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HCS55-Compliance with Scottish Care Service Regulation Policy

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Registration Number: {{org_field_registration_no}}

Compliance with Scottish Care Service Regulation Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} operates in full compliance with the current legal and regulatory framework for Care at Home services in Scotland. This includes the Regulation of Care (Scotland) Act 2001, the Public Services Reform (Scotland) Act 2010, the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, the Health and Care (Staffing) (Scotland) Act 2019, the Health and Social Care Standards, Care Inspectorate requirements and quality frameworks, and the Scottish Social Services Council (SSSC) Codes of Practice.

This policy sets out how {{org_field_name}} maintains safe, effective, compassionate, rights-based and person-led care and support, and how the service monitors, evidences and improves compliance with legal, regulatory, professional and contractual expectations.

This policy ensures that:

2. Scope

This policy applies to:

3. Legal and Regulatory Framework

This policy aligns with the current legal, regulatory and best-practice framework for Care at Home services in Scotland, including but not limited to:

{{org_field_name}} will review this policy whenever legislation, statutory guidance, Care Inspectorate guidance, SSSC requirements or national best practice changes.

4. Registration and Regulatory Compliance

4.1 Registration with the Care Inspectorate

{{org_field_name}} is a registered provider with the Care Inspectorate, ensuring compliance with all regulatory expectations. We:

The Registered Manager will maintain an up-to-date register of Care Inspectorate notifications submitted by the service, including the date of the event, date of notification, category of notification, summary of action taken, follow-up required and evidence of closure. This register will be reviewed as part of quality assurance and governance processes.

4.2 Compliance with SSSC Registration, Codes of Practice and Workforce Regulation

4.3 Fit Provider, Fit Manager and Governance

{{org_field_name}} will ensure that the provider, Registered Manager and any person with management or governance responsibility remain fit to provide, manage and oversee the service. This includes maintaining appropriate qualifications, experience, competence, integrity, health, professional registration where required, and capacity to comply with all legal and regulatory duties.

The organisation will maintain clear governance arrangements for monitoring compliance, including named responsibility for Care Inspectorate registration, SSSC registration monitoring, complaints, incidents, adult protection, staffing, training, quality assurance, notifications, data protection, health and safety and policy review.

Any matter that may affect the fitness of the provider, manager or service will be escalated promptly to the appropriate senior person and notified to the Care Inspectorate or other relevant authority where required.

5. Quality Assurance and Monitoring Compliance

5.1 Internal Audits, Self-Evaluation and Quality Assurance

To maintain compliance and drive improvement, {{org_field_name}} will operate a structured quality assurance and self-evaluation system. This will include:

5.2 Care Inspectorate Inspections and Regulatory Scrutiny

{{org_field_name}} will cooperate fully, openly and promptly with Care Inspectorate inspections, investigations, information requests, improvement activity and enforcement processes.

The Registered Manager will ensure that accurate and up-to-date evidence is available, including registration documents, policies, staff records, training records, supervision records, personal plans, risk assessments, medication records, incident and accident records, complaints records, notification records, quality assurance audits, improvement plans and evidence of outcomes for people.

Staff must answer inspectors truthfully and professionally and must never conceal, alter or destroy records or discourage people, carers or staff from speaking openly with inspectors.

Inspection findings, areas for improvement, requirements or enforcement actions will be reviewed by the Registered Manager and senior leadership. A written action plan will be developed, implemented, monitored and reviewed for effectiveness.

People we support, carers, representatives and staff will be informed of inspection outcomes in an accessible way, where appropriate, and the service will use inspection learning to improve care and support.

5.3 Records, Notifications and Evidence of Compliance

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

Records must demonstrate that care and support is planned, delivered, reviewed and improved in line with the person’s assessed needs, wishes, choices, outcomes, risks and rights. Records must be factual, respectful, dated, attributable to the person making the entry, and completed as soon as practicable.

The service will maintain records relating to: people using the service; personal plans; risk assessments; reviews; medication support; financial transactions undertaken on behalf of people; incidents and accidents; complaints; adult protection; Care Inspectorate notifications; staff recruitment; PVG and disclosure checks; SSSC registration; training; supervision; appraisal; quality assurance; and business continuity.

