{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

CIW Regulations Policy

1. Purpose

The purpose of this policy is to set out the regulatory framework that applies to {{org_field_name}} as a service operating in Wales and regulated by Care Inspectorate Wales (CIW). It explains how we interpret and apply Welsh legislation in everyday practice, how our governance and quality assurance align with CIW expectations, and how we communicate our compliance to people using our services, their families, professionals and commissioners. The policy is written in plain language so that all staff understand what is required of them and how their actions contribute to safe, effective, well-led and person-centred care.

2. Scope

This policy applies to everyone working for {{org_field_name}}—including the Responsible Individual (RI), Registered Manager (RM), senior staff and all care and administrative colleagues. It is also relevant to people who use our services and their families, visiting professionals, commissioning bodies, and CIW inspectors who wish to understand our approach to regulatory compliance in Wales.

3. Related Policies

Read this policy alongside (non-exhaustive): CHW04 Good Governance; CHW05 Statement of Purpose; CHW11 Safe Care and Treatment; CHW13 Safeguarding Adults from Abuse and Improper Treatment; CHW15 Regulated Activities Compliance; CHW27 Staff Supervision, Training and Development; CHW35 Openness and Candour.

4. Legal and Regulatory Framework (Wales)

{{org_field_name}} operates within the regulatory framework established by the Regulation and Inspection of Social Care (Wales) Act 2016, as amended, including by the Health and Social Care (Wales) Act 2025.

The principal legislation and regulations applicable to the operation and regulation of the service include:

• 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 Regulated Services (Registration) (Wales) Regulations 2017, as amended;
• the Regulated Services (Annual Returns) (Wales) Regulations 2017, as amended;
• the Regulated Services (Inspection Ratings) (Wales) Regulations 2025; and
• the Regulated Services (Penalty Notices) (Wales) Regulations 2019, as amended.

{{org_field_name}} must have regard to the statutory guidance issued by the Welsh Ministers under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016 when meeting requirements imposed on service providers and Responsible Individuals.

Care Inspectorate Wales acts on behalf of the Welsh Ministers as the service regulator and uses the legislation, regulations, statutory guidance and its published codes, frameworks and regulatory policies when determining whether a registered provider and Responsible Individual are meeting their regulatory duties.

The service also operates in accordance with other legislation applicable to the care and support it provides, including, where relevant:

• the Social Services and Well-being (Wales) Act 2014;
• the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards;
• the Human Rights Act 1998;
• the Equality Act 2010;
• the Welsh Language (Wales) Measure 2011;
• the Data Protection Act 2018 and UK GDPR;
• the Safeguarding Vulnerable Groups Act 2006; and
• applicable Welsh legislation and statutory requirements concerning health, safety, safeguarding, infection prevention and control and the provision of health and social care.

Where legislation, regulations or statutory guidance are amended, {{org_field_name}} will ensure that its policies, procedures and operational arrangements are reviewed and amended as necessary so that the service continues to comply with its legal and regulatory obligations.

5. Our Governance and Compliance Approach

5.1 Understanding CIW Expectations

The RI and RM maintain up-to-date knowledge of RISCA and CIW guidance and ensure that policies, procedures, audits and training reflect Welsh requirements. Staff are inducted and refreshed on: safe care and treatment; safeguarding; capacity and consent; complaints and compliments; openness and candour; record-keeping; information governance; and reporting duties to CIW and local safeguarding teams.

5.2 Roles and Responsibilities

Service Provider

The service provider retains overall responsibility for ensuring that the regulated service complies with the Regulation and Inspection of Social Care (Wales) Act 2016, as amended, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and other legislation and regulations applicable to the service.

The service provider will ensure that sufficient governance, staffing, financial, physical and other resources are available to provide the service safely and in accordance with the Statement of Purpose.

