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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Spot Checks Policy

1. Purpose

At {{org_field_name}}, we are committed to maintaining safe, effective, caring, responsive and well-led support. This policy explains how planned and unplanned spot checks will be used as part of the organisation’s governance, supervision, competency-assessment and quality-assurance arrangements. Spot checks will assess the quality and safety of regulated activities, the experience and outcomes of people receiving support, staff practice and compliance with legislation, regulatory requirements, care and support plans, risk assessments and organisational policies.

Spot checks are one element of the organisation’s wider quality-assurance system. They will be proportionate, risk-based, respectful and focused on learning and improvement. They will not replace formal supervision, competency assessments, audits, incident investigations, safeguarding enquiries, complaints investigations, whistleblowing arrangements or disciplinary procedures. Information obtained through spot checks will be considered alongside feedback from people receiving support, relatives and representatives, staff feedback, complaints, compliments, incidents, medicines audits, safeguarding information, staffing information and other quality indicators.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, the Care Quality Commission (Registration) Regulations 2009, the Care Act 2014, the Mental Capacity Act 2005, the Human Rights Act 1998, the Equality Act 2010, the Data Protection Act 2018 and the UK General Data Protection Regulation. Relevant regulated activity requirements include Regulations 9, 10, 11, 12, 13, 16, 17, 18, 19, 20 and 20A, where applicable.

2. Supported Living, Consent and Access to People’s Homes

People receiving supported living services normally occupy their accommodation under a tenancy, licence or other occupancy agreement. Their accommodation is their home and must not be treated as a care establishment or as premises to which managers and auditors have an automatic right of entry.

A spot check involving entry into a person’s private home will only take place:

• With the person’s valid consent;
• In accordance with any lawful access arrangement in the person’s tenancy, licence, occupancy agreement or support agreement;
• With the agreement of a person lawfully authorised to act on the person’s behalf, where applicable; or
• Where entry is otherwise permitted or required by law, including in a genuine emergency involving an immediate risk of serious harm.

The person must be given information about the purpose and likely nature of spot checks in a format they can understand. Consent must be voluntary, specific and capable of being withdrawn. A person’s refusal to allow a manager or auditor to enter their home must be respected unless there is an immediate and lawful reason to enter. Refusal must not result in unfair, punitive or discriminatory treatment.

Where there is reason to doubt whether a person has capacity to decide about access for a particular spot check, staff must follow the Mental Capacity Act 2005. Capacity must be assessed in relation to the specific decision at the relevant time. No relative, advocate or member of staff may consent on behalf of an adult unless they have the relevant legal authority. Where the person lacks capacity and no authorised representative can make the decision, any decision must be made in the person’s best interests and be the least restrictive available option.

The checker must identify themselves, explain the purpose of the visit and seek permission before entering private areas or observing support. Consent to receive care does not automatically amount to consent to managerial observation. Particular care must be taken during personal care, medication support, health-related discussions, religious observance, contact with family or friends and any other private activity.

Unannounced spot checks may be unannounced to staff, but this does not remove the requirement to respect the person’s right to decide who enters their home.

3. Scope

This policy applies to all employees, workers, agency staff, bank staff, volunteers, students and contractors whose work may be observed or reviewed through a spot check. It also applies to registered managers, service managers, team leaders, quality-assurance personnel and any external person authorised to conduct a spot check on behalf of {{org_field_name}}.

Spot checks may cover the delivery and management of regulated personal care and related support activities. They may include staff practice, people’s experiences, consent, dignity, safeguarding, medicines, infection prevention and control, record-keeping, staffing, communication, lone working, incident management, restrictive practices, complaints awareness and compliance with care and support plans.

Spot checks must remain within the scope of the organisation’s responsibility. They must not be used to inspect or control aspects of a person’s private life, home or tenancy that are unrelated to the regulated activity or the support being provided.

This policy applies at every location from which or at which {{org_field_name}} carries on a regulated activity, including office-based records checks and checks undertaken while support is being provided in a person’s own home or in the community.

