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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Safe Care and Treatment Policy

1. Purpose

This policy sets out how {{org_field_name}} ensures that people living at the care home receive safe, effective and appropriate care and support in accordance with:

• the Regulation and Inspection of Social Care (Wales) Act 2016, as amended;
• the Health and Social Care (Wales) Act 2025, where applicable;
• the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• the Welsh Ministers’ statutory guidance issued under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016;
• the Regulated Services (Inspection Ratings) (Wales) Regulations 2025; and
• current Care Inspectorate Wales requirements applicable to care home services.

The purpose of this policy is to ensure that care and support is provided with sufficient care, competence and skill and in a way which protects, promotes and maintains the safety and well-being of individuals.

{{org_field_name}} will ensure that avoidable harm is prevented wherever reasonably practicable, identified risks are assessed and managed proportionately, individuals are supported to take positive risks where appropriate, and prompt action is taken when safety or quality may be compromised.

The service will maintain effective governance, incident management, safeguarding, quality assurance and learning arrangements so that concerns, accidents, incidents, complaints, safeguarding matters and other relevant information are reviewed and used to improve the quality and safety of the service.

2. Scope

This policy applies to all staff, managers, agency workers, volunteers and others working at or on behalf of {{org_field_name}} in connection with the provision of the care home service.

It applies to all aspects of the safe delivery of care and support, including:

• assessment and management of risk;
• medicines management;
• infection prevention and control;
• safe staffing;
• safeguarding;
• restrictive practices and deprivation of liberty;
• falls prevention;
• nutrition and hydration;
• use of equipment and medical devices;
• emergency arrangements;
• incident management;
• statutory notifications;
• staff training and competence; and
• monitoring, reviewing and improving the quality and safety of the service.

This policy must be read alongside the service’s related policies and procedures, including those covering safeguarding, medicines, infection prevention and control, health and safety, risk management, use of control or restraint, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, complaints, whistleblowing, emergency and business continuity arrangements, records management and quality assurance.

3. Legal and Regulatory Framework

{{org_field_name}} will have regard to and comply with, where applicable:

• the Regulation and Inspection of Social Care (Wales) Act 2016, as amended;
• the Health and Social Care (Wales) Act 2025;
• the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• the Welsh Ministers’ current statutory guidance for service providers and Responsible Individuals issued under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016;
• the Regulated Services (Inspection Ratings) (Wales) Regulations 2025;
• the Regulated Services (Annual Returns) (Wales) Regulations 2017, as amended;
• the Social Services and Well-being (Wales) Act 2014;
• the Mental Capacity Act 2005;
• the Mental Capacity Act 2005 Code of Practice;
• the Deprivation of Liberty Safeguards and associated statutory guidance;
• the Human Rights Act 1998;
• the Equality Act 2010;
• the Health and Safety at Work etc. Act 1974;
• the Control of Substances Hazardous to Health Regulations 2002;
• applicable fire safety legislation;
• the Data Protection Act 2018 and UK GDPR;
• applicable Social Care Wales Codes of Professional Practice and the Code of Practice for Employers of Social Care Staff;
• applicable Welsh language requirements and current Welsh Government guidance concerning the Active Offer;
• the Wales Safeguarding Procedures; and
• current Care Inspectorate Wales inspection, notification, annual return and ratings requirements.

Policies and procedures will be kept under review and updated where changes in legislation, statutory guidance, the Statement of Purpose or regulatory requirements affect the operation of the service.

4. Key Areas of Safe Care and Treatment

4.1 Duty of Candour (Openness and honesty when things go wrong)

We act in an open and transparent way with individuals receiving care and support and, where appropriate, their representatives. This includes:

• telling the individual (and/or their representative) what has happened, in a way they can understand;
• explaining the immediate actions taken to keep them safe;
• explaining what will be investigated, by whom, and the expected timescales;
• providing information about the outcome of any investigation and learning identified; and
• offering a timely apology where it is appropriate to do so.

We will not tolerate bullying, victimisation, or obstruction of staff raising concerns or exercising professional candour. Where we identify potential breaches of professional candour by registered staff, we will take appropriate action, including referral to the relevant professional regulator where required.

4.2. Risk Assessment and Management

To ensure residents’ safety, we:

• Conduct comprehensive risk assessments upon admission and review them regularly.
• Identify potential hazards, including falls, pressure ulcers, and medication errors.
• Implement personalised risk management plans tailored to individual needs.
• Train staff in risk assessment procedures and ensure they understand their role in maintaining a safe environment.