Responsible Individual

The Responsible Individual provides effective oversight of the management, quality, safety and regulatory compliance of the service and fulfils the duties imposed upon the Responsible Individual by Parts 16 to 20 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

For a care home service, the Responsible Individual will:

• visit each place in respect of which they are designated and meet with staff and individuals using the service at least every three months;
• ensure that each visit is documented, including the date of the visit, discussions undertaken, records reviewed, findings and any actions required;
• maintain effective oversight of the Registered Manager and the management of the service;
• ensure appropriate arrangements are in place whenever the Registered Manager is absent or there is no manager;
• report to the service provider on the adequacy of resources at least quarterly where the regulatory requirement to make such a report applies;
• obtain and report the views of individuals using the service, their representatives where appropriate, service commissioners and staff about the quality of care and support and how it can be improved;
• ensure there are effective systems for recording incidents, complaints and matters requiring notification;
• ensure effective systems are in place for maintaining accurate and complete records;
• ensure suitable arrangements are in place for keeping policies and procedures up to date;
• ensure the quality of care and support is formally reviewed as often as required and at least every six months;
• prepare the required Quality of Care Review report for the service provider following each Regulation 80 review, where applicable;
• prepare the statement of compliance required for inclusion within the service provider’s annual return; and
• ensure notifications for which the Responsible Individual is legally responsible are submitted to Care Inspectorate Wales within the required timescale and in the required manner.

Registered Manager

The Registered Manager is responsible for the day-to-day management of the service and for ensuring that care and support are provided in accordance with the Statement of Purpose, legislation, regulations and the service’s policies and procedures.

The Registered Manager will:

• maintain effective day-to-day systems for regulatory compliance;
• deploy sufficient suitably qualified, skilled, competent and experienced staff;
• oversee care planning, risk management, safeguarding, medicines management, incidents, complaints, staffing, training and record-keeping;
• ensure staff understand and follow applicable policies and procedures;
• maintain records and evidence required to demonstrate compliance;
• promptly inform the Responsible Individual and service provider of significant risks, incidents, regulatory concerns and other matters requiring their attention; and
• support the Responsible Individual in carrying out regulatory oversight and quality-monitoring duties.

All Staff

All staff must work in accordance with legislation, regulations, the Statement of Purpose, their job description, applicable codes of professional practice and the policies and procedures of {{org_field_name}}.

Staff must:

• provide safe, respectful and person-centred care and support;
• maintain accurate, complete and contemporaneous records;
• identify and report safeguarding concerns, incidents, accidents, complaints and other significant events promptly;
• raise concerns where they believe the safety, rights or well-being of an individual may be compromised;
• complete required induction, training, supervision and appraisal; and
• co-operate with quality assurance, inspection, audit and improvement activity.

5.3 Quality Assurance and the Quality of Care Review

{{org_field_name}} will maintain effective arrangements 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 in accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

The Quality of Care Review will include consideration and analysis of:

• the views and feedback obtained from individuals using the service;
• the views of representatives, where appropriate;
• the views of service commissioners;
• the views of staff;
• the outcome of Responsible Individual visits;
• incidents and notifiable incidents;
• safeguarding matters;
• whistleblowing concerns;
• concerns and complaints;
• action taken in response to complaints;
• trends and patterns identified through incidents, accidents and near misses;
• records of the use of control, restraint or restrictive practice where applicable;
• relevant inspection findings and regulatory requirements;
• audits of care and support records, including the accuracy and completeness of records;
• care planning and personal-plan audits;
• medicines-management audits where applicable;
• staffing, training and supervision information;
• infection prevention and control;
• environmental, premises and equipment matters where applicable; and
• progress against previous improvement actions.

Information arising from the review will be analysed to identify risks, themes, learning, areas of good practice and areas requiring improvement.

Following each formal Regulation 80 review, the Responsible Individual will prepare a report to the service provider, where required by the Regulations. The report will include:

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

Actions arising from quality monitoring and review will be recorded, allocated to an appropriate person, given a timescale for completion and monitored until completed and demonstrated to be effective.

The findings of quality monitoring and review will be used to improve the service and will inform the Responsible Individual’s statement of compliance for inclusion within the service provider’s annual return.

5.4 Notifications and Reportable Events

{{org_field_name}} will maintain effective arrangements to identify, record and notify all events that must be reported 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.

The service provider will ensure that notifications required under Regulation 60 and Schedule 3 are made to Care Inspectorate Wales and, where applicable, to another authority specified by the Regulations.

Reportable matters include, where applicable:

• revisions to the Statement of Purpose;
• specified changes concerning the service provider or persons involved in its management and control;
• specified absences or changes involving the Responsible Individual;
• abuse or allegations of abuse involving the service provider, a member of staff or a volunteer;
• specified criminal convictions;
• allegations of misconduct by a member of staff;
• category 3 or 4 pressure damage or unstageable pressure damage;
• serious accidents or injuries;
• outbreaks of infectious disease;
• incidents reported to the police;
• events that prevent, or could prevent, the service provider from continuing to provide the service safely;
• the death of an individual where accommodation is provided;
• requests to a supervisory body concerning the application of the Deprivation of Liberty Safeguards;
• significant alteration or extension of the premises;
• acquisition of additional premises; and
• other events specified within Schedule 3 that apply to the service.