4. Related Policies

• SL07 – Person-Centred Care Policy
• SL08 – Dignity and Respect Policy
• SL12 – Safe Care and Treatment Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL21 – Medication Management and Administration Policy
• SL16 – Infection Prevention and Control Policy
• SL17 – Good Governance Policy
• SL34 – Confidentiality and Data Protection (UK GDPR) Policy

• Consent and Mental Capacity Policy.
• Equality, Diversity, Inclusion and Human Rights Policy.
• Complaints and Compliments Policy.
• Duty of Candour Policy.
• Staff Supervision and Appraisal Policy.
• Staff Training and Competency Policy.
• Disciplinary Policy.
• Whistleblowing or Freedom to Speak Up Policy.
• Lone Working Policy.
• Incident, Accident and Near-Miss Reporting Policy.
• Risk Management Policy.
• Record-Keeping Policy.
• Information Governance and Records Retention Policy.
• Restrictive Practice Policy.
• Tenancy, Occupancy and Housing Rights Policy.
• Quality Assurance and Audit Policy.
• Business Continuity Policy.
• CQC Notifications Policy.
• Accessible Information and Communication Policy.
• Visitors and Access to People’s Homes Policy, where applicable.

5. Objectives of Spot Checks

Spot checks are carried out to:

• Assess and improve the quality, safety and consistency of the regulated activity.
• Obtain assurance that people receive person-centred support that reflects their needs, choices, abilities, preferences, protected characteristics and desired outcomes.
• Obtain and consider the person’s experience of the support being provided.
• Confirm that staff understand and follow care and support plans, risk assessments, medicines instructions, communication plans and agreed working practices.
• Verify staff competence and identify learning, supervision and development needs.
• Identify unsafe, abusive, neglectful, discriminatory, restrictive or otherwise improper practice.
• Confirm that people’s dignity, privacy, independence, autonomy and human rights are respected.
• Check that consent is obtained and recorded and that Mental Capacity Act 2005 requirements are followed where relevant.
• Assess whether staffing arrangements and staff deployment are safe and appropriate.
• Identify emerging risks, recurring concerns and patterns that require wider organisational action.
• Ensure concerns are escalated promptly and appropriate notifications, safeguarding referrals and duty of candour processes are completed.
• Recognise good practice and share learning across the service.
• Provide reliable evidence for governance meetings, service improvement plans and regulatory assurance.

6. Types of Spot Checks

Spot checks may be planned, short-notice or unannounced to staff. Whether a check is announced or unannounced will depend on its purpose, the identified risks and the rights and preferences of the person receiving support. An unannounced check for staff does not authorise unannounced entry into a person’s private home.

6.1 Person-Centred Support, Consent, Dignity and Human Rights

• Observe whether staff communicate respectfully and in a way the person understands.
• Confirm that care and support reflect the person’s current care plan, assessed needs, strengths, choices, cultural needs, protected characteristics and desired outcomes.
• Confirm that valid consent is obtained before care or treatment is delivered and that any refusal or withdrawal of consent is respected and recorded.
• Confirm that Mental Capacity Act 2005 requirements, best-interests decisions and any lawful restrictions are understood and followed.
• Assess whether privacy and dignity are protected, particularly during personal care, medication support and sensitive conversations.
• Confirm that staff promote independence and do not complete tasks unnecessarily on the person’s behalf.
• Check that staff understand and use the person’s communication plan and make reasonable adjustments.
• Seek the person’s views about whether they feel safe, respected, listened to and in control of their support.
• Confirm that staff do not impose institutional routines, blanket restrictions or house rules that interfere with individual tenancy rights or personal choices.

6.2 Medication Administration and Management

• Confirm that medicines support is provided in accordance with the person’s care plan, medicines risk assessment, current prescription and level of agreed support.
• Check that the person’s consent, capacity, preferences, independence and right to self-administer medicines have been considered.
• Verify that Medication Administration Records and other medicines records are complete, accurate, legible, contemporaneous and free from unexplained gaps.
• Check that medicines are stored securely and appropriately without unnecessarily restricting the person’s access to their own medicines.
• Confirm that controlled drugs, ‘when required’ medicines, covert medicines and time-sensitive medicines are managed in accordance with applicable procedures.
• Check that allergies, adverse effects, refusals, omissions, errors and changes in medicines are recognised, recorded and escalated.
• Confirm that staff undertaking medicines tasks have received relevant training and have a current, role-specific competency assessment.
• Check arrangements for ordering, receipt, stock balance, disposal and transfer of medicines where these responsibilities are held by the provider.