The Registered Manager will ensure that all required Care Inspectorate notifications are submitted within required timescales and that follow-up action is recorded and monitored.

6. Delivering Safe and Effective Care

6.1 Person-Centred, Rights-Based and Outcome-Focused Care

All care and support provided by {{org_field_name}} will be person-centred, rights-based, outcome-focused and consistent with the Health and Social Care Standards. People will be treated with dignity, compassion, kindness and respect and will be recognised as experts in their own experiences, needs and wishes.

Care and support will be planned and delivered in partnership with the person, and where appropriate and lawful, their family, carers, representatives, attorneys, guardians, advocates and relevant professionals.

People will be supported to make informed choices, exercise control over their daily lives, communicate in their preferred way, maintain privacy and dignity, and participate in decisions about their care and support.

Where a person has reduced capacity or requires decision-making support, staff will follow the Adults with Incapacity (Scotland) Act 2000, relevant codes of practice, guardianship or power of attorney arrangements, and the principles of benefit, least restriction, taking account of the person’s wishes and involving relevant others.

The service will respect the person’s right to take positive risks. Risks will be assessed and managed in a way that balances safety with autonomy, independence, choice, dignity and quality of life. Restrictions must be lawful, necessary, proportionate, the least restrictive option available, recorded in the personal plan, and reviewed regularly.

6.2 Personal Plans

Every person receiving a registered care service from {{org_field_name}} must have a written personal plan within 28 days of starting to use the service. This applies even where the person receives the service infrequently or irregularly. People and their families or representatives cannot opt out of having a personal plan.

The personal plan will set out how the person’s assessed needs will be met, as well as their wishes, choices, outcomes, strengths, communication needs, preferences, risks, support arrangements and any agreed restrictions or safeguards.

The personal plan will be developed with the person and, where appropriate and lawful, their family, carers, representatives, advocates and relevant professionals. The person will be given a copy of their plan in a format they can understand and access.

Personal plans will be reviewed whenever there is a significant change in the person’s needs, wishes, risks, health, medication, circumstances, outcomes or service arrangements, and at least once every six months. A record of the review, the people involved, decisions made and changes required will be kept.

Personal planning will be dynamic and outcome-focused. Staff will use day-to-day observations, conversations, feedback, incidents, complaints, reviews and professional input to evaluate whether the plan remains right for the person and whether agreed outcomes are being achieved.

6.3 Safe Staffing, Workforce Planning and Competence

{{org_field_name}} will comply with the Health and Care (Staffing) (Scotland) Act 2019 and will ensure that appropriate staffing is in place to provide safe, high-quality, person-centred care and support. Staffing decisions will take account of people’s assessed needs, wishes, outcomes, risks, dependency levels, complexity, travel time, continuity of care, staff skills, staff wellbeing, supervision needs and contingency arrangements.

The service will ensure that staff are suitably recruited, inducted, trained, supervised, supported and competent before working alone or carrying out delegated or higher-risk tasks.

Staffing arrangements will be reviewed through care planning, risk assessment, rota monitoring, missed/late visit analysis, incident analysis, complaints, staff feedback, supervision, quality assurance and changes in the needs of people using the service.

Staff must not be allocated tasks unless they have the required competence, training, support and authority to carry them out safely. Where staff are not confident or competent to perform a task, they must report this to a manager immediately and must not proceed unless safe arrangements are in place.

{{org_field_name}} will maintain records of staffing assessments, training, competency checks, supervision, appraisal, registration status, PVG membership, absence, vacancies, agency use and actions taken to address staffing risks.

The service will promote staff wellbeing and will have systems for staff to report resourcing, operational or workload concerns that may affect safe care. Concerns will be reviewed and escalated where necessary.

6.4 Safer Recruitment, PVG and Disclosure

{{org_field_name}} will operate safer recruitment procedures to ensure that people appointed to work with people using the service are suitable, competent and legally eligible to do so.

Recruitment checks will include identity checks, right-to-work checks, employment history, explanation of gaps in employment, references, qualification checks, SSSC registration checks where applicable, professional registration checks where applicable, and PVG/disclosure checks appropriate to the role.

From 1 April 2025, PVG scheme membership is a legal requirement for people carrying out regulated roles with children or protected adults in Scotland. {{org_field_name}} will assess each role against the regulated role criteria and ensure that workers, volunteers, students, contractors or others do not carry out regulated role activities unless appropriate PVG membership is in place.

