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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Regulatory Compliance with the Care Inspectorate and Statutory Requirements Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} operates in full compliance with the Care Inspectorate, Scottish social care legislation, the Health and Social Care Standards, the SSSC Codes of Practice, and all other relevant statutory and regulatory requirements that apply to Care at Home services in Scotland. As a registered home care provider, we are legally required to meet all applicable regulatory and statutory obligations, ensuring that our services promote the wellbeing, rights, and dignity of the people we support.

This policy supports a rights-based, person-led and outcome-focused approach to care and support. It ensures that regulatory compliance is not treated as a paperwork exercise, but as a means of promoting safe, compassionate, consistent and high-quality care for people receiving support in their own homes.

This policy outlines:

• Our commitment to continuous compliance with Care Inspectorate regulations.
• The responsibilities of management and staff in upholding regulatory standards.
• Processes for monitoring, reporting, and improving service quality.
• How we manage inspections, audits, and feedback effectively.

2. Scope

This policy applies to:

• All employees, including care workers, supervisors, and management.
• Volunteers, agency staff, and contractors involved in service delivery.
• Students, apprentices, temporary workers and any other person undertaking work or placement activity within the service.
• The registered provider, responsible individual, registered manager and any person involved in governance, quality assurance, supervision or oversight of the service.
• Individuals receiving care and their families, ensuring they understand their rights.
• External regulatory bodies and stakeholders, including local authorities and healthcare partners.

3. Legal and Regulatory Framework

{{org_field_name}} will comply with all legislation, regulations, standards and guidance relevant to the operation of a registered Care at Home service in Scotland. This includes, but is not limited to:

• Public Services Reform (Scotland) Act 2010 – establishing Social Care and Social Work Improvement Scotland, known as the Care Inspectorate, and setting out the regulatory framework for care services.
• Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) – including requirements relating to welfare of people using services, personal plans, fitness of providers, managers and employees, staffing, complaints and offences.
• Social Care and Social Work Improvement Scotland (Registration) Regulations 2011 (SSI 2011/28) – including requirements relating to registration, records and certificates of registration.
• Public Services Reform (Social Services Inspections) (Scotland) Regulations 2011 – setting out inspection arrangements and powers.
• Health and Social Care Standards: My support, my life – the national standards describing what people should experience when using health, social care or social work services in Scotland.
• Care Inspectorate Quality Framework for Support Services (Care at Home, including Supported Living Models of Support) – used for self-evaluation, scrutiny and improvement support.
• SSSC Codes of Practice for Social Service Workers and Employers 2024 – setting out the standards of practice and behaviour expected of social service workers and employers.
• Health and Care (Staffing) (Scotland) Act 2019 and statutory guidance – requiring appropriate staffing for the health, wellbeing and safety of people using care services, safe and high-quality care, and staff wellbeing.
• Adult Support and Protection (Scotland) Act 2007 – setting out duties to identify, report and respond to adults at risk of harm.
• Adults with Incapacity (Scotland) Act 2000 – setting out principles and legal safeguards where an adult lacks capacity to make some or all decisions.
• Mental Health (Care and Treatment) (Scotland) Act 2003 – where relevant to people’s rights, safeguards, care and treatment.
• Human Rights Act 1998 – ensuring people’s rights, dignity, privacy, family life, autonomy and freedoms are respected.
• Equality Act 2010 – requiring equality, non-discrimination and reasonable adjustments.
• Data Protection Act 2018 and UK GDPR – governing the lawful, fair, secure and transparent processing of personal data.
• Public Interest Disclosure Act 1998 – protecting workers who raise whistleblowing concerns.
• Protection of Vulnerable Groups (Scotland) Act 2007, as amended – supporting safe recruitment and barring arrangements for regulated work with protected adults.
• Health and Safety at Work etc. Act 1974 and associated regulations – requiring safe working arrangements for staff, people supported and others affected by the service.
• Care Inspectorate notification and record keeping guidance for adult services, including current notification categories and reporting routes.
• Any other current legislation, statutory guidance, national guidance, local adult protection procedures, commissioning requirements and contractual requirements relevant to the service.

