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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Quality Assurance Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} monitors, reviews and improves the quality and safety of the care and support provided to individuals living at the service. The policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and the Welsh Government statutory guidance for care home services. It confirms how the Provider, Responsible Individual, Registered Manager and staff will use audits, feedback, incidents, complaints, safeguarding information, workforce information, inspection findings and other quality indicators to identify learning, drive continuous improvement and ensure individuals are supported to achieve their personal outcomes.

This policy aligns with:

• The Regulation and Inspection of Social Care (Wales) Act 2016.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.
• The Regulated Services (Annual Returns) (Wales) Regulations 2017, as amended.
• Welsh Government statutory guidance for service providers and responsible individuals on meeting service standard regulations for care home services, Version 3, March 2024.
• CIW guidance on completing the Quality of Care Review, including the updated guidance and refreshed report template published in February 2026.
• CIW guidance for Responsible Individuals on statutory visits to regulated services.
• The Social Services and Well-being (Wales) Act 2014.
• The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, where applicable.
• The Equality Act 2010.
• The Welsh language duties and the principles of “More than just words”, including actively offering Welsh language services where this is needed or preferred.
• The Health and Social Care (Wales) Act 2025, in relation to the requirement to publish the Annual Return.

2. Scope

This policy applies to:

• All staff members, including care workers, managers, and administrative personnel.
• Service users and their families, ensuring they have a voice in quality assurance processes.
• External professionals and regulatory bodies, including CIW, local authorities, and healthcare partners.

For the purposes of this policy, the term “individual” means any person receiving care and support from the service. The term includes people living at the care home and, where appropriate, their representatives, advocates, family members or others lawfully acting on their behalf.

The policy covers:

• Internal and external quality assurance measures.
• Service user feedback and engagement.
• Auditing, inspections, and compliance monitoring.
• Continuous improvement and staff development.

3. Principles of Quality Assurance

3.1. Commitment to High Standards and Continuous Improvement

At {{org_field_name}}, we are committed to:

• Delivering person-centred, safe, and effective care that meets regulatory standards.
• A culture of learning, where feedback and incidents drive improvement.
• Transparency and accountability, ensuring that quality assurance is embedded in all aspects of service delivery.

We actively encourage staff, service users, and families to contribute to ongoing improvements.

3.2. Monitoring and Evaluating Service Quality

{{org_field_name}} will maintain effective arrangements for monitoring, reviewing and improving the quality of care and support provided by the service. These arrangements will be proportionate to the size, nature and statement of purpose of the service and will include clear responsibility for who completes each activity, how often it is completed, how findings are recorded, and how actions are monitored to completion.

The service will monitor quality through a planned programme of audits, checks and reviews, including but not limited to:

• care and support planning, including personal plans, risk assessments and review records;
• medication management;
• infection prevention and control;
• safeguarding records and referrals;
• accidents, incidents, falls, near misses and notifiable events;
• use of control, restraint or restrictive practice, where applicable;
• complaints, concerns, compliments and whistleblowing;
• staffing levels, staff deployment, supervision, training, recruitment and registration;
• health and safety, fire safety, premises, equipment and environmental checks;
• nutrition, hydration, skin integrity, continence, oral health and access to healthcare;
• record keeping, including the accuracy, completeness and security of records;
• feedback from individuals, representatives, staff, commissioners, placing authorities where relevant, professionals and visitors;
• outcomes from CIW inspections, local authority monitoring visits, professional reviews and external audits.

The Registered Manager will ensure routine audits are completed and action plans are developed where improvement is required. The Responsible Individual will maintain oversight of quality assurance systems and will ensure the findings are used to inform Responsible Individual visits, Quality of Care Reviews, the Annual Return and wider service improvement planning.

Where monitoring identifies that the quality or safety of the service is, or may be, compromised, immediate action will be taken to reduce risk, protect individuals and improve practice. Actions will be recorded, allocated to a named person, given a timescale and reviewed until completed.

3.3. Quality of Care Review

The Responsible Individual will ensure there is a system for monitoring, reviewing and improving the quality of care and support provided by the service. A Quality of Care Review will be completed as often as required and at least every six months.

