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Regulated Activities Compliance Policy

1. Introduction

Our Home Care business is committed to full compliance with the regulations governing Regulated Activities under the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA). We ensure that all care and support services provided to individuals are safe, effective, person-centred, and in line with the legal requirements set out by Care Inspectorate Wales (CIW).

This policy is informed by and must be read alongside: the Regulation and Inspection of Social Care (Wales) Act 2016; the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended); Welsh Government Statutory Guidance for providers of care home and domiciliary support services (last updated 27 March 2024); CIW guidance on notifications (CIW Online), Responsible Individual statutory visits, and Annual Returns; and Social Care Wales codes of professional practice and duty of candour guidance.

This policy applies to all employees, including Care Assistants, Senior Carers, Coordinators, Managers, and Directors. It provides guidance for CIW inspectors on how we manage regulated activities efficiently while ensuring quality, safety, and continuous improvement in service delivery.

2. Key Principles of Regulated Activities Compliance

We adhere to the following principles to ensure compliance with RISCA and CIW standards:

• Person-Centred Care: Care is tailored to the needs and preferences of each service user, promoting independence, dignity, and choice.
• Quality and Safety: We maintain the highest standards in delivering care, ensuring the well-being of service users at all times.
• Workforce Competency: All staff are trained, qualified, and competent to provide care in compliance with CIW Workforce Standards.
• Governance and Accountability: We have a clear organisational structure with effective leadership and oversight.
• Continuous Improvement: We regularly review and improve our services to ensure best practices are maintained.

3. How We Manage Regulated Activities Efficiently

A. Statutory Notifications to CIW (CIW Online)

We maintain an effective system to identify, record and submit statutory notifications to CIW within required timescales, using CIW Online, in line with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended). Notifications are logged, quality-checked by management, and trended for learning through our governance and quality review processes.

For Staff: Report without delay any incident, allegation, safeguarding concern, complaint or other event that may require notification. Record factual details in the incident/concern record and escalate to the Registered Manager/on-call manager.

For Managers/RI: Determine whether a CIW notification is required, submit via CIW Online, retain evidence of submission, and include learning in six-monthly quality of care reviews.

For CIW Inspectors: A notification log, related investigations, outcomes and evidence of CIW Online submissions are available.

B. Registration and Compliance with CIW

Our service is registered with Care Inspectorate Wales (CIW) and complies with all conditions of registration, ensuring that we meet the legal requirements for providing regulated activities.

For Staff:

• Understand the scope of regulated activities under RISCA 2016.
• Follow policies and procedures aligned with CIW’s Code of Practice.
• Report any issues related to compliance or service delivery to senior management.

For CIW Inspectors:

• Registration documents, service statements, and inspection reports are available for review.
• We maintain records of compliance monitoring and annual service evaluations.

C. Person-Centred Care and Support Planning

Each service user receives a Comprehensive Needs Assessment (CNA) and a Personalised Care Plan (PCP) to ensure care is tailored to their specific needs, preferences, and health conditions.

For Staff:

• Deliver care as per the service user’s PCP, updating plans as needed.
• Involve service users in decisions about their care and support.
• Record and report changes in health, behaviour, or needs through the Service Review Process (SRP).

For CIW Inspectors:

• Care plans demonstrate individualised, outcome-focused care.
• Evidence of regular care reviews and adjustments is available.

D. Quality Assurance and Monitoring

We have a Quality Assurance Framework (QAF) in place to monitor, evaluate, and improve service delivery.

For Staff:

• Participate in Quality and Safety Audits (QSA) conducted quarterly.
• Report service user feedback and concerns via the Service User Feedback System (SUFS).
• Follow procedures for escalating and resolving complaints efficiently.

For CIW Inspectors:

• Documented audits and quality assurance reports are available for review.
• Service improvement plans show how feedback leads to enhancements in care.

In addition to internal audits, the Responsible Individual (RI) ensures there are arrangements to monitor, review and improve the quality and safety of care and support, including a formal quality of care review at least every six months. This review includes analysis of aggregated data on incidents, notifiable incidents, safeguarding matters, whistleblowing, concerns and complaints, and the outcomes of record audits. A written report is produced with an assessment of standards and clear recommendations for improvement, which is actioned and tracked through governance.

E. Safe Staffing and Workforce Development

We ensure that all staff meet the Social Care Wales (SCW) registration requirements and receive ongoing training.

For Staff:

• Complete Mandatory Training (MT) in safeguarding, moving and handling, medication administration, and dementia care.
• Undergo Annual Competency Assessments (ACA) to ensure skills remain up to date.
• Maintain professional conduct in line with the Code of Professional Practice for Social Care (CPPSC).

For CIW Inspectors:

• Training records confirm all staff meet required competency standards.
• Supervision logs and appraisals demonstrate continuous professional development.

F. Safeguarding and Protection from Harm

We follow All Wales Safeguarding Procedures to protect service users from abuse, neglect, or exploitation.

For Staff:

• Recognise and report safeguarding concerns through the Safeguarding Referral Process (SRP).
• Complete Safeguarding Adults Level 2 (SAL2) training.
• Adhere to the Whistleblowing Policy (WP) to report concerns safely.

