CH153-CQC Regulations Policy
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{{org_field_name}}
Registration Number: {{org_field_registration_no}}
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 be familiar with and adhere to the 13 Fundamental Standards of care, which include: person-centred care, dignity and respect, consent, safety, safeguarding, food and drink, premises and equipment, complaints, good governance, staffing, fit and proper staff, duty of candour, and display of ratings. We ensure that these standards are integrated into our daily operations, training, and audits. Information about these standards is provided in induction and reinforced through regular team briefings and training sessions. This ensures all staff understand how their roles contribute to maintaining compliance.
4.2 Governance and Leadership Responsibilities
The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} and the Nominated Individual {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}} hold overall responsibility for ensuring compliance with CQC regulations. They lead governance systems that monitor, evaluate, and improve the quality of services. They ensure all regulatory notifications, reports, and correspondence are completed on time and are accurate. Regular quality assurance audits are completed, and findings are reviewed in management meetings with action plans developed where necessary.
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
All staff receive training relevant to their role, covering areas such as safeguarding, infection control, moving and handling, medication administration, consent, confidentiality, and emergency procedures. Refresher training is conducted annually or sooner if required. Staff are assessed through supervisions, competency assessments, spot checks, and annual appraisals. Training compliance is monitored and recorded on our central training matrix, which is reviewed by the Registered Manager.
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 Incident Reporting and Notifications
We are committed to being open and transparent in line with Regulation 20 – Duty of Candour. All incidents, near misses, and safeguarding concerns are logged, investigated, and reported appropriately. The Registered Manager ensures that any incidents that meet the threshold for CQC notification (such as deaths, abuse allegations, serious injuries, or unauthorised absences) are reported without delay using the appropriate forms and channels, in compliance with Regulation 18 – Notification of Other Incidents.
4.7 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.
4.8 Monitoring and Continuous Improvement
Internal audits are conducted monthly or quarterly across key areas such as care planning, health and safety, medication, infection control, and staffing. Results are used to create action plans, improve training, and adjust procedures. The Registered Manager holds quarterly reviews of CQC compliance and benchmarks the service against the Key Lines of Enquiry (KLOEs) to ensure our service meets the five domains of being Safe, Effective, Caring, Responsive, and Well-led. The outcomes are shared with staff and used to drive improvement.
4.9 Preparing for Inspection
Staff are trained to understand the CQC inspection process and how their roles support the five key questions. Mock inspections are carried out periodically, and feedback is used to boost readiness and confidence. We display our latest performance rating in accordance with Regulation 20A – Display of Performance Assessments, including on our premises and website: {{org_field_website}}. Staff are encouraged to speak confidently to inspectors about their roles, values, and how they support high-quality care.
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
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.