The service will maintain a PVG and disclosure monitoring system showing the role, regulated role assessment, PVG status, date checked, certificate/disclosure reference where appropriate, outcome, risk assessment where required, renewal or update requirements, and any restrictions on duties.

Where disclosure information, barring/listing information, police information, references, conduct concerns or other information raises a suitability concern, the service will complete a recorded risk assessment and take appropriate action before confirming appointment or continuing employment.

Where required, the service will make referrals to Disclosure Scotland, SSSC or other relevant bodies if a worker is dismissed, removed from regulated work, would have been removed had they not left, or otherwise meets referral criteria.

6.5 Adult Support and Protection, Safeguarding and Protection Concerns

{{org_field_name}} will protect people from harm, abuse, neglect, exploitation and discrimination and will respond promptly to concerns. This includes physical, psychological, emotional, sexual, financial, discriminatory, domestic, organisational, self-neglect and neglect-related harm.

Staff must report any actual, suspected or alleged harm, abuse, neglect, exploitation, discriminatory behaviour, unsafe practice or concern about a person’s welfare immediately in line with the organisation’s Adult Support and Protection and safeguarding procedures.

Managers will ensure that concerns are assessed, recorded, escalated and referred to the relevant local authority Adult Support and Protection team, Police Scotland, NHS services, Care Inspectorate, SSSC, Disclosure Scotland or other relevant body where required.

The service will notify the Care Inspectorate of protection concerns and other notifiable events in line with current Care Inspectorate notification guidance and required timescales.

Staff will receive training appropriate to their role on adult support and protection, recognising signs of harm, responding to disclosures, preserving evidence, recording concerns, whistleblowing, trauma-informed responses, professional boundaries and information sharing.

The service will cooperate fully with adult support and protection inquiries, investigations, case conferences, protection planning and multi-agency risk management arrangements.

6.6 Medication Support

Where medication support forms part of the agreed service, {{org_field_name}} will ensure that medication is supported safely, lawfully and in line with the person’s personal plan, medication policy, risk assessment, consent or lawful authority, and current best-practice guidance.

Staff must only provide medication support for which they have been trained, assessed as competent and authorised. Medication support may include prompting, assisting, administering, recording, ordering, collecting, storing or disposing of medication only where this is within the agreed service and the worker’s competence.

Medication arrangements must be recorded in the personal plan and medication records. Records must include the person’s medication support needs, level of support required, consent or legal authority, known allergies where available, medication risks, arrangements for changing medication, missed or refused medication, PRN medication where applicable, and escalation procedures.

Medication errors, omissions, adverse reactions, concerns, discrepancies or near misses must be reported, recorded, investigated, escalated to relevant health professionals where required, and notified to the Care Inspectorate where notifiable.

6.7 Data Protection, Confidentiality and Information Sharing

{{org_field_name}} will process personal information lawfully, fairly, transparently and securely in line with the UK GDPR, Data Protection Act 2018, confidentiality requirements, professional codes and information-sharing duties.

People using the service will be informed about how their information is used, shared, stored, retained and destroyed. Information will only be shared where there is consent, lawful authority, contractual requirement, safeguarding need, vital interest, legal obligation, regulatory requirement or other lawful basis.

Staff must maintain confidentiality and must not access, discuss, copy, disclose or share information unless this is necessary for their role and lawful.

Information may be shared without consent where necessary to protect the person or others from harm, to comply with adult support and protection duties, to support emergency care, to meet Care Inspectorate, SSSC, Disclosure Scotland or legal requirements, or where otherwise permitted or required by law.

Personal plans, records and electronic systems must be stored securely, access-controlled, backed up where applicable, and retained or destroyed in line with organisational retention schedules.

6.8 Duty of Candour and Open Communication

{{org_field_name}} will promote a culture of openness, honesty, learning and accountability. Where something has gone wrong, or may have gone wrong, and has caused or may have caused harm, staff must report this immediately and managers must ensure that the matter is reviewed, recorded, investigated and escalated appropriately.

Where the statutory organisational duty of candour applies, {{org_field_name}} will follow the required duty of candour procedure, including notifying the affected person or their representative, offering an apology, reviewing the incident, offering support, identifying learning, implementing improvements and keeping required records.

