{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Spot Checks Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} conducts regular spot checks to maintain high standards of care delivery, regulatory compliance, staff performance, and service user safety. Spot checks are unannounced visits carried out by management to assess the quality of care, adherence to policies, and staff conduct in real-time.

This policy supports compliance with the following legislation and statutory guidance:

• 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 and domiciliary support service providers (last updated 27 March 2024). In particular, this policy supports the service’s governance arrangements for monitoring, reviewing and improving quality (including Regulation 8 and the Responsible Individual’s Quality of Care Review requirements).
• Social Services and Well-being (Wales) Act 2014 (well-being and person-centred practice).
• Data Protection Act 2018 / UK GDPR (confidentiality, lawful processing and secure storage).
• Health and Safety at Work etc. Act 1974 (safe working practices for staff and people supported).

2. Scope

This policy applies to:

• All employees, including care workers, supervisors, and managers.
• Service users and their families, ensuring they receive the highest level of care.
• Regulatory bodies, including CIW, as part of ongoing quality monitoring.

It covers:

• The purpose and benefits of spot checks.
• How spot checks are conducted.
• What is monitored during a spot check.
• Roles and responsibilities of staff.
• Reporting, feedback, and follow-up actions.
• Confidentiality and compliance with GDPR.

3. Purpose and Benefits of Spot Checks

Spot checks help to:

• Ensure service users receive high-quality, safe, and dignified care.
• Monitor staff performance and compliance with care plans and policies.
• Identify any training needs or areas for improvement.
• Reduce risks of neglect, abuse, or misconduct.
• Gather feedback from service users and families.
• Ensure workplace safety and infection control procedures are followed.

4. How Spot Checks Are Conducted

4.1 Frequency of Spot Checks

• Spot checks are conducted at least once per quarter for each care worker.
• Additional spot checks may be carried out:
  • If concerns are raised about a staff member’s performance.
  • Following complaints from service users or families.
  • After incidents requiring investigation.

4.2 Notification and Unannounced Visits

• Spot checks are typically unannounced to ensure an accurate assessment of real-time care delivery.
• In some cases, service users and families may be informed in advance to ensure cooperation.

4.3 Who Conducts Spot Checks?

• Registered Manager or Senior Supervisor is responsible for conducting spot checks.
• Trained Quality Assurance Officers may also carry out spot checks as part of service evaluations.

4.4 Responsible Individual statutory quarterly visits (Regulation 73)

In addition to operational spot checks completed by management, the Responsible Individual (RI) will complete an in-person visit at least once every three months in line with Regulation 73 and CIW guidance. For domiciliary support services this may include visiting a representative sample of individuals in their own home (with consent), speaking with staff, and reviewing selected records (including complaints and events). The RI visit findings will be documented and used to inform the six-monthly Quality of Care Review and service improvement planning.

5. What is Monitored During a Spot Check?

Spot checks assess:

5.1 Service User Well-being

• Is the service user safe, comfortable, and receiving appropriate care?
• Are care plans being followed correctly?
• Is the service user treated with dignity, respect, and kindness?

5.2 Staff Performance and Conduct

• Are care workers punctual and professionally presented?
• Do they follow safe moving and handling procedures?
• Are medication management and administration correctly followed?
• Are infection control procedures being adhered to?
• Is staff communication with service users and families appropriate and respectful?

5.3 Documentation and Record-Keeping

• Are care records and MAR charts updated and accurate?
• Is the service user’s daily log completed correctly?
• Are risk assessments being followed and updated as needed?

5.4 Health and Safety Compliance

• Are work environments safe, clean, and free from hazards?
• Are PPE and infection control measures being used correctly?
• Are any hazards reported and addressed appropriately?

6. Roles and Responsibilities

6.1 Responsibilities of the Registered Manager

• Oversee and schedule spot checks for all care workers.
• Ensure findings from spot checks are documented and reviewed.
• Address any concerns or incidents immediately.
• Ensure any training needs identified during spot checks are actioned.