4. Registration with the Care Inspectorate

{{org_field_name}} operates as a registered home care provider with the Care Inspectorate and must:

• Maintain a valid Care Inspectorate registration and comply with all conditions of registration.
• Display or make available the certificate of registration as required.
• Ensure the service operates only within the registered service type, aims and objectives, geographical area and conditions approved by the Care Inspectorate.
• Notify the Care Inspectorate of changes to registration details, ownership, legal entity, service delivery arrangements, manager, provider fitness or other notifiable matters as required.
• Apply for a variation to registration before making any regulated change that requires Care Inspectorate approval.
• Submit annual returns, self-evaluation information and any other required information accurately and within the required timescales.
• Ensure the Care Inspectorate has access to records, staff, people supported and premises as required for inspection, complaint investigation, enforcement or regulatory activity.
• Maintain contingency arrangements to support continuity of care if the service is disrupted, transferred, closed or unable to operate safely.

4.1 Aims, Objectives and Service Information

{{org_field_name}} will maintain a clear, accurate and up-to-date statement of aims and objectives for the service. This will explain what the service provides, who the service is for, the geographical area covered, any limits to the service, contact arrangements, emergency or out-of-hours arrangements, and how people can raise concerns or complaints.

People receiving support, their representatives and relevant professionals will be given accessible information about the service before or at the start of support. Information will be provided in a format and language that the person can understand wherever reasonably practicable.

5. Meeting the Health and Social Care Standards

{{org_field_name}} will use the Health and Social Care Standards to guide the planning, delivery, review and improvement of care and support. The Standards are rights-based, person-led and outcome-focused and apply to the experiences people should have when using health, social care and social work services in Scotland.

We will ensure that people experience care and support that reflects the following principles:

• Dignity and respect – people are treated with kindness, compassion, dignity and respect.
• Compassion – staff respond sensitively to people’s needs, wishes, choices and circumstances.
• Be included – people are involved in decisions about their care and support, including reviews and changes.
• Responsive care and support – support is planned around the person’s assessed needs, wishes, outcomes and choices.
• Wellbeing – the service supports people’s health, safety, independence, relationships, rights and quality of life.

The Standards will be embedded in care planning, staff induction, supervision, quality assurance, audits, complaints learning, improvement planning and inspection preparation.

5.1 Personal Plans

{{org_field_name}} will ensure that every person receiving care and support has a personal plan in place within 28 days of starting to use the service, in accordance with Regulation 5 of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011.

The personal plan will set out how the person’s health, welfare, safety, assessed needs, wishes, choices, outcomes, communication needs, risks and preferences will be met. The plan will be developed with the person and, where appropriate, their representative, family, carers, advocate and relevant professionals.

Personal plans will be reviewed with the person and relevant others at least once every six months, or sooner where there is a change in the person’s needs, wishes, risks, health, medication, support arrangements, capacity, outcomes or circumstances.

Personal planning will follow a proportionate and outcome-focused approach, including assessment, risk assessment, care and support planning, daily evaluation, review and quality assurance. Plans will be accessible to the person in a format they can understand and will be used by staff to guide consistent, safe and person-centred support.

6. Compliance Monitoring and Internal Audits

To ensure ongoing compliance, {{org_field_name}} implements a robust monitoring system:

• Regular audits of personal plans, risk assessments, medication records, daily notes, incident records, complaints, staff files, training records, supervision records and service user feedback.
• Direct observations, spot checks, competency assessments and supervision visits to ensure staff practice is safe, respectful and consistent with people’s personal plans.
• Review and analysis of accidents, incidents, near misses, missed or late visits, safeguarding concerns, complaints, compliments and Care Inspectorate notifications.
• Regular feedback from people supported, families, representatives, staff, commissioners and partner professionals.
• Self-evaluation using the Care Inspectorate quality framework, including evidence of what is working well, what needs to improve and what action will be taken.
• Improvement plans with named responsible persons, timescales, progress updates and evidence of completed actions.
• Governance meetings where compliance trends, risk, staffing, quality indicators and improvement actions are reviewed.
• Learning from inspections, complaints, incidents, adult protection activity, SSSC referrals, staff feedback and external guidance.

