DC11-Safe Care and Treatment Policy

Registration Number: {{org_field_registration_no}}

Safe Care and Treatment Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} delivers safe, effective, and high-quality care in accordance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 12. We are committed to preventing harm, reducing risks, and continuously improving care standards to enhance the well-being of service users.

This policy outlines our structured approach to managing safe care and treatment efficiently while complying with Care Quality Commission (CQC) requirements and best practice guidelines.

2. Scope

This policy applies to:

All domiciliary care staff, including care workers, supervisors, and management.
Service users and their families, ensuring they receive high-quality and risk-free care.
External healthcare professionals, who collaborate with us to provide safe care services.

It covers:

Legal and regulatory requirements for safe care.
Risk assessment and management.
Medication safety and administration.
Infection prevention and control.
Staff training and competency.
Monitoring, incident reporting, and continuous improvement.

3. Legal and Regulatory Framework

This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including (but not limited to):

Regulation 12 – Safe care and treatment (risk assessment/mitigation; safe premises/equipment; medicines management; infection prevention and control; safe handover/shared care).
Regulation 17 – Good governance (robust systems and audits to assess, monitor and improve safety and quality).
Regulation 18 – Staffing (sufficient numbers of suitably qualified, competent, skilled and experienced staff).
Regulation 20 – Duty of candour (openness and transparency when things go wrong).
Regulation 13 – Safeguarding service users from abuse and improper treatment (including timely escalation and reporting).
Regulation 11 – Need for consent (including Mental Capacity Act decision-making and best-interest processes).

This policy also links to:

Care Quality Commission (Registration) Regulations 2009 (statutory notifications to CQC).
Care Act 2014 safeguarding duties and local authority safeguarding procedures.
Mental Capacity Act 2005 and associated guidance for capacity assessments and best-interest decisions.
Health and Safety at Work etc. Act 1974, RIDDOR 2013, COSHH 2002, and safe systems for lone working in the community.
Data Protection Act 2018 / UK GDPR for safe, lawful handling and sharing of information for care.
Current UKHSA/NHS infection prevention and control guidance relevant to care in people’s homes.

We also map evidence for this policy to the CQC assessment framework, including the “Safe” quality statements (and other relevant statements such as governance, learning culture, and risk management).

4. Risk Assessment and Management

To ensure safe care, we implement:

Comprehensive risk assessments for each service user upon care commencement.
Regular risk reviews, updated when health conditions change.
Personalised care plans, addressing individual safety needs.
Use of assistive equipment, such as hoists and mobility aids, to reduce fall risks.
Emergency response plans, detailing steps to follow in case of critical incidents.

Domiciliary-care specific risk assessment requirements

In addition to general health risks, risk assessments and care plans must specifically consider (where relevant):

Falls risk, mobility and transfers (including safe moving and handling in the person’s home environment).
Skin integrity/pressure ulcer risk, continence/catheter care risks, nutrition/hydration, choking/aspiration risk.
Medicines risks (including self-administration, PRN medicines, allergies, side effects, and storage risks in the home).
Infection risks and household environmental factors (cleanliness, pets, waste disposal, outbreaks).
Fire safety/home environment risks (trip hazards, smoking, oxygen use, hoarding risks where relevant).
Lone working and personal safety of staff, including escalation when staff feel unsafe to deliver care.

Review standard: Risk assessments must be reviewed at least annually, and immediately when there is a change in the person’s condition, environment, medicines, or after an incident/near miss.

Escalation: Where risks cannot be safely mitigated within our competence and resources, we will escalate to the relevant clinician/commissioner/family (as appropriate) and consider whether care should be paused/adjusted until safe arrangements are confirmed.

5. Medication Safety and Administration

{{org_field_name}} ensures safe medication management through:

Strict adherence to MAR (Medication Administration Records) for accurate documentation.
Training staff in safe medication handling, administration, and storage.
Regular audits of medication procedures, ensuring compliance with regulatory standards.
Clear protocols for reporting medication errors and adverse drug reactions.
Service user education on medication management, promoting self-administration where appropriate.

5.1 Self-administration and consent

We will assess and record whether the person can self-administer medicines safely. Where support is required, we will document the agreed level of support (prompting, assisting, or administering) and ensure consent is valid and reviewed. If capacity is in doubt, Mental Capacity Act processes will be followed and best-interest decisions recorded.

5.2 Ordering, storage, transport and disposal

Staff must follow the care plan for ordering/collection arrangements and ensure medicines are stored as directed (including fridge requirements where applicable). Medicines must be kept secure within the home where risks are identified (e.g., children/visitors/cognitive impairment). We will support safe return/disposal of unwanted medicines via the community pharmacy (not domestic waste), unless local arrangements state otherwise.

5.3 Administration standards (including PRN and “when required”)

PRN medicines must have clear written guidance in the care plan (indication, dose, minimum interval, maximum daily dose, and when to seek clinical advice). Staff must record the reason for PRN administration and the outcome/effect where appropriate.

5.4 Controlled drugs and high-risk medicines

Where controlled drugs or other high-risk medicines are supported, we will apply enhanced checks, recording and escalation (including immediate reporting of discrepancies, missing items, or suspected diversion).