Where the service provides care and support to children, the additional notification requirements contained within Schedule 3 will also be followed, including notifications to the appropriate placing authority, local authority, police, health board or other body where required.

The Responsible Individual will separately ensure that notifications required under Regulation 84 and Schedule 4 are made to Care Inspectorate Wales. These include relevant matters concerning the appointment, absence, return, replacement or cessation of the Registered Manager and other events specified by Schedule 4.

Unless a different timescale is expressly specified within the Regulations, notifications will be made without delay and in writing. Notifications will be made in the manner and form required by Care Inspectorate Wales.

Internal records will clearly record:

• the event;
• the date and time of the event;
• immediate action taken to protect individuals;
• any medical, safeguarding or other professional action taken;
• who was informed;
• whether a statutory notification was required;
• when and how the notification was submitted;
• the person who submitted it;
• any reference or acknowledgement received;
• investigation findings; and
• resulting actions and learning.

Where an event also meets safeguarding thresholds, an appropriate safeguarding report or referral will be made in accordance with the Wales Safeguarding Procedures and local safeguarding arrangements. Making a safeguarding referral does not remove or replace any separate requirement to make a statutory notification to Care Inspectorate Wales.

5.5 Staff Training, Supervision and Competence

{{org_field_name}} will ensure that all staff and volunteers receive the induction, training, supervision, appraisal and development necessary for them to perform their roles safely and competently and to meet the care and support needs of individuals using the service.

All new staff and volunteers will receive an induction appropriate to their role. Social care workers will complete the applicable Social Care Wales induction requirements within the required timescale, together with service-specific induction.

Training will reflect:

• the Statement of Purpose;
• the role and responsibilities of the member of staff;
• the assessed needs of individuals using the service;
• applicable legislation and statutory guidance;
• Social Care Wales requirements;
• learning identified through incidents, complaints, safeguarding, audits and quality reviews; and
• any specialist care or equipment relevant to the person’s role.

Core and role-specific training will include, where applicable:

• safeguarding;
• mental capacity, consent and Deprivation of Liberty Safeguards;
• medicines;
• moving and handling;
• infection prevention and control;
• health and safety;
• record-keeping and information governance;
• equality, dignity and human rights;
• professional boundaries;
• communication;
• Welsh-language needs and the Active Offer;
• positive behaviour support and restrictive practices where applicable; and
• any specialist training required to meet the needs of individuals receiving the service.

Staff will meet individually with their line manager, or another appropriate senior person, for formal one-to-one supervision no less than quarterly.

All staff will receive an appraisal at least annually. Supervision and appraisal will provide opportunities to review performance, competence, conduct, training and development needs, professional responsibilities and the staff member’s contribution to achieving positive outcomes for individuals.

Competence will be assessed in practice where this is necessary for the activity being undertaken. Additional supervision, training or competency assessment will be provided where an audit, incident, complaint, safeguarding matter, observation of practice or other evidence identifies a concern.

{{org_field_name}} will maintain records of induction, training, supervision, appraisal and competency assessment.

Where a member of staff is required to be registered with Social Care Wales or another professional or occupational regulator, {{org_field_name}} will verify the person’s registration and support them to maintain the registration required for their role.

5.6 The Welsh Language and Communication

We promote the Active Offer by offering services in Welsh without people having to ask. We record language preferences in care plans and make reasonable adjustments so people can receive information and communicate in their preferred language and format.

5.7 Information Governance and Record-Keeping

We maintain secure, contemporaneous and accurate records that evidence compliance with Welsh regulations and CIW guidance. Records are retained and disposed of in line with legal requirements. Personal data is processed lawfully and transparently under the UK GDPR and Data Protection Act 2018.

5.8 Annual Return

The service provider will complete, submit and publish its annual return in accordance with 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.

The annual return will cover the preceding financial year and will contain the information required by legislation and by the applicable annual-return regulations.