6.2 Responsibilities of Care Staff

• Comply with all workplace policies and procedures.
• Follow care plans and provide high-quality service at all times.
• Engage positively with spot checks as a tool for professional development.
• Cooperate with supervisors during spot checks.

6.3 Responsibilities of Service Users and Families

• Provide feedback about care delivery.
• Report any concerns about service quality or staff conduct.

7. Reporting, Feedback, and Follow-Up Actions

7.1 Documenting Spot Check Findings

• A Spot Check Report Form must be completed after every visit.
• Reports include:
  • Date and time of the visit.
  • Names of the care worker and service user.
  • Observations on care quality and staff performance.
  • Any concerns or areas for improvement.
  • Action plan for training or corrective measures (if required).
  • Whether the visit forms part of an RI quarterly visit (where applicable).
  • Numbers of individuals / representatives spoken with and numbers of staff spoken with (where applicable).
  • A summary of feedback gathered (including communication needs and preferred language where relevant).
  • Key observations and the conclusion/outcome rating (e.g., compliant / minor shortfalls / significant concern) and who has been informed.
  • Escalations made on the day (e.g., safeguarding advice sought, manager on-call contacted).

7.2 Providing Feedback to Staff

• Care workers receive constructive feedback after every spot check.
• Positive feedback is recognised to encourage good practice.
• Any areas of concern are discussed professionally and supportively.

7.3 Addressing Concerns and Non-Compliance

• If a staff member fails to meet standards, they may be subject to:
  • Additional training or supervision.
  • A formal performance review.
  • Disciplinary procedures if serious misconduct is found.
• Service users and families are informed if their concerns have been addressed.

7.4 Safeguarding, notifiable incidents and escalation

If a spot check identifies actual or suspected abuse, neglect, improper treatment, serious poor practice, medication error causing harm, or immediate safety risk, the observer will:

1. take immediate protective action to reduce risk,
2. inform the Registered Manager (or on-call manager) the same day,
3. follow the organisation’s Safeguarding and Incident Reporting procedures, including referral to the relevant local authority safeguarding process where required, and
4. ensure any event meeting the legal threshold for notification to CIW is reported without delay using the CIW notification process.
   Learning from these matters will be captured in the service’s quality monitoring and improvement arrangements and considered within the Responsible Individual’s quality review cycle.

8. Confidentiality and GDPR Compliance

Information gathered during spot checks will be processed lawfully, fairly and transparently, limited to what is necessary for quality and safety monitoring, and stored securely in line with UK GDPR / Data Protection Act 2018 and the Confidentiality and Data Protection Policy (DCW34). Records will be retained only for the required retention period, with access restricted to those who need it for supervision, governance, safeguarding, or regulatory purposes (including CIW inspection activity where required).

9. Monitoring and Compliance

The Registered Manager is responsible for ensuring this policy is implemented and that spot check activity forms part of the service’s Regulation 8 arrangements for monitoring, reviewing and improving the quality and safety of care and support. Spot check findings will be collated and analysed alongside feedback, incidents, safeguarding matters, concerns, whistleblowing and complaints to identify themes, training needs and service improvements.

The Responsible Individual will receive a summary of spot check outcomes to inform the six-monthly Quality of Care Review (Regulation 80) and resulting recommendations and improvement actions. Actions will be tracked to completion and reviewed for impact. Spot check records will be maintained in a way that provides clear evidence for CIW inspections and the published inspection ratings approach now applied to domiciliary support services.

10. Related Policies

This policy should be read in conjunction with:

• Staff Conduct and Code of Ethics Policy (DCW28).
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13).
• Health and Safety at Work Policy (DCW16).
• Medication Management and Administration Policy (DCW21).
• Risk Management and Assessment Policy (DCW18).

11. Policy Review

This policy will be reviewed annually or sooner if required by legislative updates, CIW guidance, or operational needs.

---

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.