6.3 Record-Keeping and Documentation

• Check that records are accurate, complete, legible, contemporaneous and attributable to the person who created them.
• Confirm that daily records describe the care and support actually provided, the person’s response, relevant changes, refusals, incidents and actions taken.
• Check that records distinguish fact, professional judgement and information reported by another person.
• Confirm that records are consistent with care plans, risk assessments, medicines records, incident reports and staff handovers.
• Check that records do not contain disrespectful, discriminatory, judgemental, unnecessary or unsupported language.
• Verify that corrections are made transparently and that records have not been improperly altered, deleted or backdated.
• Confirm that confidential information is accessed, used and shared only where necessary and lawful.
• Check compliance with the Data Protection Act 2018, UK GDPR, organisational retention schedules and secure storage arrangements.
• Confirm that any electronic record has appropriate access controls and an auditable history of entries and amendments.

6.4 Safeguarding and Risk Management

• Check whether staff can recognise indicators of abuse, neglect, self-neglect, exploitation, coercive control, discriminatory abuse, organisational abuse and improper treatment.
• Confirm that staff understand how to take immediate action to protect a person and how to report safeguarding concerns internally and externally.
• Verify that safeguarding concerns have been recorded, escalated and referred to the local authority safeguarding team, police, CQC or other agencies where required.
• Confirm that staff know how to raise concerns through the organisation’s whistleblowing arrangements and that they understand they will not suffer detriment for raising a concern in good faith.
• Check that risk assessments are current, proportionate, person-centred and reflect positive risk-taking.
• Confirm that staff understand changes in risk and know when and how to escalate concerns.
• Check that any restrictive practice is lawful, necessary, proportionate, the least restrictive option and subject to review.
• Confirm that risk controls do not unnecessarily restrict the person’s freedom, independence, relationships, activities or use of their home.
• Check that lessons from incidents, near misses, safeguarding concerns and complaints have been implemented.

6.5 Infection Prevention and Control

• Check whether hand hygiene, personal protective equipment and safe working practices are proportionate to the task and current infection risks.
• Confirm that staff follow the person’s infection-control risk assessment and any relevant clinical or public-health advice.
• Check that equipment used by the provider is clean, safe and maintained appropriately.
• Confirm that staff understand the management of exposure incidents, spillages, waste, laundry and sharps where relevant to their role.
• Ensure infection-control arrangements respect the fact that the environment is the person’s home and do not impose unnecessary institutional practices.
• Identify environmental concerns that fall within the provider’s responsibility and distinguish these from repairs or housing matters that are the landlord’s responsibility.
• Confirm that concerns outside the provider’s direct responsibility have been reported to the appropriate landlord, housing provider or other responsible organisation with the person’s involvement.

6.6 Staff Conduct and Professionalism

• Observe whether staff are kind, respectful, attentive and responsive.
• Confirm that staff maintain appropriate professional boundaries.
• Check that staff do not use personal mobile telephones, social media, photography, audio recording or video recording inappropriately.
• Confirm that staff protect confidentiality and do not discuss people in public areas or with unauthorised persons.
• Check punctuality, attendance, handover practice and compliance with agreed staffing arrangements.
• Confirm that staff understand lone-working, emergency and escalation procedures.
• Check that staff can access current policies, care plans, risk assessments and management advice.
• Identify training, competency, supervision or performance-management needs.
• Identify fatigue, workload, unsafe deployment or staffing pressures that may affect the quality or safety of support.
• Confirm that staff understand the organisation’s complaints, safeguarding, whistleblowing and duty of candour procedures.
• Recognise examples of good practice and positive professional conduct.

6.7 People’s Experience and Feedback

Where the person agrees, the checker will speak with them privately and in a manner suited to their communication needs. The checker will ask whether the person:

• Feels safe and respected;
• Is supported by staff they know and trust;
• Receives support at agreed times;
• Is involved in decisions about their support;
• Understands how to raise a concern or complaint;
• Feels listened to when they express preferences or refuse support;
• Has sufficient privacy and control within their home;
• Is supported to maintain independence, relationships and community involvement; and
• Wishes anything to change.

The person must not be pressured to participate. Their decision not to speak with the checker must be respected. Feedback must be recorded accurately and acted upon. Where communication support or an advocate is required, appropriate arrangements must be offered.

6.8 Complaints, Incidents, Notifications and Duty of Candour

• Check that staff know how to support people to make complaints or raise concerns.
• Review whether recent incidents, complaints, safeguarding concerns and near misses have been appropriately recorded, reported and investigated.
• Confirm that immediate safety actions have been completed.
• Check whether the registered manager has considered the need for notifications to CQC, the local authority, commissioners, police, health professionals, insurers or other relevant bodies.
• Confirm that the statutory duty of candour has been considered after any notifiable safety incident.
• Check whether the person or their lawful representative has received information, an apology and appropriate support where required.
• Confirm that lessons learned have been communicated and embedded in practice.