4.3. Restrictive practice, control/restraint, and deprivation of liberty

We adopt a positive, proactive and least restrictive approach. Restrictive practice (including physical, mechanical, chemical, environmental restriction or restraint) is used only when absolutely necessary, for the shortest time, and in a way that is proportionate to the risk of harm.

We will ensure:

• there is a clear policy and procedure on restrictive practice/control/restraint reflecting current national guidance;
• staff are trained and competent in any technique used;
• each incident is recorded within 24 hours, including triggers, de-escalation attempts, duration, outcome, injury (if any), and learning;
• incidents are reviewed within governance processes to reduce recurrence; and
• where a person may lack capacity, we follow the Mental Capacity Act 2005, act in the person’s best interests, and ensure any deprivation of liberty occurs only with lawful authority (including DoLS where applicable).

4.4. Medication Management

Proper medication management is essential to ensure residents receive the right treatment safely. We have a medicines policy and procedures aligned to current legislation and national guidance. This includes systems for:

• ordering/re-ordering and maintaining sufficient supply;
• secure storage (including controlled drugs where applicable);
• administration (including “as required” medicines, recording refusals, and monitoring side effects);
• safe disposal and return of medicines;
• covert administration only where there is documented lawful authority and best-interest decision-making;
• supporting individuals to manage their own medicines where appropriate;
• delegated medicines tasks only where consistent with national guidance / professional codes; and
• regular audit, reconciliation and management oversight, with learning acted upon.

4.5. Infection Prevention and Control

Preventing the spread of infections is a critical aspect of safe care. At {{org_field_name}}, we:

• Adhere to Public Health Wales infection control guidelines.
• Ensure that hand hygiene protocols are strictly followed.
• Implement cleaning schedules and use appropriate disinfectants.
• Provide regular infection control training to all staff.
• Monitor and report infection outbreaks to local health authorities as required.

4.6. Governance, Monitoring and Quality of Care Review

{{org_field_name}} will maintain effective systems for monitoring, reviewing and improving the quality and safety of the care and support provided.

The Responsible Individual will put suitable arrangements in place to establish and maintain a system for monitoring, reviewing and improving the quality of care and support provided by the service.

The Responsible Individual will ensure that the quality of care and support is formally reviewed as often as required and at least every six months.

Each quality-of-care review will include, as applicable:

• consideration of the views of individuals receiving care and support and the views of representatives, staff and service commissioners;
• analysis of aggregated information relating to accidents and incidents;
• analysis of notifiable incidents;
• safeguarding matters;
• concerns and complaints;
• whistleblowing matters;
• use of control, restraint or restrictive practices;
• falls;
• medicines errors and medicines-management audits;
• pressure damage and other significant clinical risks;
• infection prevention and control information;
• staffing and workforce concerns affecting the safety or quality of the service;
• findings from Care Inspectorate Wales inspections;
• findings arising from Responsible Individual visits;
• the outcome of audits of the accuracy and completeness of records, including personal plans; and
• progress against previous actions and improvement plans.

On completion of each formal quality-of-care review, the Responsible Individual will prepare a report for the service provider which includes:

• an assessment of the standard of care and support provided; and
• recommendations for improvement.

The service provider and Responsible Individual will ensure that identified risks, shortfalls and required improvements are acted upon promptly and proportionately and that progress against improvement actions is monitored.

The findings of quality assurance activity will be used to inform the Responsible Individual’s statement of compliance and the service provider’s annual return.

The service provider will submit its annual return in accordance with the statutory requirements and, from 2026, will publish the required publication copy of the annual return on its own publicly accessible website within the statutory timescale. The transaction copy generated for the service provider’s records will not be published.

The service will retain evidence demonstrating how monitoring, audit, feedback, incidents, complaints, safeguarding matters and regulatory findings have resulted in learning and improvements to the safety and quality of care.

4.7. Care Inspectorate Wales Inspection Ratings

{{org_field_name}} will cooperate fully with Care Inspectorate Wales inspections and will maintain sufficient evidence to demonstrate compliance with the applicable statutory requirements and the outcomes achieved for individuals.

Care Inspectorate Wales may award ratings to the service under the Regulated Services (Inspection Ratings) (Wales) Regulations 2025.

The current Care Inspectorate Wales rating categories are:

• Excellent;
• Good;
• Requires improvement; and
• Requires significant improvement.

Ratings are awarded against the applicable inspection themes and there is no separate overall provider rating.