Staff must be open and honest with managers, people using the service and carers when practice has or may have caused harm or loss, in line with the SSSC Codes of Practice.

6.9 Business Continuity and Service Disruption

{{org_field_name}} will maintain business continuity arrangements to reduce risks to people using the service during emergencies, severe weather, staff shortages, transport disruption, IT failure, cyber incident, infection outbreak, utilities failure, provider failure or other significant disruption.

The service will identify people who may be at higher risk if visits are delayed, shortened or missed and will maintain contingency plans for priority visits, emergency contact arrangements, escalation to families or representatives, communication with commissioners and professionals, and notification to the Care Inspectorate where required.

Missed, late or significantly shortened visits must be recorded, reviewed and investigated. The service will take immediate action to reduce harm, inform relevant people, identify causes and prevent recurrence.

7. Incident Reporting and Continuous Improvement

7.1 Incident, Accident and Near-Miss Management

All incidents, accidents, near misses, medication errors, missed or late visits, safeguarding concerns, complaints, concerns, allegations, equipment failures and other adverse events must be reported, recorded, reviewed and acted upon in line with organisational procedures and Care Inspectorate requirements.

Managers will assess immediate risk, ensure the person is safe, seek medical or emergency support where required, inform families or representatives where appropriate and lawful, notify relevant professionals or authorities, and submit Care Inspectorate notifications where required.

Incidents will be investigated proportionately. Investigations will identify what happened, why it happened, whether policies and personal plans were followed, whether staffing or training contributed, what action is required, and what learning must be shared.

Learning from incidents will be used to update personal plans, risk assessments, staffing arrangements, training, supervision, policies and service improvement plans.

7.2 Complaints, Concerns and Feedback

People we support, families, carers, representatives, advocates, staff and professionals will be encouraged to raise complaints, concerns, comments and compliments. Information on how to complain will be provided in an accessible format and will include how to complain directly to {{org_field_name}}, the Care Inspectorate and relevant commissioners.

Complaints will be acknowledged, investigated and responded to within the timescales set out in the Complaints Policy. The service will be open, fair and respectful and will not treat anyone adversely because they have raised a concern or complaint.

Complaint outcomes and learning will be recorded and reviewed as part of quality assurance and continuous improvement.

7.3 Whistleblowing

Staff are encouraged and supported to raise concerns about unsafe, discriminatory, inappropriate, unlawful or poor practice. Staff may raise concerns with a manager, senior leader, the Care Inspectorate, SSSC, local authority, Disclosure Scotland, Police Scotland, Health and Safety Executive or another relevant body, depending on the nature of the concern.

{{org_field_name}} will not tolerate victimisation, bullying, dismissal, detrimental treatment or retaliation against a person who raises a concern in good faith or makes a protected disclosure.

7.4 Continuous Learning, Development and Reflective Practice

{{org_field_name}} will ensure that staff receive induction, training, supervision, appraisal, competency assessment and continuous professional learning appropriate to their role, responsibilities and the needs of people using the service.

Training and development will include, as applicable: Health and Social Care Standards; SSSC Codes of Practice 2024; adult support and protection; medication support; moving and assisting; infection prevention and control; health and safety; food hygiene; equality and diversity; human rights; Adults with Incapacity; mental health; dementia; learning disability; autism; trauma-informed practice; record keeping; confidentiality and data protection; complaints; duty of candour; whistleblowing; lone working; and emergency procedures.

Supervision will provide staff with opportunities to reflect on practice, wellbeing, learning needs, professional boundaries, ethical issues, incidents, complaints, feedback and continuous improvement.

The service will maintain training and competency records and will take action where training, competence, conduct or performance does not meet expected standards.

8. Roles and Responsibilities

8.1 Responsibilities of All Staff

8.2 Responsibilities of Managers and Supervisors

8.3 Responsibilities of the Organisation

9. Related Policies and Procedures

This policy should be read alongside:

10. Policy Review

This policy will be reviewed at least annually and sooner where required due to:

The Registered Manager is responsible for ensuring that this policy remains current and that any amendments are communicated to staff and relevant stakeholders. Staff will be required to read and confirm understanding of any significant changes.

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.

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