies are stored securely and made easily accessible to all staff. Each policy includes review dates and named persons responsible for updates. We ensure that all policy updates are communicated to staff, and changes are reflected in practice through training, supervision, and observation.

4.4 Training and Competency

{{org_field_name}} must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed to meet the needs of people using the service and the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

All staff must receive appropriate induction, support, training, professional development, supervision and appraisal necessary to enable them to perform the duties for which they are employed. Training requirements must be determined by the person’s role, responsibilities, competence and the needs and risks of the people using the service.

Training relevant to individual roles may include safeguarding, infection prevention and control, moving and handling, medicines management, consent and the Mental Capacity Act 2005, confidentiality and information governance, emergency procedures, health and safety and any other training required for the safe performance of the person’s duties.

In accordance with the statutory requirements applying to CQC-registered providers, {{org_field_name}} must ensure that all staff receive training on learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability, at a level appropriate to their role. This requirement applies to all staff whose work may bring them into contact with autistic people or people with a learning disability and is not limited to staff working in specialist learning disability or autism services.

Learning disability and autism training must comply with the applicable statutory requirements and the current code of practice issued under the Health and Social Care Act 2008. The service must ensure that staff receive appropriate supervision so that they demonstrate and maintain competence in understanding and responding to the needs of autistic people and people with a learning disability.

Staff competence must be assessed where necessary before they undertake duties without supervision and must be reviewed at appropriate intervals. Refresher or additional training must be provided whenever required by legislation, recognised guidance, the person’s role, changes in practice, an identified competency need or the needs of people using the service.

Training, supervision, appraisal and competency records must be maintained and monitored. Where training or competence requirements are not being met, appropriate action must be taken without delay.

4.5 Safe and Effective Care Delivery

We deliver care that is person-centred and based on comprehensive assessments of needs, wishes, and preferences. Care plans are regularly reviewed and involve the person, their family, and professionals. We ensure safety by carrying out risk assessments, implementing safeguarding protocols, and responding promptly to incidents. Infection control measures, medication audits, and health and safety checks are completed in line with our internal schedules and CQC guidance. Our aim is to provide services that minimise harm and maximise independence and well-being.

4.6 Visiting and Accompanying

In accordance with Regulation 9A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, {{org_field_name}} must facilitate people living in the care home to receive visits at the premises and must not discourage people from taking visits outside the care home, unless exceptional circumstances apply.

The starting position must be that visits can take place. Where a risk is identified, the service must consider and implement necessary and proportionate measures to enable the visit to take place safely wherever reasonably possible rather than imposing a blanket restriction.

Arrangements and decisions about visiting must:

• take account of the person’s wishes and preferences so far as reasonably practicable;
• take account of the person’s care or treatment plan;
• consider individual risks and circumstances;
• involve the person and, where appropriate, their family members, friends, representatives or advocates;
• comply with applicable consent, Mental Capacity Act 2005 and human rights requirements; and
• be reviewed where circumstances change.

Any restriction on visiting must be based on exceptional circumstances, be necessary and proportionate to the identified risk, apply for no longer than necessary and be recorded together with the reasons for the decision and any review undertaken.

Nothing in this section permits blanket visiting restrictions based solely on diagnosis, disability, age, convenience, staffing arrangements or generalised risk where a safe and proportionate alternative can reasonably be implemented.

4.7 Incident Reporting and Statutory Notifications

{{org_field_name}} must ensure that incidents, accidents, safeguarding concerns, allegations of abuse, near misses and other significant events are recorded, responded to, reviewed and investigated as appropriate. Immediate action must be taken to protect people from actual or potential harm and any required referral must be made to the appropriate external authority.

The Registered Provider and Registered Manager must ensure that statutory notifications are submitted to the Care Quality Commission where required by the Care Quality Commission (Registration) Regulations 2009 and other applicable legislation.

Notifications must be made using the current method and form specified by the Care Quality Commission and within the statutory timescale applicable to the particular notification. Where the regulations require notification “without delay”, the notification must be made without delay once the registered person becomes aware that the notification requirement has been met.

This includes, where applicable:

• notification of the death of a person using the service in accordance with Regulation 16 where the death occurred whilst regulated activity was being provided or where the death has, or may have, resulted from the carrying on of the regulated activity;
• notification of serious injuries meeting the statutory threshold;
• notification of abuse or allegations of abuse;
• notification of incidents reported to or investigated by the police where the statutory notification criteria are met;
• notification of events that prevent, or appear likely to prevent, the service from being able to continue to carry on the regulated activity safely and properly;
• notification of relevant outcomes concerning applications to deprive a person of their liberty where notification is required;
• notification of other incidents specified by Regulation 18 of the Care Quality Commission (Registration) Regulations 2009; and
• any other statutory notification required because of a change affecting the provider, registered manager, regulated activity, location or other registration details.