{{org_field_name}} will display its current Care Inspectorate Wales ratings in accordance with the Regulated Services (Inspection Ratings) (Wales) Regulations 2025 and current Care Inspectorate Wales requirements.

This will include displaying ratings on the provider’s website and displaying the prescribed ratings information at the care home where this is legally required.

Where a statutory exemption from physical display applies, the service will comply with the applicable alternative requirements.

Following publication of an inspection report or ratings, the Registered Manager, Responsible Individual and service provider will review the findings and ensure that any required improvement or enforcement action is addressed within the timescale required by Care Inspectorate Wales.

Where the service receives a rating of Requires improvement or Requires significant improvement, the service will identify the action required to address the concerns, monitor progress and maintain evidence demonstrating the improvements made.

The service will ensure that only its current applicable ratings are displayed and that information about its ratings is accurate and consistent with that published by Care Inspectorate Wales.

4.8. Incident Management, Records and Statutory Notifications

{{org_field_name}} will maintain accurate, complete, contemporaneous and secure records relating to accidents, incidents, safeguarding matters, injuries, pressure damage, outbreaks of infectious disease, restrictive practices, deprivation of liberty, complaints and other events relevant to the safety and well-being of individuals.

Records will include, as applicable:

• the date and time of the event;
• the individual or individuals affected;
• a factual description of what occurred;
• any injury, harm or potential harm identified;
• immediate action taken;
• treatment or professional advice sought;
• persons or organisations informed;
• safeguarding action taken;
• whether the event meets the criteria for statutory notification;
• details of any notification made;
• the outcome of any investigation;
• actions arising; and
• identified learning and measures taken to reduce the likelihood of recurrence.

Notifications by the service provider

The service provider will ensure that Care Inspectorate Wales is notified of events which are required to be notified under Regulation 60 and Schedule 3 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Relevant notifications include, where applicable:

• abuse or an allegation of abuse involving the service provider, a member of staff or a volunteer;
• an allegation of misconduct by a member of staff;
• any occurrence of Category 3 or Category 4 pressure damage or unstageable pressure damage;
• a serious accident or injury to an individual;
• an outbreak of infectious disease;
• an incident reported to the police;
• any event which prevents, or could prevent, the service provider from continuing to provide the service safely;
• the death of an individual accommodated at the care home and the circumstances of the death;
• any request to a supervisory body in relation to an application under the Deprivation of Liberty Safeguards;
• significant alterations or proposed significant alterations to the premises;
• acquisition or proposed acquisition of additional premises; and
• any other event specified in Schedule 3 which is applicable to the service.

Notifications required under Regulation 60 will include the details required by the Regulations and, unless a different timescale is expressly specified, will be made without delay and in writing, in the manner and form required by Care Inspectorate Wales.

Where the Regulations prescribe a specific notification period, that statutory period will be followed.

Notifications by the Responsible Individual

The Responsible Individual will separately ensure that Care Inspectorate Wales is notified of events for which the Responsible Individual has a statutory duty to notify under Regulation 84 and Schedule 4.

These include applicable matters concerning:

• appointment of the manager;
• expected or unexpected absence of the manager;
• absence of the manager lasting more than 28 days;
• interim management arrangements;
• the manager’s return from absence;
• another person managing or proposing to manage the service; and
• the appointed manager ceasing or proposing to cease managing the service.

Unless otherwise specified in the Regulations, notifications made by the Responsible Individual will be made without delay and in writing and in the form or manner required by Care Inspectorate Wales.

Operational arrangements

The Registered Manager may coordinate, prepare or submit notifications as part of the service’s agreed operational arrangements, but this does not remove or transfer the statutory responsibilities placed upon the service provider or Responsible Individual by the Regulations.

The Registered Manager will ensure that potential notifiable events are escalated immediately to the service provider and Responsible Individual so that the statutory notification duty can be discharged within the required timescale.

The service will retain evidence of notifications made, including the date of notification, the information submitted and any subsequent communication or action required by Care Inspectorate Wales.

Patterns and themes arising from accidents, incidents, safeguarding matters, complaints, restrictive practices, pressure damage, medication errors and other safety events will be analysed through the service’s quality assurance arrangements and will inform the six-monthly quality-of-care review.

4.9. Falls Prevention and Mobility Support

{{org_field_name}} will identify, assess and manage the risk of falls while recognising each individual’s rights, independence, choices and entitlement to positive risk-taking.