7. Care Inspectorate Inspections

The Care Inspectorate conducts planned and unannounced inspections to assess:

• Care quality and person-centred support.
• Staff training, recruitment, and workforce management.
• Record-keeping, policies, and procedures compliance.
• Safeguarding and risk management.
• Leadership, governance, and continuous improvement efforts.

Inspections will be approached openly and transparently. Staff must cooperate with inspectors, provide accurate information, make relevant records available, and support people receiving care, relatives, representatives and staff to share their experiences if they wish to do so.

How We Manage Inspections Efficiently

• Pre-Inspection Preparation: We maintain up-to-date records, including care plans, risk assessments, staff training logs, and policies.
• Staff Readiness: All employees are briefed on inspection expectations and trained in compliance-related procedures.
• Service User and Family Engagement: We encourage open dialogue between inspectors and the people we support.
• Action Planning: Following inspections, complaints, regulatory contact or enforcement activity, we will review all findings, requirements, areas for improvement and recommendations. We will prepare a clear improvement action plan, allocate responsibility, set timescales, monitor progress and provide updates or evidence to the Care Inspectorate where required.

7.1 Regulatory Enforcement and Improvement Notices

Where the Care Inspectorate identifies concerns about the quality, safety or regulatory compliance of the service, {{org_field_name}} will respond promptly, transparently and effectively.

Where a requirement, area for improvement, improvement notice, condition, proposal to cancel registration or other enforcement action is issued, the registered provider and registered manager will:

• review the regulatory finding immediately;
• assess any immediate risk to people supported;
• take urgent action where health, welfare or safety may be affected;
• prepare and implement an improvement action plan;
• communicate with staff, people supported, representatives, commissioners and partner agencies where appropriate;
• provide evidence of improvement to the Care Inspectorate within required timescales; and
• ensure learning is embedded into policy, training, supervision, quality assurance and practice.

8. Reporting Requirements and Notifications

{{org_field_name}} will notify the Care Inspectorate immediately, or within the timescale required by current Care Inspectorate guidance, when a notifiable event occurs. Notifications will be submitted through the correct Care Inspectorate system, including eForms or the digital portal, as applicable.

Notifiable events include, but are not limited to:

• accidents, incidents or injuries;
• outbreak of infectious disease;
• death of a person using the care service;
• protection concerns, including adult protection concerns and allegations of abuse or harm;
• significant equipment breakdown where this affects people’s care or safety;
• allegation of misconduct by a provider or employee;
• criminal convictions or matters that may affect the fitness of a manager, provider or worker;
• the provider becoming unfit;
• absence of the manager;
• planned refurbishment, alteration or extension of premises where applicable;
• change of registration details;
• controlled drugs incidents, where applicable;
• large scale investigation notifications where the service is involved in, or becomes aware of, relevant adult protection processes; and
• any other matter required by Care Inspectorate guidance or legislation.

All notifications will be factual, timely, accurate and recorded internally. The registered manager, or delegated senior person, will ensure that follow-up actions are completed, relevant people are informed, records are updated and any learning is included in the service improvement plan.

Where an incident also requires reporting to another body, such as the local authority adult protection team, Police Scotland, Health and Safety Executive, commissioner, SSSC, Disclosure Scotland, NHS service or Information Commissioner’s Office, this will be completed in line with the relevant procedure.

8.1 Records the Service Must Keep

{{org_field_name}} will maintain accurate, complete, up-to-date and secure records required by legislation, Care Inspectorate guidance, contractual requirements and organisational policy.

Records will include, where applicable:

• personal plans and reviews;
• assessments and risk assessments;
• daily care and support records;
• medication support records;
• accident, incident and near miss records;
• adult protection and safeguarding records;
• complaints, concerns, compliments and outcomes;
• staff recruitment, PVG, right to work, references and induction records;
• training, supervision, appraisal and competency records;
• quality assurance audits and improvement plans;
• Care Inspectorate notifications and related follow-up;
• policies, procedures and review records;
• business continuity and contingency records;
• financial transaction records where staff support people with money, shopping or property; and
• any other records required by current Care Inspectorate guidance.