5.5 Recording on MAR and managing missed/refused doses

Staff must record administration immediately on the MAR using agreed codes, and document and escalate missed/refused doses according to the care plan (including contacting the prescriber/pharmacy/111/999 where clinically indicated).

5.6 Medication incidents, learning and duty of candour

Any medication error/near miss/adverse reaction must be: (1) made safe immediately, (2) reported via the incident system, (3) escalated to a manager without delay, (4) referred for clinical advice as required, (5) reviewed for learning and trend analysis. Where the incident meets the threshold for duty of candour, we will follow our duty of candour process.

6. Infection Prevention and Control (IPC) Measures

To safeguard service users and staff, {{org_field_name}} implements:

Hand hygiene training and availability of PPE (Personal Protective Equipment).
Regular sanitisation of care environments and safe disposal of clinical waste.
Protocols for managing infectious outbreaks, ensuring continuity of care.
Vaccination programs for staff, including flu and COVID-19 immunisation.

6.1 Standard precautions in people’s homes

Staff will apply standard precautions at every visit, including hand hygiene, appropriate PPE based on risk assessment, safe management of linen, safe waste handling, and safe cleaning of reusable equipment.

6.2 Managing suspected/confirmed infection and outbreaks

Where a person has suspected or confirmed infection, staff will follow current UKHSA/NHS guidance and the person’s care plan, including: enhanced PPE if required, minimising cross-contamination, clear instructions for cleaning and waste, and prompt escalation to managers/health professionals.

6.3 IPC training, audit and assurance

IPC competence will be checked in supervision and spot checks. We will complete IPC audits and act on findings, including refresher training and supply checks (PPE availability and correct use).

6.4 Vaccination

We will support staff access to recommended vaccinations (e.g., seasonal influenza and COVID-19 where advised) and will risk assess deployment for outbreaks to protect people at increased risk.

7. Staff Training and Competency

To maintain high standards, all care workers:

Complete mandatory induction training on safe care and treatment.
Attend annual refresher training in infection control, medication safety, and risk management.
Receive supervised competency assessments before performing high-risk care tasks.
Are encouraged to participate in continuous professional development (CPD).

Safe staffing and deployment

We will plan and review staffing levels, visit timing, and travel arrangements to ensure calls can be delivered safely and without rushing. We will not allocate tasks beyond a worker’s assessed competence.

High-risk task sign-off

Staff must be signed off as competent (with documented observation and reassessment) before undertaking higher risk activities such as medicines administration, moving and handling with equipment, catheter care (if provided), and enhanced infection control precautions.

8. Incident Reporting and Learning from Mistakes

{{org_field_name}} promotes atransparent, no-blame culture in reporting incidents by:

Encouraging staff to report accidents, near-misses, and safeguarding concerns.
Investigating all incidents thoroughly and documenting corrective actions.
Conducting root cause analyses to prevent reoccurrence of safety issues.
Sharing learning outcomes with staff to promote continuous improvement.

Safeguarding and external reporting

Any allegation or suspicion of abuse or neglect will be escalated immediately in line with safeguarding procedures, including referral to the local authority safeguarding team and, where required, statutory notification to CQC.

Safety governance

Trends from incidents/near misses (including medicines and IPC) will be reviewed at least quarterly by management, with actions, owners, deadlines, and evidence of completion recorded.

9. Duty of Candour (Regulation 20)

We act in an open and transparent way with people receiving care and/or their representatives. Where a notifiable safety incident occurs, we will:

Notify the person (or relevant person) as soon as reasonably practicable.
Provide a truthful account of what is known at the time, including what further enquiries will take place.
Offer an apology and appropriate support.
Provide written follow-up of the verbal notification.
Keep a clear record of all duty of candour actions taken and ensure learning is embedded.

Managers are responsible for determining duty of candour thresholds and ensuring staff are supported to apply the process consistently.

10. Statutory Notifications to CQC (Registration Regulations 2009)

We will submit statutory notifications to CQC within required timescales for notifiable events and incidents, including (where applicable): deaths, serious injuries, allegations of abuse, events that stop the service running safely, and other notifiable incidents as defined in the CQC Registration Regulations and CQC guidance.

The Registered Manager (or delegate) is responsible for ensuring notifications are made, records retained, and learning actions tracked.

11. Monitoring, Evaluation, and Continuous Improvement

To uphold safety standards, we:

Maintain a safety audit programme (e.g., medicines/MAR audit, incident trend review, IPC audit, care plan/risk assessment audit, competency/spot checks) with documented actions and follow-up.
Review quality and safety information against CQC’s assessment framework quality statements, ensuring evidence is current, triangulated and outcomes-focused.
Use complaints, compliments, feedback and incidents to evidence learning and improvement, and communicate changes to staff.
Ensure management reviews consider safeguarding, duty of candour, notifications, staffing safety and service continuity risks.

12. Policy Review and Updates

This policy is reviewed annually or sooner if:

Internal audits identify the need for policy improvements.

Legislative or regulatory changes impact its content.

CQC or local authority feedback requires adjustments.

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.