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

• feedback from individuals using the service;
• feedback from representatives, advocates and families, where appropriate;
• feedback from staff;
• feedback from service commissioners and placing authorities, where relevant;
• complaints, concerns and compliments;
• safeguarding matters;
• whistleblowing matters;
• accidents, incidents, near misses and notifiable events;
• use of control, restraint or restrictive practice, where applicable;
• medication errors and other clinical or care-related trends;
• falls, pressure damage, infection prevention and control information, nutrition, hydration and other relevant care indicators;
• audits of the accuracy and completeness of records;
• outcomes from Responsible Individual visits;
• CIW inspection findings, local authority monitoring findings and other external feedback;
• progress against previous quality improvement actions.

On completion of the review, the Responsible Individual will prepare a written Quality of Care Review report for the service provider. The report will include an assessment of the standard of care and support provided and recommendations for improvement. The report will be used to inform the service’s improvement plan, the statement of compliance within the Annual Return, and ongoing governance arrangements.

The service will have regard to CIW’s current Quality of Care Review guidance and may use CIW’s current template where this supports effective self-evaluation and improvement.

3.4. Engagement, Involvement and Feedback

The views of individuals, representatives, families, advocates, staff, commissioners, placing authorities where relevant, visiting professionals and other stakeholders are central to the service’s quality assurance framework. Feedback will be actively encouraged, recorded, analysed and used to improve the service.

Feedback will be gathered through a range of methods, including:

• individual conversations and key worker discussions;
• resident meetings and group discussions;
• surveys and questionnaires;
• family and representative feedback;
• staff meetings, supervision and reflective practice discussions;
• commissioner and placing authority feedback;
• professional feedback;
• complaints, concerns, compliments and suggestions;
• observations of care and support;
• advocacy input where appropriate.

Methods of engagement will be appropriate to the person’s age, level of understanding, communication needs, language needs, disability, cognitive impairment, sensory needs and preferences. Where required, information will be provided in accessible formats and people will be supported to express their views.

The Registered Manager will ensure feedback is reviewed regularly and that themes, trends and individual issues are identified. The Responsible Individual will ensure feedback is considered as part of the Quality of Care Review and that the service provider takes feedback into account when making decisions about service improvement.

Individuals and their representatives will be informed, where appropriate, about changes made as a result of feedback.

3.5. Compliance with CIW Requirements, Inspections and Annual Returns

{{org_field_name}} will maintain readiness for CIW inspection at all times by ensuring that the service is delivered in accordance with its statement of purpose, legal requirements, CIW guidance, policies and procedures.

The service will:

• maintain accurate and up-to-date records that demonstrate compliance and good outcomes for individuals;
• respond promptly and effectively to CIW inspection findings, recommendations, priority action notices or improvement notices;
• maintain an improvement plan to address any shortfalls identified through inspection, audit, complaints, safeguarding, incidents or feedback;
• ensure CIW notifications are submitted where required by regulation;
• ensure the Responsible Individual and Registered Manager maintain oversight of regulatory compliance;
• ensure learning from CIW inspection findings is shared with staff and embedded into practice.

The service provider will complete and submit the Annual Return through CIW Online within the required timescale each year. The Annual Return will be informed by the latest Quality of Care Review, Responsible Individual visits, audit findings, workforce information, feedback and improvement activity.

From 2026, the service provider will publish the submitted Annual Return on its own website by the required deadline and will make copies available on request, in line with CIW requirements and the Health and Social Care (Wales) Act 2025.

3.6. Responsible Individual Visits

The Responsible Individual will visit the service in person at least once every three months, or more frequently where required, to monitor the performance of the service against its statement of purpose and to inform the Quality of Care Review.

During each visit, the Responsible Individual will, as appropriate:

• speak with individuals using the service, with their consent and where possible in private;
• speak with representatives, families or advocates where appropriate;
• meet with staff;
• observe the quality and safety of care and support;
• inspect the premises, facilities and environment;
• review selected records, including care records, incident records, complaints records, safeguarding records, staffing records and audit records;
• consider whether the service is supporting individuals to achieve their personal outcomes;
• identify good practice, risks, shortfalls and areas for improvement.

Each Responsible Individual visit will be documented. The record will include the date of the visit, people spoken with, records reviewed, observations made, findings, actions required, the person responsible for each action and the timescale for completion. The Registered Manager will ensure actions from Responsible Individual visits are incorporated into the service improvement plan and reviewed until completed.

