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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Regulated Activities Compliance Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} complies with all legal and regulatory requirements associated with delivering regulated activities under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This policy reflects the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as amended, including amendments in force from 30 March 2025. This policy outlines our approach to ensuring that all care and support services provided by our organisation meet the required standards set by the Care Quality Commission (CQC) and other relevant bodies. By adhering to this policy, we ensure that our service remains legally compliant, safe, effective, and person-centred.

2. Scope

This policy applies to all staff, including management, carers, support workers, and administrative personnel who contribute to the provision of regulated activities. It covers all aspects of compliance, including registration, governance, safety, safeguarding, staffing, and quality assurance.

3. Principles of Regulated Activities Compliance

{{org_field_name}} is committed to ensuring that all regulated activities comply with CQC standards and legal obligations. Our approach is based on the following key principles:

Fundamental Standards Compliance
We comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended) and evidence compliance with the CQC Fundamental Standards across all regulated activities we deliver. In particular, we ensure:

• Regulation 9 (Person-centred care): Care and support plans are individualised, outcome-focused, reviewed regularly, and reflect assessed needs, preferences and risks.
• Regulation 10 (Dignity and respect): People are treated with dignity, privacy is maintained, and equality and human rights are actively promoted.
• Regulation 11 (Need for consent): We obtain valid consent for care and support and apply the Mental Capacity Act 2005 and best-interest decision-making where a person lacks capacity.
• Regulation 12 (Safe care and treatment): Risks are assessed and mitigated, medicines are managed safely, and care is delivered in line with safe practice and clinical / best-practice guidance.
• Regulation 15 (Premises and equipment): Premises used to support people are safe and suitable, and equipment is maintained and used appropriately.
• Regulation 18 (Staffing): We deploy sufficient numbers of suitably skilled, competent and experienced staff, and ensure ongoing supervision, appraisal and development.
• Regulation 20 (Duty of candour): We act openly and transparently when things go wrong, meeting the requirements for notifications, apology, investigation and learning.
• Regulation 20A (Display of performance assessments): We display our performance assessments (including ratings, where applicable) as required and in line with CQC guidance.
• Regulation 22 (Information to be provided): We provide information to CQC as required and ensure information shared is accurate, complete, and submitted within required timeframes.
  Evidence of compliance is maintained through audits, supervision, incident/complaint learning, service-user feedback, and governance reporting.

Registration and Statement of Purpose Compliance

• We ensure that our organisation is registered with the CQC for all regulated activities we provide, as required under the Health and Social Care Act 2008.
• Our Statement of Purpose clearly outlines the nature of our services, our values, and how we meet the needs of the people we support.
• Any changes to our regulated activities, locations, Registered Manager / Nominated Individual details, or the information contained within our Statement of Purpose are notified to CQC without delay, in line with the Care Quality Commission (Registration) Regulations 2009 (including Regulation 12 – Statement of Purpose, and the relevant ‘notice of changes’ / notifications requirements). We maintain a clear internal process to identify notifiable changes and submit statutory notifications within required timescales.

Good Governance and Leadership

• We maintain strong governance structures to ensure accountability and compliance with all CQC Fundamental Standards.
• Our leadership team, including the Registered Manager and Nominated Individual, provide clear oversight and ensure continuous monitoring of service quality.
• We conduct regular internal audits to assess compliance with key regulations and identify areas for improvement.

CQC Assessment Framework Alignment

Our governance and quality assurance processes are structured to evidence outcomes against CQC’s assessment framework (Safe, Effective, Caring, Responsive, Well-led) and the associated quality statements. We map audits, KPI monitoring, service-user feedback, incident/complaint learning, staffing metrics, safeguarding oversight, and equality/human-rights monitoring to the relevant quality statements and maintain an evidence file to support assessments and inspections.

Safety and Risk Management

• We operate a proactive approach to identifying, assessing, and managing risks related to the delivery of regulated activities.
• Risk assessments are carried out regularly, and necessary actions are taken to prevent incidents or harm.
• All staff are trained in risk management and incident reporting to ensure a safe environment for the people we support.
• We comply with Regulation 12 – Safe Care and Treatment, ensuring that all care provided is appropriate, meets individual needs, and is delivered safely.

Safeguarding and Duty of Candour

• We have a robust Safeguarding Policy in place to protect individuals from abuse, harm, or neglect.
• All staff undergo safeguarding training and are required to report concerns in accordance with Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment.
• We operate in an open and transparent manner, fulfilling our Duty of Candour (Regulation 20) by ensuring that all incidents are reported and families are informed promptly.