Regulation 17 notifications concerning the death or unauthorised absence of a person detained or liable to be detained under the Mental Health Act 1983 must only be made where Regulation 17 applies. An ordinary missing-person incident involving a care home resident must not be described automatically as a Regulation 17 unauthorised absence notification. Such an incident must nevertheless be managed immediately in accordance with safeguarding, missing-person and risk-management procedures and notified to the Care Quality Commission if another statutory notification threshold is met.

The duty of candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is separate from the statutory notification requirements. Where a notifiable safety incident meets the Regulation 20 threshold, {{org_field_name}} must follow the statutory duty of candour requirements in addition to making any required CQC notification.

Records must demonstrate the incident, action taken, investigation where appropriate, whether a statutory notification was required, when and how it was submitted, and any learning or improvement arising from the event.

4.8 Complaints and Feedback Handling

In accordance with Regulation 16, all complaints are taken seriously and handled in a timely and professional manner. People we support, their families, and representatives are encouraged to provide feedback through surveys, reviews, and open dialogue. Complaints are investigated thoroughly and any learning points are shared with the team to prevent recurrence. Complaints logs and actions are monitored by management and discussed at governance meetings.

4.9 Monitoring and Continuous Improvement

{{org_field_name}} must maintain effective systems and processes to assess, monitor and improve the quality and safety of the services provided and the quality of the experience of people using the service, in accordance with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Governance arrangements must enable the service to:

• assess and monitor the quality and safety of services;
• assess, monitor and mitigate risks relating to the health, safety and welfare of people using the service and others;
• maintain accurate, complete and contemporaneous records;
• obtain and act on feedback from people using the service and other relevant persons;
• identify where improvement is required;
• implement and monitor improvement actions; and
• evaluate and improve the effectiveness of governance arrangements.

Internal audits and quality assurance reviews must be undertaken at intervals appropriate to the level of risk and the needs of the service. Findings must result in documented action where improvement is required, with responsibility and timescales identified and completion monitored.

The Registered Manager must maintain oversight of compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and applicable Care Quality Commission requirements.

When reviewing CQC readiness and quality performance, the service must use the Care Quality Commission’s current assessment framework, including the five key questions and applicable quality statements, rather than relying on superseded Key Lines of Enquiry as the current assessment framework.

The outcomes of governance activity, audits, feedback, incidents, complaints and regulatory assessments must be used to identify learning and drive improvement in the quality and safety of the service.

4.10 CQC Assessment, Inspection and Display of Ratings

{{org_field_name}} must co-operate with the Care Quality Commission in the exercise of its regulatory functions and must ensure that staff understand their responsibilities in relation to CQC assessment and inspection.

Staff must be able to explain their roles and responsibilities, how they protect the safety and rights of people using the service, and how the service implements relevant policies and regulatory requirements in practice.

The service must maintain evidence necessary to demonstrate compliance with the regulations, including evidence relating to people’s experiences, care records, risk management, staffing and competence, medicines, safeguarding, complaints, incidents, governance, quality assurance and improvement.

Where {{org_field_name}} has received a CQC rating to which Regulation 20A applies, the most recent applicable CQC rating must be displayed in accordance with Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At each premises from which regulated activities are provided, at least one sign showing the most recent applicable CQC rating must be displayed conspicuously, legibly and in a place accessible to people using the service.

Where {{org_field_name}} maintains a website, the website must display the information required by Regulation 20A, including:

• the Care Quality Commission’s website address;
• information enabling people to access the most recent CQC assessment of the provider and, where applicable, the relevant premises or regulated activities;
• the most recent applicable CQC rating;
• a clear indication of the premises or regulated activities to which each displayed rating relates; and
• the date on which each displayed rating was given by the Care Quality Commission.

Where the provider’s principal place of business is subject to the separate display requirements under Regulation 20A, the required rating information must also be displayed there.

Ratings must remain conspicuous, legible and up to date. The current published CQC rating must continue to be displayed where required even where the provider has requested a review of the rating.

The service must use the Care Quality Commission’s current assessment framework when preparing for assessment or inspection and must ensure that governance systems can demonstrate compliance with the applicable regulations and quality statements.

5. Policy Review

This policy is reviewed annually or in response to:

• Changes in CQC regulations or guidance
• Internal audits or inspections highlighting policy gaps
• Lessons learned from incidents, complaints, or staff feedback

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.