This Welsh Government statutory guidance sets out how service providers and responsible individuals must meet regulatory requirements under the Regulation and Inspection of Social Care (Wales) Act 2016 and associated 2017 Regulations. It covers governance, care planning, staffing, safeguarding, premises, financial sustainability, and quality assurance obligations for four regulated service types: care home services, domiciliary support services, secure accommodation services, and residential family centre services. Operators must maintain a statement of purpose, implement required policies and procedures, and ensure a designated responsible individual oversees compliance. Care Inspectorate Wales (CIW) uses this guidance to inform registration decisions and enforcement action.
View official source1 Document title
The Regulation and Inspection
of Social Care (Wales) Act 2016
Statutory Guidance
For service providers and responsible individuals on meeting service
standard regulations for:
• Care home services
• Domiciliary support services
• Secure accommodation; and
• Residential family centre services
This statutory guidance relates to Parts 3 to 20 of The Regulated
Services (Service Providers and Responsible Individuals) (Wales)
Regulations 2017, as amended
gov.wales
© Crown copyright 2024, Welsh Government, WG49456, Digital ISBN 978-1-83577-680-3
Mae’r ddogfen hon ar gael yn Gymraeg hefyd / This document is also available in Welsh
Rydym yn croesawu gohebiaeth a galwadau ffôn yn Gymraeg / We welcome correspondence and telephone calls in Welsh
Version 3 – March 2024
Contents
About this guidance…………………………………………………………................. 1
List of key terms ……………………………………………………............................ 4
Useful links …………………………………………………………………………….. 6
Chapter 1: Requirements on Service Providers
1.1 General requirements on service providers ………………………………… 9
1.2 Requirements on service providers as to the steps to be taken before
agreeing to provide care and support ………………………………………. 21
1.3 Requirements on service providers as to the steps to be taken on
commencement of the provision of care and support ……………………. 25
1.4 Requirements on service providers as to the information to be provided
to individuals on commencement of the provision of care and support …. 31
1.5 Requirements on service providers as to the standard of care and
support to be provided ………………………………………………………... 35
1.6 Requirements on service providers – Safeguarding ………………….…… 47
1.7 Requirements on service providers which only apply where
accommodation is provided ………………………………………………….. 56
1.8 Requirements on service providers as to staffing …………………………. 58
1.9 Requirements on service providers in respect of domiciliary support
services ………………………………………………………………………… 70
1.10 Requirements on service providers as to premises, facilities and
equipment ……………………………………………………………………… 75
1.11 Additional requirements on service providers in respect of premises –
new accommodation ………………………………………………………….. 86
1.12 Requirements on service providers as to supplies, hygiene, health and
safety and medicines …………………………………………………………. 92
1.13 Other requirements on service providers ………………………………….. 97
Chapter 2: Requirements on Responsible Individuals
2.1 Requirements on responsible individuals for ensuring effective
management of the service …………………………………………………... 109
2.2 Requirements on responsible individuals for ensuring effective oversight
of the service …………………………………………………………………... 116
2.3 Requirements on responsible individuals for ensuring the compliance of
the service ……………………………………………………………………… 119
2.4 Requirements responsible individuals for monitoring, reviewing and
improving the quality of the regulated service ……………………………… 121
2.5 Other requirements on responsible individuals …………………………….. 123
Annex A: Parts of the Regulations not the subject of this Guidance ………….. 125
Annex B: Schedules to Regulations 35, 59, 60 and 84 …………………………… 138
1
About this guidance
This is statutory guidance issued by the Welsh Ministers under section 29 of the
Regulation and Inspection of Social Care (Wales) Act 2016 (‘the Act’).
It applies from April 2019.
The Act, the Regulated Services (Service Providers and Responsible Individuals) (Wales)
Regulations 2017, as amended (“the Regulations”) and this statutory guidance replace
requirements previously put in place under the Care Standards Act 2000 and the
associated National Minimum Standards.
This guidance sets out:
• how providers of regulated services may comply with the requirements imposed by
regulations made under section 27 of the Act, and
• how persons designated as a responsible individual for a regulated service may
comply with the requirements imposed by regulations made under section 28 of
the Act.
These requirements are contained within Parts 3 to 20 of the Regulations. These
Regulations came into force on 2 April 2018 and this guidance took effect from that date.
These Regulations have been amended by the Regulated Services (Service Providers and
Responsible Individuals) (Wales) (Amendment) Regulations 2019 (“the Amendment
Regulations”), which came into force on 1 April 2019.
Section 29(3) of the Act states that providers of regulated services and designated
responsible individuals must have regard to this guidance in meeting requirements
imposed by regulations under sections 27 and 28 of the Act.
This guidance is also relevant to those providers making an application for registration as
a service provider under section 6 of the Act. Guidance about registration has been
produced by the service regulator, Care Inspectorate Wales (CIW), and is available on its
website (see Useful Links).
This statutory guidance has been produced to cover those regulated services providing
care and support to individuals of different ages and with different aspirations and needs.
With certain exceptions, listed within Part 2 of the Regulations (see Annex A), this
guidance is specifically for providers of the following regulated services, operating
in Wales:
• care home services
• secure accommodation services
• residential family centre services
• domiciliary support services
It also applies to those persons designated as responsible individuals under the Act.
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It is detailed in part to ensure that individuals receive the right care and support to promote
their well-being and safety.
How to use this guidance
Prospective service providers and responsible individuals
Persons who wish to provide a regulated service must make an application for registration
to CIW who act as the service regulator on behalf of the Welsh Ministers. Prospective
service providers and responsible individuals must demonstrate that they will be able to
meet the requirements imposed by the Act and the Regulations and once registered, that
they will continue to meet them.