The service provider will ensure that:

• the annual return is completed accurately and in full;
• required information for each regulated service is included;
• the Responsible Individual prepares the statement of compliance relating to the place or places for which they are designated;
• the statement of compliance has regard to the assessment of the standard of care and support contained within the most recent Quality of Care Review;
• the annual return is submitted electronically through CIW Online within the prescribed timescale, which is currently no later than 26 May following the end of the relevant financial year;
• the publication copy generated through CIW Online is downloaded;
• only the publication copy is published and the transaction copy retained for internal records is not published;
• the publication copy is published on the service provider’s own website no later than 30 June following the end of the relevant financial year;
• the published annual return remains publicly accessible; and
• a copy of the annual return is made available to any person who requests one.

The service provider will maintain a website for the purpose of complying with the statutory requirement to publish its annual return.

The Registered Manager and Responsible Individual will provide the service provider with the information necessary to prepare an accurate annual return, including information derived from:

• the current Statement of Purpose;
• the most recent Quality of Care Review;
• Responsible Individual visit reports;
• staffing and workforce information;
• service capacity and occupancy information; and
• other records required for completion of the return.

Failure to submit or publish an annual return within the prescribed statutory timescale may constitute an offence and may result in regulatory or enforcement action.

6. Working With External Stakeholders

We often collaborate with local health boards, local authorities, GPs and other professionals. Where external documents or enquiries refer to regulatory regimes from outside Wales, we courteously clarify that {{org_field_name}} is regulated by CIW and provide our Statement of Purpose and CIW inspection information as the authoritative reference for our service.

7. Communication, Regulatory Information and Signposting

{{org_field_name}} will ensure that people using the service, their representatives and other relevant persons have clear and accessible information about the regulation of the service and how to raise a concern or complaint.

The service’s written guide and other information provided to individuals will include, where applicable:

• confirmation that {{org_field_name}} is regulated by Care Inspectorate Wales;
• information about how to contact Care Inspectorate Wales;
• information about how to access the service’s most recent CIW inspection report;
• information about how to access the service provider’s published annual return;
• information about how to raise a concern or make a complaint;
• information about relevant advocacy services; and
• the contact details of other bodies required by the applicable regulations and statutory guidance.

Inspection Ratings

{{org_field_name}} will comply with the Regulated Services (Inspection Ratings) (Wales) Regulations 2025.

Following publication of inspection ratings by Care Inspectorate Wales, the service provider will, without delay:

• display the most recent inspection ratings on every website maintained by, or on behalf of, the service provider;
• ensure it is clear which regulated place the ratings relate to where the provider operates more than one service or location;
• display the ratings in the form specified by the Welsh Ministers;
• ensure the ratings are legible and displayed conspicuously;
• include the date on which the inspection ratings were given; and
• make copies of the most recent inspection ratings available on request.

Where the premises-display requirement applies, {{org_field_name}} will display at least one current CIW inspection-ratings sign at the care home in a conspicuous location that is accessible to individuals using the service and visitors.

The statutory premises-display requirement does not apply to:

• a care home service provided wholly or mainly to individuals under the age of 18; or
• an adult care home service where four or fewer individuals are accommodated.

These exemptions relate only to displaying the ratings at the premises. The requirement to display the most recent inspection ratings on the service provider’s website and to make them available on request will continue to apply.

When new inspection ratings are published, outdated ratings will be replaced without delay so that the current ratings displayed by the service accurately reflect the latest ratings published by Care Inspectorate Wales.

Staff will be able to explain the role of Care Inspectorate Wales, the service’s inspection arrangements, the published inspection ratings and the routes available to individuals and representatives for raising concerns or obtaining further regulatory information.

8. Continuous Learning and Improvement

The leadership team, including {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, engages in sector networks, local forums and Social Care Wales resources to keep practice current. We encourage reflective supervision, share learning after audits and incidents, and check that agreed improvements are embedded and effective.

9. Evidence for Inspection

For inspection readiness, we maintain: an up-to-date Statement of Purpose; staff training and supervision records; incident, safeguarding and complaints logs with outcomes; quality audits and the Quality of Care Review with action plans; medicines records where applicable; up-to-date policies; and examples of feedback and co-production with people using our services and their families.

10. Policy Review

This policy is reviewed at least annually—or sooner if Welsh legislation or CIW guidance changes, or if service developments require it. Updates are communicated through team meetings, training, and supervision so that practice stays aligned with Welsh regulatory expectations.

---

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.