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Regulated Activities Compliance Policy

1. Purpose

The purpose of this policy is to ensure that our care home operates in full compliance with Regulation 4: Regulated Activities under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This policy sets out how we manage our compliance efficiently, ensuring that we meet all legal, regulatory, and operational requirements for providing regulated care services.

Our organisation is committed to ensuring that every aspect of our service is delivered safely, effectively, and in line with the fundamental standards of care set by the Care Quality Commission (CQC). Compliance with regulated activities is essential for ensuring that the care we provide meets the highest standards of safety, quality, and dignity for the people we support.

This policy details how we ensure:

• Full compliance with CQC registration requirements.
• That regulated activities are only carried out by individuals with the appropriate skills, training, and competence.
• That our premises, policies, and procedures meet all relevant regulations.
• That we have robust quality monitoring systems to maintain compliance.

2. Scope

This policy applies to:

• All staff members, including care workers, registered managers, senior management, and external professionals delivering care.
• People we support, ensuring they receive safe, high-quality, and legally compliant care.
• Regulatory bodies, including CQC, ensuring our services meet all legal obligations.
• Third-party contractors and service providers working within our care home.

It covers all regulated activities carried out in our care home, including but not limited to:

• Personal care
• Nursing care
• Accommodation for persons who require nursing or personal care
• Treatment of disease, disorder, or injury

3. Related Policies

This policy is supported by and linked to several other policies, including:

• CH04 – Good Governance Policy, ensuring strong leadership and compliance.
• CH07 – Person-Centred Care Policy, ensuring care is tailored to individual needs.
• CH08 – Dignity and Respect Policy, maintaining high standards of respect for individuals.
• CH11 – Safe Care and Treatment Policy, ensuring health and safety regulations are met.
• CH17 – Infection Prevention and Control Policy, complying with hygiene and infection control laws.
• CH19 – Emergency and Business Continuity Plan, ensuring preparedness for crises.
• CH25 – Notification of Other Incidents Policy, detailing reporting requirements.

4. Policy Statement

Our care home is committed to ensuring that all regulated activities are conducted safely, legally, and effectively. We ensure that all staff members, systems, and processes operate in accordance with CQC regulations and legal requirements to protect the health, safety, and well-being of the people we support.

We uphold the following key principles:

1. Compliance with CQC Registration Requirements – We ensure that our care home is registered for the appropriate regulated activities, as per Regulation 4.
2. Qualified and Competent Staff – Only fit and proper persons are employed in roles that involve regulated activities, following Regulation 19.
3. Safe and Effective Care Delivery – We ensure all policies, procedures, and risk management frameworks meet regulatory standards.
4. Ongoing Compliance Monitoring – We use regular audits, staff training, and internal reviews to maintain full compliance.
5. Prompt and Transparent Reporting – We notify CQC of any incidents, changes, or compliance breaches, as required by Regulations 14, 15, and 18.

5. Implementation – How We Manage Regulated Activities Compliance Efficiently

5.1 CQC Registration and Compliance

We ensure that our care home is fully registered with CQC for all regulated activities we provide. During registration and ongoing compliance, we:

• Submit all required documentation and evidence demonstrating compliance with CQC’s fundamental standards.
• Regularly review and update our Statement of Purpose, in line with Regulation 12.
• Notify CQC of any changes to our registration, service structure, or management personnel, as required by Regulations 14 and 15.

5.2 Ensuring Staff Meet Regulatory Requirements

To maintain compliance with Regulation 19 – Fit and Proper Persons Employed, we ensure that:

• All employees undergo DBS (Disclosure and Barring Service) checks before starting employment.
• Staff possess the necessary skills, qualifications, and experience to carry out regulated activities.
• All managers meet Regulation 7 – Requirements for Registered Managers.
• We provide ongoing training and professional development to maintain competency in care delivery.

5.3 Safe and Effective Care Delivery

We ensure that all regulated activities are carried out safely and effectively by:

• Conducting comprehensive risk assessments for all people we support.
• Implementing clear care plans tailored to individuals’ needs, reviewed regularly.
• Ensuring all medications are administered safely, in line with CQC standards.
• Maintaining infection control and hygiene measures, in compliance with Regulation 12 – Safe Care and Treatment.

5.4 Monitoring and Auditing Compliance

We implement a robust quality monitoring system to ensure compliance by:

• Conducting regular internal audits on all regulated activities.
• Reviewing incident reports, complaints, and safeguarding concerns.
• Holding monthly governance meetings to review compliance data.
• Using feedback from people we support, families, and staff to identify improvement areas.

5.5 Incident Reporting and Notifications

In compliance with Regulation 18 – Notification of Other Incidents, we:

• Report serious incidents, safeguarding concerns, and unexpected deaths to CQC without delay.
• Maintain a clear process for staff to report incidents, ensuring timely investigation and corrective action.
• Work with multi-agency safeguarding teams to respond to any risks of harm.

5.6 Continuous Improvement and Learning

To ensure we maintain and improve compliance:

• Lessons learned from incidents and audits are used to enhance policies and procedures.
• We conduct regular refresher training on compliance requirements.
• Service improvement plans are developed annually to align with the latest regulatory expectations.

6. Compliance with CQC Standards

This policy ensures compliance with:

• Regulation 4 – Regulated Activities, ensuring services are legally registered.
• Regulation 12 – Safe Care and Treatment, ensuring care is provided safely.
• Regulation 14 – Notice of Absence, ensuring management continuity.
• Regulation 15 – Notice of Changes, reporting changes in service structure.
• Regulation 17 – Good Governance, maintaining effective systems for oversight.
• Regulation 18 – Notification of Other Incidents, reporting incidents transparently.

7. Monitoring and Review

This policy will be reviewed annually or sooner if:

• CQC regulations are updated.
• An internal audit identifies a need for improvement.
• Significant changes occur in our care home operations.

The Registered Manager is responsible for ensuring that all staff are aware of and adhere to this policy.

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