3.7. Risk Management and Safeguarding

Quality assurance includes proactive risk management to safeguard service users and staff. This is achieved through:

• Regular risk assessments, ensuring service users’ safety and well-being.
• Incident reporting and investigation, identifying trends and implementing preventative measures.
• Staff training in safeguarding and risk management, ensuring all team members can identify and address potential risks.
• Health and safety audits, ensuring compliance with workplace safety standards.

Quality assurance activity will include analysis of safeguarding themes, incidents, accidents, near misses, falls, medication errors, pressure damage, infections, unexplained injuries, behavioural incidents, restrictive practices, complaints and whistleblowing concerns. The purpose of this analysis is to identify patterns, prevent recurrence, reduce avoidable harm and improve outcomes for individuals. Safeguarding referrals and outcomes will be reviewed by the Registered Manager and overseen by the Responsible Individual as part of governance and Quality of Care Review arrangements.

3.8. Staff Development and Performance Monitoring

Our staff play a critical role in maintaining quality standards. We support them by:

• Regular supervision and appraisals, ensuring staff receive feedback and development opportunities.
• Mandatory and ongoing training, keeping staff updated on best practices and regulations.
• Encouraging reflective practice, where staff review their work and identify improvement areas.
• Rewarding excellence, recognising and celebrating staff contributions to quality care.

All training and supervision records are documented and reviewed as part of our quality assurance framework.

Staff supervision, appraisal, training, competency checks and staff meeting records will be reviewed as part of the quality assurance process. This will include monitoring whether staff have the knowledge, skills, competence, values and registration status required for their role. Where quality monitoring identifies gaps in practice, knowledge or competence, the Registered Manager will ensure appropriate action is taken, which may include supervision, reflective practice, mentoring, additional training, competency assessment or performance management.

3.9. Incidents, Notifications, Duty of Candour and Learning

Incidents, accidents, near misses, safeguarding concerns, complaints, notifiable events and errors will be treated as opportunities to learn and improve. All staff are required to report incidents promptly and honestly in accordance with the relevant policies and procedures.

The Registered Manager will ensure incidents are recorded, reviewed and investigated proportionately. Where required, notifications will be made to CIW, safeguarding authorities, commissioners, placing authorities, health professionals, the police or other relevant bodies.

The service will analyse incidents and related records to identify themes, trends, repeated concerns, root causes and opportunities for prevention. Action plans will be developed where improvements are required, and learning will be shared with staff through supervision, meetings, handovers, training and policy updates.

{{org_field_name}} will act in an open and transparent way with individuals, their representatives and, where relevant, placing authorities. Where something has gone wrong, the service will provide a truthful explanation, offer an apology where appropriate, explain what action is being taken, and support the individual and/or their representative to ask questions or raise concerns.

The service will not tolerate bullying, victimisation or obstruction of any person who raises a concern, makes a complaint, reports a safeguarding matter, whistleblows or acts in accordance with the duty of candour.

3.10. Partnership Working and External Quality Monitoring

We work closely with external partners and professionals to maintain high-quality care, including:

• Healthcare professionals, ensuring service users receive integrated care.
• Local authorities, supporting best practices in social care.
• Pharmacists and medical practitioners, ensuring safe medication management.
• CIW and external auditors, ensuring independent quality assurance oversight.

We welcome external feedback and reviews as part of our commitment to transparency and improvement.

External feedback, professional recommendations, local authority monitoring findings, health professional advice, safeguarding outcomes, commissioner feedback and CIW inspection findings will be recorded and reviewed through the service’s quality assurance system. Where action is required, this will be added to the service improvement plan and monitored until completed.

4. Managing Quality Assurance Efficiently

4.1. Leadership and Accountability

The service provider is responsible for ensuring that effective governance systems are in place to monitor, review and improve the quality and safety of the service.

The Responsible Individual is responsible for maintaining strategic oversight of the service, ensuring effective systems are in place for quality assurance, completing Responsible Individual visits, ensuring the Quality of Care Review is completed at least every six months, and ensuring the findings of quality monitoring are reported to the service provider and used to improve the service.

The Registered Manager is responsible for the day-to-day operation of the quality assurance system, including completion of audits, review of incidents and complaints, staff supervision and training oversight, implementation of action plans, maintenance of accurate records and escalation of risks to the Responsible Individual and service provider.

Senior staff and team leaders will support frontline quality monitoring by observing practice, reviewing records, supporting staff, reporting concerns and ensuring agreed improvements are embedded into day-to-day care.