Records will be stored securely, retained in line with the organisation’s retention schedule, and made available to the Care Inspectorate and other lawful authorities when required.

9. Staff Roles and Responsibilities

Management Responsibilities

The registered provider, responsible individual and registered manager are responsible for:

• ensuring the service complies with all legislation, regulations, standards, registration conditions and Care Inspectorate guidance;
• maintaining a culture of rights, dignity, compassion, inclusion, openness, learning and continuous improvement;
• ensuring safe recruitment, PVG checks, induction, training, supervision, appraisal and competency monitoring;
• ensuring staff are registered with the SSSC where required and are supported to meet registration, qualification and continuous professional learning requirements;
• ensuring staffing arrangements are suitable to meet people’s assessed needs, wishes, outcomes and risks;
• ensuring personal plans are in place, reviewed and used to guide care;
• ensuring required notifications are made to the Care Inspectorate and other bodies;
• ensuring complaints, concerns, incidents and adult protection matters are responded to appropriately;
• ensuring accurate records are maintained and available for inspection;
• ensuring improvement actions are completed and sustained; and
• referring workers to the SSSC, Disclosure Scotland or other relevant bodies where required.

Staff Responsibilities

All staff are responsible for:

• working in accordance with the Health and Social Care Standards, SSSC Codes of Practice, organisational policies and the person’s personal plan;
• treating people with dignity, kindness, compassion and respect;
• promoting people’s rights, choices, independence and personal outcomes;
• following safe practice, including medication, infection prevention, moving and assisting, lone working and risk procedures;
• maintaining accurate, factual and timely records;
• reporting accidents, incidents, near misses, concerns, complaints, adult protection matters, missed visits or changes in a person’s wellbeing promptly;
• cooperating with audits, supervision, investigations, inspections and improvement activity;
• maintaining professional boundaries and confidentiality;
• completing required training and continuous professional learning; and
• informing management of anything that may affect their fitness, competence or ability to work safely.

9.1 SSSC Codes of Practice

{{org_field_name}} will implement the SSSC Codes of Practice for Social Service Workers and Employers 2024. The Codes will be used during recruitment, induction, probation, supervision, appraisal, team meetings, reflective practice, learning and development, investigations and fitness to practise decision-making.

The service will:

• make staff aware of the SSSC Codes and their responsibility to comply with them;
• support staff to understand how the Codes apply to their role;
• inform people supported and, where appropriate, carers and representatives about the Codes and how to raise concerns;
• promote regular discussion of the Codes in supervision and team meetings;
• take account of the Codes when reviewing conduct, competence, professional boundaries, safeguarding, record-keeping, confidentiality and fitness to practise; and
• make referrals to the SSSC where a worker’s fitness to practise may be impaired.

9.2 Staffing and Safe Staffing

{{org_field_name}} will ensure, so far as reasonably practicable, that staffing arrangements are suitable to provide safe, high-quality care and support and to meet the health, wellbeing, safety, needs, wishes and outcomes of people using the service.

Staffing arrangements will take account of:

• people’s assessed needs, personal plans, preferences and outcomes;
• visit times, travel time, continuity of care and reliability of service delivery;
• staff skills, training, competence and experience;
• medication, moving and assisting, communication, dementia, mental health, palliative care or other specialist support needs;
• lone working and environmental risks;
• feedback from people supported, representatives and staff;
• incidents, missed or late visits, complaints and quality assurance findings; and
• staff wellbeing, workload and supervision needs.

The service will escalate staffing risks promptly and take action where staffing arrangements may affect people’s care, safety, rights or wellbeing.

9.3 Safe Recruitment, PVG and Fitness

{{org_field_name}} will operate safe recruitment procedures to ensure that people employed or engaged by the service are suitable to work with people receiving care and support.

Recruitment checks will include, as applicable:

• identity checks;
• right to work checks;
• application and employment history checks, including explanation of gaps;
• references;
• interview and values-based assessment;
• PVG scheme membership or appropriate Disclosure Scotland checks;
• professional registration checks, including SSSC registration where required;
• qualification and training checks; and
• assessment of conduct, competence and fitness for the role.

Staff must inform the service immediately of any matter that may affect their suitability, fitness, PVG status, SSSC registration or ability to work safely.