For CIW Inspectors:

• Safeguarding logs show how concerns are reported and addressed.
• Training records confirm compliance with safeguarding protocols.

G. Safe Medication Management

We have strict protocols for the safe storage, administration, and disposal of medication in line with current Wales medicines governance requirements, relevant national guidance (including NICE where applicable), and our Medication Policy and competency framework.

For Staff:

• Administer medication only if trained and competency-checked through Medication Administration Competency (MAC).
• Record all medication administration in the Electronic Medication Administration Record (eMAR) system.
• Report medication errors immediately via the Medication Incident Reporting System (MIRS).

For CIW Inspectors:

• eMAR logs provide a clear record of medication administration.
• Audits confirm compliance with Medication Handling Policies (MHP).

H. Infection Prevention and Control (IPC)

We follow rigorous Infection Prevention and Control (IPC) protocols to prevent the spread of infections.

For Staff:

• Wear Personal Protective Equipment (PPE) as required.
• Follow Hand Hygiene Standards (HHS) and clean care environments regularly.
• Dispose of clinical waste in designated Infectious Waste Bins (IWB).

For CIW Inspectors:

• Infection control policies and procedures are reviewed and updated regularly.
• Staff training logs confirm compliance with infection control measures.

I. Emergency Preparedness and Incident Management

We have robust plans in place to respond to emergencies, unexpected incidents, and service disruptions.

For Staff:

• Follow the Emergency Response Plan (ERP) for medical emergencies, fire safety, and service disruptions.
• Ensure Service User Emergency Contact (SUEC) details are kept up to date.
• Report incidents using the Critical Incident Report (CIR) process.

For CIW Inspectors:

• Incident reports demonstrate how risks are managed and mitigated.
• Business continuity plans are reviewed and tested annually.

Domiciliary Support Service: Schedule of Visits & Time Recording

We operate systems that comply with the domiciliary support service requirements, including maintaining a schedule of visits for each domiciliary care worker that clearly delineates travel time, visit time and (where applicable) rest breaks. Visit times are planned to be sufficient to deliver care and support in line with each person’s personal plan, and we keep an accurate record of actual travel and visit time to assure safe delivery and fair working practices.

For Staff: Access your schedule of visits, record actual arrival/departure times accurately, and report where allocated times are not sufficient to deliver the personal plan safely.

For Managers: Ensure schedules are issued, monitored, and reviewed; investigate missed/shortened visits and take corrective action; and analyse trends as part of quality assurance.

4. Governance and Continuous Improvement

We have a governance structure that ensures accountability, transparency, and continuous service improvement.

The Responsible Individual completes and records statutory visits to the regulated service in line with CIW expectations. Each visit is documented with findings, evidence reviewed, feedback gathered, and required actions with owners and timescales. Actions are monitored through governance until closed.

What We Do:

• Conduct Quarterly Compliance Audits (QCA) to monitor adherence to regulations.
• Hold Senior Leadership Meetings (SLM) to review service performance.
• Use Satisfaction Surveys (SS) to gather feedback from service users and families.

For CIW Inspectors:

• Evidence of robust governance, compliance monitoring, and service evaluations is available for review.
• Policies and procedures are regularly updated to align with new CIW standards.

Duty of Candour (Openness and transparency)

We act in an open and transparent way with individuals receiving care and support and (where appropriate) their representatives. When things go wrong we explain what happened in an accessible way, provide updates on reviews/investigations, offer an apology where appropriate, and record actions taken to reduce the risk of recurrence. Managers support staff to meet professional expectations on candour, and any concerns about obstructing candour are investigated and managed appropriately.

Records management and audit trail

We maintain effective systems for the creation, accuracy, completeness, retention and secure storage of records required for the regulated service. Where records are electronic, access is controlled, staff have individual logins, and an audit trail identifies entries and amendments. Record audits form part of the RI’s quality review arrangements and are used to drive improvements.

Written guide to the service (information at commencement)

We provide each individual (and where appropriate their representative/commissioner) with an up-to-date written guide to the service, reviewed at least annually. The guide explains what the service provides, how care is delivered, charges/terms, how to raise concerns/complaints, and how to escalate if dissatisfied. The guide is provided in an accessible format (for example, easy read, large print, preferred language) and staff support individuals to understand it.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to ensure compliance with CIW standards.
• Annual Reviews: Full compliance check against Regulated Activities Regulations.
• The RI prepares the statement of compliance that forms part of the provider’s Annual Return submission to CIW. The statement of compliance is informed by the RI’s quality of care review reports and the provider’s quality assurance evidence. Annual Return submission deadlines, evidence sources and approvals are diarised and tracked to completion.
• Staff Supervisions & Appraisals: Carried out every six months to maintain high care standards.

Learning from complaints, concerns, safeguarding, incidents and whistleblowing is aggregated, trended and reviewed within the RI quality of care review cycle, and shared with staff to improve practice.

6. Conclusion

We are dedicated to providing safe, high-quality, and person-centred care in full compliance with CIW regulations and RISCA standards. This policy ensures that our regulated activities meet the highest standards of safety, accountability, and continuous improvement.

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