Staffing and Workforce Compliance

• We ensure we have sufficient numbers of suitably skilled, competent and experienced staff to meet people’s needs safely (Regulation 18 – Staffing) and we recruit safely using robust pre-employment checks to ensure staff are fit and proper for their roles (Regulation 19 – Fit and proper persons employed).
• All employees undergo robust recruitment checks, including DBS (Disclosure and Barring Service) clearance, reference verification, and qualification assessments.
• Staff receive a structured induction, role-specific training, competency assessment, and ongoing supervision and appraisal. Staffing deployment and skill mix are reviewed in response to changes in people’s needs, risks, incidents, safeguarding concerns, and feedback, with escalation to senior management where staffing levels may compromise safety or outcomes.
• We maintain adequate staffing levels at all times to ensure safe and effective service delivery.
• Staff receive continuous professional development, and training records are reviewed regularly.

Medication Management

• Medication support is delivered in line with Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance), including safe prescribing/ordering (where applicable), storage, administration, recording, error management, and disposal. Medication practice is regularly audited and staff competency is assessed and refreshed to ensure safe outcomes.
• All medication management practices, including storage, administration, and disposal, are regularly audited to ensure safety and effectiveness.
• Staff handling medications receive specialised training and competency assessments.

Record-Keeping and Information Governance

• We maintain accurate, up-to-date, and secure records in accordance with Regulation 17 – Good Governance.
• All personal data is handled in compliance with GDPR (General Data Protection Regulation) requirements to protect the confidentiality of the people we support.
• Our policies on information sharing and record retention ensure that documentation is clear, accessible, and legally compliant.

Complaints, Feedback, and Continuous Improvement

• We operate a transparent and accessible complaints procedure as outlined in Regulation 16 – Receiving and Acting on Complaints.
• Complaints and feedback from the people we support, their families, and other stakeholders are actively encouraged and used to improve service delivery.
• Lessons learned from complaints, incidents, and feedback are incorporated into training and service enhancements.

Emergency Preparedness and Business Continuity

• We have a detailed Emergency and Business Continuity Plan to ensure service continuity in case of emergencies such as pandemics, extreme weather, or operational disruptions.
• Staff are trained in emergency protocols, including fire safety, first aid, and evacuation procedures.

Quality Assurance and Regulatory Compliance Monitoring

• Regular quality assurance checks and compliance audits are conducted to monitor adherence to CQC regulations.
• The Registered Manager is responsible for submitting statutory notifications to CQC when required, including significant incidents, changes in service provision, and safeguarding concerns.
• Statutory notifications include (where applicable): safeguarding allegations, serious injuries, deaths, incidents affecting safe running of the service, police involvement, unauthorised absences, returns from long absence, changes to registered details (including Registered Manager / Nominated Individual changes), and changes to the Statement of Purpose. We maintain an internal tracker to confirm: what happened, which notification applies, the submission deadline, who is responsible for drafting and authorising, evidence attached, and confirmation of submission.
• We benchmark our performance against national best practices and CQC guidance to continuously enhance our service delivery.

Display of Performance Assessments (Regulation 20A)

We display our CQC performance assessment outcome (including ratings, where applicable) in the required formats and locations, including making it accessible to people using the service and the public. We complete periodic checks to ensure displayed information remains current after any updated assessment, publication, or re-rating and we keep evidence of compliance within governance records.

4. Roles and Responsibilities

• Registered Manager: Responsible for ensuring that all regulated activities meet CQC compliance requirements and that all necessary registrations are maintained.
• Nominated Individual: Provides strategic oversight and ensures governance structures are effective in maintaining regulatory compliance.
• Directors / Officers (where applicable): The provider ensures directors/officers meet Regulation 5 (Fit and proper persons: directors), including appropriate checks, declarations, and ongoing monitoring of fitness (conduct, competence, qualifications/experience, and integrity), with records retained as part of governance documentation.
• All Staff: Expected to understand and adhere to all regulations, policies, and procedures relevant to their roles, and report any concerns related to compliance.
• Health and Safety Lead: Ensures all risk management and safety measures are implemented and reviewed regularly.
• Safeguarding Lead: Oversees all safeguarding concerns and ensures compliance with relevant legislation and reporting obligations.
• Compliance Team: Conducts internal audits, ensures records are maintained, and provides support to the Registered Manager in ensuring CQC compliance.

5. Related Policies

This policy should be read in conjunction with:

• SL04 – Good Governance Policy
• SL05 – Statement of Purpose Policy
• SL11 – Safe Care and Treatment Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL16 – Health and Safety at Work Policy
• SL19 – Emergency and Business Continuity Plan
• SL21 – Medication Management and Administration Policy
• SL25 – Notification of Other Incidents Policy

6. Policy Review

This policy will be reviewed annually or sooner if legislative changes, CQC requirements, or organisational needs necessitate an update. Any updates will be communicated to all staff to ensure continued compliance with regulated activities and best practices in supported living service delivery.

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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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