6.9 Recording, Photography and Surveillance

A spot check must not involve covert audio recording, video recording, photography or other surveillance. Photographs, audio recordings or video recordings may only be made where there is a clear and lawful purpose, the person has given informed consent or another lawful authority applies, a data-protection assessment has been completed where required and the recording is strictly necessary and proportionate.

Recording must never take place during intimate care or in circumstances where it would unjustifiably interfere with privacy, dignity or the rights of the person or another occupant. Managers must follow the organisation’s surveillance, consent and data-protection procedures before any recording technology is used.

7. Frequency and Process of Spot Checks

The registered manager will maintain a documented, risk-based spot-check programme. Every service, staff group, shift pattern and relevant regulated activity will be sampled at a frequency proportionate to risk. As a minimum, each supported living service will be subject to a documented spot check at least quarterly. Additional checks will be completed where concerns, changes or emerging risks justify increased oversight.

Factors determining frequency will include:

• The needs and vulnerability of people receiving support;
• The complexity of support being delivered;
• New staff, agency staff or staff whose competence requires further assurance;
• Night support, lone working and other practice that is less visible to managers;
• Medicines errors or concerns;
• Safeguarding concerns;
• Complaints or whistleblowing disclosures;
• Incidents, near misses or missed visits;
• Changes in staffing, management or service delivery;
• Deterioration in record quality;
• Previous spot-check findings;
• Concerns raised by people, relatives, commissioners or professionals; and
• Any regulatory action, service improvement plan or condition of registration.

A fixed quarterly check must not delay an immediate check or management intervention where information suggests that people may be at risk.

Spot checks will only be conducted by a manager, team leader, quality-assurance officer or other person who has been formally authorised and is competent to assess the relevant area of practice. A person checking medicines practice must have sufficient medicines knowledge and competence. A person must not conduct a spot check where an actual or perceived conflict of interest would undermine the objectivity of the findings.

Where practicable, higher-risk checks and checks following repeated concerns will be completed or reviewed by a manager who is independent of the staff team concerned.

Staff may or may not receive advance notice. Decisions about notice will be based on the purpose of the check, risks, employment considerations and the rights of people receiving support. The checker must not mislead, entrap or deliberately provoke staff. Unannounced observation must be conducted fairly and proportionately and must not compromise the person’s safety, dignity, consent or privacy.

Before a spot check, the checker must:

• Confirm the purpose and scope of the check;
• Review relevant previous findings, risks and action plans;
• Confirm arrangements for lawful access to any person’s home;
• Consider consent, communication and reasonable-adjustment needs;
• Ensure that they have no conflict of interest; and
• Select the appropriate checklist for the area being assessed.

At the start of a check, the checker must:

• Identify themselves;
• Explain the purpose of the check;
• Seek the person’s permission before entering or remaining in their home;
• Explain what will be observed or reviewed;
• Minimise disruption to care and the person’s routine; and
• Stop or modify the check where continuing would compromise dignity, consent, safety or wellbeing.

During the check, the checker must:

• Record objective evidence rather than unsupported opinion;
• Distinguish observed facts from information reported by others;
• Speak privately with the person and staff where appropriate;
• Avoid accessing records or areas that are outside the authorised scope;
• Take immediate action where there is an urgent risk; and
• Preserve evidence where a serious incident, safeguarding matter or potential disciplinary issue is identified.

At the end of the check, the checker must:

• Explain immediate findings to the relevant staff member where it is safe and appropriate to do so;
• Give the staff member an opportunity to provide factual clarification;
• Record positive practice as well as concerns;
• Agree or recommend actions, responsible persons and completion dates;
• Escalate serious matters without delay; and
• Ensure the person receiving support is informed of relevant outcomes in an accessible manner where the findings affect them.

8. Reporting, Grading and Follow-Up Actions

Every spot check must be recorded on the approved spot-check form. The report must include:

• Date, time, location and duration;
• Whether the check was announced or unannounced to staff;
• The name and role of the checker;
• The staff members whose practice was reviewed;
• The scope and reason for the check;
• Confirmation of consent and access arrangements;
• Evidence reviewed;
• People’s feedback, where provided;
• Positive findings;
• Areas requiring improvement;
• Immediate actions taken;
• Risk rating;
• Agreed actions;
• Named action owners;
• Completion dates;
• Escalations, referrals or notifications required; and
• The date and outcome of follow-up verification.