All staff are responsible for maintaining quality by following policies and procedures, reporting concerns, contributing to learning, supporting individuals to achieve their personal outcomes, and raising any issue that may affect the quality or safety of care.

4.2. Staff Training and Engagement

• Mandatory quality assurance training ensures all staff understand their role in maintaining standards.
• Regular team meetings and workshops promote shared responsibility for quality.
• Encouraging staff to report concerns, ensuring proactive identification of issues.

Staff will be encouraged and supported to raise concerns, make suggestions and contribute to improvement activity. Staff feedback will be gathered through supervision, appraisal, staff meetings, surveys, reflective practice, debriefs following incidents and direct discussion with the Registered Manager or Responsible Individual. Staff views will be considered as part of Quality of Care Reviews and service improvement planning.

4.3. Monitoring and Continuous Improvement

The service will operate a continuous improvement cycle of monitoring, analysis, action, review and learning. Monthly audits and routine checks will be used to identify compliance, good practice, risk and areas for improvement. The Registered Manager will ensure action plans are developed and reviewed regularly.

The Responsible Individual will ensure that the quality of care and support is formally reviewed at least every six months through the Quality of Care Review process. This review will consider feedback, audit outcomes, incident trends, safeguarding matters, complaints, whistleblowing, staffing, record keeping, inspection findings, Responsible Individual visits and progress against previous actions.

The service improvement plan will clearly identify the improvement required, the action to be taken, the person responsible, the timescale for completion, progress updates and evidence of completion. Where improvement actions are not completed within the expected timescale, this will be escalated to the Registered Manager, Responsible Individual and service provider as appropriate.

4.4. Records, Audit Trail and Evidence

The service will maintain clear records of quality assurance activity, including audits, checks, feedback, meetings, incidents, complaints, safeguarding matters, Responsible Individual visits, Quality of Care Reviews, action plans and improvement outcomes.

Records will be accurate, complete, legible, dated and stored securely. Where electronic records are used, staff will have individual access credentials so that entries and amendments can be traced to the person who made them. The accuracy and completeness of records will be audited and findings will be included in the Quality of Care Review process.

Quality assurance records will be made available to CIW, commissioners or other authorised bodies where required.

4.5. Statement of Purpose, Policies and Procedures

Quality assurance activity will include checking whether the service is being delivered in accordance with the current statement of purpose. Where monitoring identifies that the service being provided differs from the statement of purpose, or where changes to the service are planned, the Registered Manager and Responsible Individual will ensure this is escalated and managed in accordance with CIW requirements.

Policies and procedures will be reviewed at least annually, or sooner where required due to changes in legislation, statutory guidance, CIW guidance, inspection findings, safeguarding learning, incidents, complaints, best practice or changes to the statement of purpose.

Where changes to policies or procedures directly affect individuals or their representatives, these changes will be communicated in a timely and accessible way. Staff will be informed of policy changes and, where necessary, provided with additional guidance or training.

4.6. Welsh Language, Communication and Accessibility

The service will take reasonable steps to meet individuals’ language and communication needs. Quality assurance activity will consider whether individuals are receiving information in a language, style, format and method they can understand, and whether communication aids, interpretation, advocacy or accessible formats are required.

The service will evidence its commitment to providing, or working towards actively offering, Welsh language care and support for individuals whose first language is Welsh or who prefer to communicate in Welsh.

Feedback and engagement methods will be adapted to support people with sensory impairment, cognitive impairment, dementia, learning disability, mental health needs, communication difficulties or other needs that may affect their ability to express views.

5. Related Policies

This policy is supported by:

• CHW04 – Good Governance Policy
• CHW11 – Safe Care and Treatment Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW18 – Risk Management and Assessment Policy
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW27 – Staff Supervision, Training, and Development Policy

6. Policy Review

This policy will be reviewed at least annually, or sooner where required due to changes in legislation, CIW guidance, Welsh Government statutory guidance, the statement of purpose, inspection findings, safeguarding learning, complaints, incidents, audit findings or best practice.

The Responsible Individual and Registered Manager will ensure that any changes to this policy are communicated to relevant staff. Where changes affect individuals, representatives or other stakeholders, these changes will be communicated in an accessible and timely way.

Evidence of policy review, staff communication and any associated training will be retained as part of the service’s quality assurance records.

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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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