Where an individual is at risk of falls, the service will:

• assess the risk as part of the provider assessment and relevant risk-assessment processes;
• ensure identified falls risks and agreed risk-management measures are reflected in the individual’s personal plan;
• review risk assessments and the personal plan where there is a fall, near miss, significant change in mobility, deterioration in health or other change affecting the individual’s level of risk;
• provide or facilitate access to appropriate mobility aids and adaptations;
• ensure equipment provided is suitable, safe and appropriately maintained;
• ensure staff have the competence required to provide safe moving and handling support;
• maintain the care home environment so that avoidable trip and environmental hazards are identified and addressed;
• seek relevant healthcare or specialist advice where required; and
• record and review falls and near misses so that recurring risks, patterns and required improvements are identified.

Following a fall, staff will take appropriate immediate action, assess the individual for injury in accordance with their training and the service’s procedures, obtain medical assistance where required, record the incident and consider whether safeguarding, statutory notification or other escalation is required.

Falls information will be reviewed as part of the service’s incident-analysis and quality-assurance arrangements.

4.10. Emergency Procedures and Contingency Planning

Emergencies require a swift and effective response. We ensure safety by:

• Having comprehensive emergency protocols covering fires, medical emergencies, and power failures.
• Training staff in first aid and CPR to handle medical emergencies effectively.
• Conducting regular fire drills and ensuring all staff understand evacuation procedures.
• Maintaining emergency contact lists for health services and next of kin.

4.11. Safeguarding and Protection from Abuse

All residents have the right to feel safe and free from abuse. To ensure this, we:

• Have a zero-tolerance policy for abuse, neglect, and poor treatment.
• Train staff in safeguarding procedures, ensuring they know how to identify and report abuse.
• Ensure prompt reporting of safeguarding concerns to the local authority safeguarding team and CIW.
• Conduct thorough background checks on all staff before employment.

4.12. Nutrition, Hydration, and Safe Food Handling

Proper nutrition and hydration are essential for health and well-being. We ensure this by:

• Providing balanced, nutritious meals tailored to residents’ dietary needs.
• Conducting hydration monitoring for residents at risk of dehydration.
• Training staff in safe food handling and hygiene in compliance with Food Standards Agency (FSA) regulations.
• Ensuring residents’ dietary preferences and restrictions are documented and followed.

4.13. Safe Handling of Equipment and Medical Devices

Medical devices and care equipment must be used safely to prevent harm. We ensure this by:

• Conducting regular equipment maintenance and safety checks.
• Training staff in the correct use of medical devices.
• Ensuring residents have access to assistive technology and mobility aids suited to their needs.

4.14. Staff Training and Competency in Safe Care

Ensuring staff are competent in safe care practices is critical. We achieve this by:

• Providing mandatory health and safety training for all new staff.
• Conducting regular refresher courses on key safety topics, including moving and handling, infection control, and safeguarding.
• Holding supervision and competency assessments to evaluate staff knowledge and application of safety procedures.

4.15. Welsh language and accessible communication

We communicate with individuals in a way they understand and in their preferred language and format, including making an active offer for Welsh language services where appropriate. Information about safe care practices, risks, incidents and learning will be provided in accessible formats (for example easy read, large print, translated information) and with appropriate support (including advocates/interpreters) where required.

5. Related Policies

• CHW07: Person-Centred Care Policy
• CHW08: Dignity and Respect Policy
• CHW12: Meeting Nutritional and Hydration Needs Policy
• CHW13: Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW16: Health and Safety at Work Policy
• CHW17: Infection Prevention and Control Policy
• CHW18: Risk Management and Assessment Policy
• CHW19: Emergency and Business Continuity Plan
• CHW21: Medication Management and Administration Policy

6. Policy Review

This policy will be reviewed at least annually and sooner where necessary.

An earlier review will be undertaken where there is:

• a change in legislation or regulations;
• revised Welsh Government statutory guidance;
• a change in Care Inspectorate Wales requirements or regulatory guidance;
• a change to the service’s Statement of Purpose;
• a relevant inspection finding or enforcement requirement;
• learning arising from a serious incident, safeguarding matter, complaint or investigation;
• significant learning arising from the quality-of-care review; or
• another change which may affect the safe or lawful operation of the service.

The Responsible Individual will ensure that suitable arrangements are in place for this policy and related procedures to be kept up to date, having regard to the Statement of Purpose.

Where changes are made, relevant staff will be informed of the changes and provided with any training, instruction or support necessary to implement them.

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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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