Findings will be graded as:

• Immediate or critical risk: There is actual or potential serious harm, abuse, neglect, unsafe care or a serious regulatory breach. Immediate protective action and escalation are required.
• Major concern: There is a significant failure that could affect safety, rights or quality and requires prompt management action.
• Improvement required: The concern does not present an immediate serious risk but requires correction within an agreed timescale.
• Compliant: Required standards are met.
• Good practice: Practice exceeds the required standard or demonstrates learning that should be shared.

Immediate or critical risks must be reported to the registered manager or on-call manager without delay and before the checker leaves wherever possible. Emergency services, the local authority safeguarding team, police, commissioners, CQC or other agencies must be contacted where required.

A written action plan must be completed for every finding requiring improvement. Actions must be specific, measurable, achievable, relevant and time-bound. The registered manager must ensure that completion is verified through evidence and must not close an action solely on the basis that a staff member states it has been completed.

Repeated findings must be subject to a root-cause or thematic review. The review must consider whether the cause relates to staffing levels, workload, leadership, training, systems, communication, resources, commissioning arrangements or organisational culture rather than attributing every failure solely to an individual worker.

Where a finding may require a safeguarding enquiry, disciplinary investigation or formal competency process, the spot-check report will be treated as initial evidence only. The matter will be handled under the relevant procedure, and no disciplinary conclusion will be reached solely through the spot-check process.

The registered manager will review completed spot checks at least monthly. Significant themes, overdue actions and repeated concerns will be escalated through the organisation’s governance structure to the provider or nominated individual.

9. Staff Support and Development

• The primary purposes of spot checks are assurance, learning, risk reduction and improvement. However, where a check identifies possible misconduct, wilful neglect, abuse, dishonesty, unsafe practice or repeated failure to follow reasonable instructions, the matter may be referred to safeguarding, disciplinary, capability, competency or professional-referral procedures. Any such process will be fair, evidence-based and separate from the spot check itself.
• Where improvement is required, the manager will determine the appropriate response. This may include reflective discussion, coaching, mentoring, increased supervision, refresher training, reassessment of competence, changes to duties, a performance improvement plan or formal action under another organisational procedure.

• Staff will receive feedback promptly and will be given a reasonable opportunity to comment on factual accuracy.
• Staff may record their response or disagreement on the spot-check form.
• Signing a spot-check record confirms receipt and discussion; it does not necessarily indicate agreement with every finding.
• Staff must not be subjected to retaliation for raising concerns, admitting errors or participating honestly in a spot check.
• Learning identified through spot checks will inform supervision, appraisal, team meetings, training plans and service improvement work.

10. Confidentiality, Information Governance and Data Protection

Personal information obtained during a spot check will be processed in accordance with the Data Protection Act 2018, UK GDPR, the common-law duty of confidentiality and the organisation’s information-governance policies.

Only information that is relevant and necessary for the stated purpose of the check will be collected. Spot-check reports must not contain excessive personal information, unsupported allegations or information about other occupants that is not relevant to the regulated activity.

Reports will be stored securely with access restricted to authorised persons who require the information for their role. Information will only be shared with external bodies where there is a lawful basis, including safeguarding, regulatory, contractual or legal requirements.

The lawful basis and any special-category condition for processing must be identified through the organisation’s data-protection arrangements. Where a report contains information about health, disability, safeguarding, disciplinary matters or criminal allegations, it must receive an appropriate level of protection.

Spot-check reports will be retained in accordance with the organisation’s approved records-retention schedule. The policy owner must ensure that the retention period is documented and that records are securely destroyed when no longer required, unless they must be preserved for safeguarding, legal, regulatory, insurance or employment proceedings.

Staff and people receiving support may request access to personal information about them in accordance with data-protection law, subject to applicable exemptions and the rights of other people.

Spot-check information must not be copied to personal devices, informal messaging applications or unauthorised email accounts.

11. Governance, Monitoring and Continuous Improvement

The registered manager will review the spot-check programme at least quarterly to evaluate:

• Whether planned checks were completed;
• Whether the sample covered different staff members, locations, shifts and areas of practice;
• Whether checks reflected known and emerging risks;
• The number and severity of findings;
• Repeated or recurring concerns;
• Action-plan completion and overdue actions;
• Feedback from people receiving support;
• Medicines, safeguarding, incident and complaint themes;
• Staffing, supervision and training implications;
• Equality and human-rights implications;
• Whether previous improvement actions have resulted in sustained change; and
• Whether the spot-check system itself remains effective and proportionate.