10. Continuous Improvement and Best Practice

{{org_field_name}} promotes a learning culture where compliance, quality assurance and feedback are used to improve outcomes for people supported.

We will:

• use the Care Inspectorate Quality Framework for Support Services (Care at Home, including Supported Living Models of Support) to support self-evaluation;
• seek, record and act on feedback from people supported, relatives, representatives, staff, commissioners and partner agencies;
• analyse incidents, complaints, missed visits, notifications, audits and inspection findings to identify themes and learning;
• maintain an improvement plan that is reviewed regularly by management;
• share learning with staff through supervision, team meetings, briefings and training;
• update policies, procedures and practice when legislation, guidance or best practice changes;
• support innovation, digital improvement and evidence-based practice where this benefits people supported; and
• ensure improvement actions lead to measurable changes in people’s experiences, outcomes, safety and wellbeing.

10.1 Complaints, Concerns and Feedback

{{org_field_name}} will ensure that people supported, relatives, representatives, advocates, staff and others can raise complaints, concerns, comments and compliments without fear of disadvantage or retaliation.

The service will:

• provide accessible information about how to complain or give feedback;
• support people to use advocacy or representation where they wish;
• acknowledge, investigate and respond to complaints in line with the Complaints and Feedback Policy;
• take immediate action where a complaint identifies risk of harm or poor care;
• inform people that they may complain directly to the Care Inspectorate at any time;
• record complaints, outcomes, learning and actions taken; and
• use complaints and feedback to improve the service.

10.2 Adult Protection and Duty to Report Harm

{{org_field_name}} will protect adults at risk of harm by ensuring that all staff understand how to identify, report, record and respond to actual or suspected harm, neglect, abuse, exploitation or poor practice.

Staff must report concerns immediately in line with the Safeguarding and Adult Protection Policy, local adult protection procedures and Care Inspectorate notification guidance. Management will ensure that referrals are made to the relevant local authority adult protection team, Police Scotland, health services, commissioners, the Care Inspectorate, SSSC, Disclosure Scotland or other relevant bodies as required.

The service will cooperate fully with adult protection inquiries, investigations, large scale investigations, case conferences, protection plans and any related regulatory activity.

10.3 Data Protection, Confidentiality and Information Sharing

{{org_field_name}} will process personal information lawfully, fairly, transparently and securely in accordance with UK GDPR, the Data Protection Act 2018, organisational policy and relevant information sharing duties.

Staff must maintain confidentiality and only access, use or share information where this is required for care delivery, safeguarding, regulatory compliance, legal obligations, contractual requirements or another lawful basis.

Information may be shared without consent where necessary to protect a person from harm, comply with the law, support adult protection processes, report notifiable events, cooperate with regulators or prevent serious risk. Decisions to share information will be recorded.

10.4 Business Continuity and Service Disruption

{{org_field_name}} will maintain contingency and business continuity arrangements to ensure, as far as reasonably practicable, continuity of care and support during disruption.

This includes arrangements for:

• staff absence, sickness or shortages;
• severe weather or travel disruption;
• infectious disease outbreaks;
• IT, telephony or electronic care planning failure;
• failure of key equipment or systems;
• emergency changes to visit schedules;
• temporary inability to deliver a planned visit; and
• service closure, transfer or serious operational disruption.

People supported, representatives, commissioners, partner agencies and the Care Inspectorate will be informed where disruption may affect care, safety or regulatory compliance.

11. Related Policies

This policy should be read alongside:

• Quality Assurance and Continuous Improvement Policy.
• Health and Safety Policy.
• Safeguarding and Adult Protection Policy.
• Training and Development Policy.
• Complaints and Feedback Policy.

12. Policy Review

This policy will be reviewed at least annually, or sooner where there are changes to legislation, Care Inspectorate guidance, SSSC requirements, Health and Social Care Standards, contractual requirements, organisational structure, service delivery, inspection findings, complaints, incidents, adult protection learning or operational risk.

The registered manager is responsible for ensuring that this policy remains current and that staff are informed of any changes. Where changes affect practice, staff will receive appropriate communication, guidance, supervision or training.

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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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