A quarterly summary will be presented through the organisation’s governance arrangements. The summary will identify themes, risks, good practice, learning, completed improvements and actions requiring provider-level oversight.

The organisation will compare spot-check findings with other evidence, including:

• Complaints and compliments;
• Safeguarding concerns;
• Incidents and near misses;
• Medicines audits;
• Care-record audits;
• Staff turnover, sickness and vacancy information;
• Training and supervision compliance;
• Feedback from people, relatives, advocates and professionals;
• Commissioner monitoring;
• CQC correspondence and assessment findings; and
• Previous action plans.

The registered manager will ensure that lessons are shared in an accessible and proportionate manner. Information about individuals will be anonymised when shared for general learning unless identification is necessary and lawful.

The provider or nominated individual will receive assurance that significant risks are being managed and that corrective actions are effective. Unresolved or repeated concerns will be escalated and may result in additional resources, independent audit or formal service-improvement arrangements.

12. Roles and Responsibilities

The Provider or Nominated Individual will:

• Ensure that effective governance and quality-assurance systems are in place.
• Receive assurance about serious risks, repeated concerns and overdue actions.
• Ensure sufficient resources are available to implement improvements.
• Hold the registered manager accountable for the effectiveness of the spot-check programme.

The Registered Manager will:

• Maintain and approve the risk-based spot-check schedule.
• Ensure checkers are authorised, trained and competent.
• Ensure lawful access, consent, dignity and privacy requirements are followed.
• Review all serious findings and ensure immediate action is taken.
• Make or oversee safeguarding referrals, notifications and duty of candour actions.
• Monitor action plans and verify completion.
• Report themes and unresolved risks through governance arrangements.
• Review whether spot checks are effective and proportionate.

Team Leaders and Authorised Checkers will:

• Conduct spot checks objectively and within the scope of their competence.
• Identify themselves and obtain appropriate permission before entering a person’s home.
• Record clear, factual and balanced evidence.
• Take immediate action where a person is at risk.
• Maintain confidentiality.
• Avoid conflicts of interest.
• Provide constructive feedback.
• Escalate concerns within required timescales.

Staff will:

• Co-operate honestly and professionally with lawful spot checks.
• Provide accurate information and access to relevant organisational records.
• Continue to prioritise the person’s safety, dignity and needs during the check.
• Report unsafe practice and safeguarding concerns.
• Complete agreed learning and improvement actions.
• Raise concerns where they believe the spot-check process is unsafe, unfair or infringes a person’s rights.

People Receiving Support will:

• Be informed about the organisation’s quality-assurance arrangements in an accessible format.
• Be asked for permission before a checker enters their private home, except where a lawful emergency exception applies.
• Be free to provide feedback or decline to participate.
• Be informed of findings and actions that directly affect their support.
• Be supported to complain or raise concerns about how a spot check was conducted.

13. Equality, Accessibility and Human Rights

Spot checks will be planned and conducted in a way that respects the Human Rights Act 1998 and the Equality Act 2010. No person or staff member will be treated unfairly because of age, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

Reasonable adjustments will be made where required. This may include the use of easy-read information, interpreters, communication aids, additional time, advocacy or a checker of a particular sex where this is necessary to protect dignity during sensitive observation.

The checker will consider whether staff practice promotes autonomy, family life, privacy, freedom from degrading treatment, freedom of expression and freedom from discrimination. Cultural differences or disability-related communication must not be wrongly interpreted as non-compliance, aggression or lack of engagement.

Any restriction identified during a spot check must be reviewed to establish whether it is lawful, necessary, proportionate and the least restrictive option.

14. Policy Review and Assurance

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

• Legislation or statutory guidance changes;
• CQC publishes or implements relevant regulatory or assessment changes;
• A serious incident, safeguarding concern, complaint or whistleblowing disclosure identifies a policy weakness;
• Spot-check findings show repeated or systemic non-compliance;
• The organisation changes its regulated activities, service model or governance structure;
• Feedback from people receiving support, staff, commissioners or partner agencies identifies a need for revision; or
• An inspection, assessment, audit, enforcement action or legal decision indicates that changes are required.

The policy owner will record the sources considered during each review, the amendments made, the person approving the revised policy and how the changes were communicated to staff.

Staff must confirm that they have read and understood material changes. Additional briefing, supervision or competency assessment will be provided where the changes affect practice.

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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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