In order to grant an application to register, CIW must be satisfied that any prospective
provider of regulated services can and will meet the standards of service provision
specified in regulations under section 27 of the Act. CIW must also be satisfied that
persons designated as a responsible individual can and will comply with the duties set out
in regulations under section 28 of the Act.
CIW will use this guidance to inform its decisions to grant or refuse applications for
registration as a service provider.
Registered service providers and designated responsible individuals
Registered providers of regulated services and designated responsible individuals must
meet the requirements of the Act and the Regulations. In doing so they must have
regard to this statutory guidance which is intended to help them understand how they
can meet the applicable requirements within the Regulations. CIW will use this guidance
to inform decisions about the extent to which registered providers are meeting those
requirements and when considering whether to take enforcement action.
Service providers remain responsible for deciding how the requirements will be met, taking
into account the needs of individuals using the service and the statement of purpose for
the regulated service.
If registered service providers and designated responsible individuals do not follow
this guidance, they must provide evidence that their chosen approach enables them to
meet the applicable requirements within the Regulations.
Structure of this guidance
This guidance sets out the following:
• A summary of the intention of each Part of the Regulations
Parts 3 to 15 of the Regulations, made under section 27 of the Act, set out the
requirements on a service provider in relation to the standard of service that must be
provided. They highlight the importance of the well-being of individuals who are receiving
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care and support1. They also impose other requirements on service providers related to
the operation of the regulated service.
Parts 16 to 20 of the Regulations, made under section 28 of the Act, set out the duties
placed on the designated responsible individual in relation to a regulated service. These
duties include a requirement to supervise the management of the service including the
appointment of a suitable and fit manager. The intention is to ensure that a designated
person at an appropriately senior level holds accountability for both service quality and
compliance and to ensure that there is a clear chain of accountability linking the corporate
responsibility of the service provider and the responsible individual with the role of the
manager of the regulated service.
• The text of each regulation
It is important that service providers and responsible individuals refer to the text of each
regulation as the first source of information about what the requirements are and how to
meet them. This guidance provides further explanation on how to meet the individual
components of each regulation where further clarification and definition may be helpful.
Where the text of the regulation itself is self-explanatory, no further guidance is given.
• Guidance on the requirements of individual components of the regulation
The guidance on individual components of each regulation should not be considered
exhaustive as there may be other ways that service providers and responsible individuals
can show that they meet each component of the regulation.
Annex A sets out parts of the Regulations that are not the subject of this guidance, as they
are not made under section 27 or 28 of the Act. Annex B contains the Schedules to
regulations 35, 59, 60 and 84. These annexes have been included for reference only.
Enforcement
Parts 3 to 20 of the Regulations set out clear requirements which registered providers and
responsible individuals must adhere to. CIW, as the service regulator, can take
enforcement action against any registered service provider and responsible individual that
does not adhere to these legal requirements.
Any enforcement action taken by CIW will be proportionate and will look at the impact on
or risk to individuals using the regulated service.
Examples of enforcement action may include:
• imposing conditions on a service provider’s registration;
• cancelling a service provider’s registration;
• issuing an improvement notice;
1 These standards are linked to the well-being statement for people who need care and support and carers
who need support. https://www.gov.wales/well-being-statement-people-who-need-care-and-carers
4
• issuing a fixed penalty notice.
Further information on the offences which service providers and responsible individuals
may commit if they do not comply with the requirements of the Act and these Regulations,
and the different statutory and non-statutory enforcement actions that CIW may take in
response, are set out within CIW’s Securing Improvement and Enforcement guidance.
This is available on CIW’s website.
List of key terms used within this guidance
Term Meaning
The Act The Regulation and Inspection of Social Care (Wales) Act 2016
The 2014 Act The Social Services and Well-being (Wales) Act 2014
Care and support
plan
A plan put in place by the local authority under section 54 (in relation
to adults, children or a carer) or section 83 (in relation to children
looked after and accommodated children) of the 2014 Act
Personal outcomes • In relation to an adult, means the outcomes that the adult wishes
to achieve in day-to-day life;
• In relation to a child, means—
i. the outcomes that the child wishes to achieve; or
ii. the outcomes that any persons with parental
responsibility wish to achieve in relation to the child
Personal plan The plan required to be prepared in accordance with regulation 15
Provider
assessment
The assessment which is required to be carried out by the service
provider in accordance with regulation 18
Registered nurses Any nurse registered on Part 1 of the Nursing and Midwifery Council
professional register and coming from any of the four recognised
fields of practice (competencies): adult, mental health, learning
disability and children. In addition to their initial registration, the
registered nurse should have developed knowledge and skills that
make them competent to care for individuals.
Representative Any person having legal authority, or the consent of the individual to
act on the individual’s behalf
Responsible
individual
(See section 21 of
the Act for a full
description)
Must be either:
• where the service provider is an individual, the service provider;
• where the service provider is a partnership, one of the partners;
• where the service provider is a body corporate, other than a local
authority
o a director or similar officer of the body;
o in the case of a public limited company, a director or
company secretary;
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o in the case of a body corporate whose affairs are
managed by its members, a member of the body;
• where the service provider is an unincorporated body, a member
of the body;
• where the service provider is a local authority, an officer of the
local authority designated by the authority’s director of social
services;
and whom CIW are satisfied is a fit and proper person to be a
responsible individual;
and is designated by a service provider in respect of a place at, from
or in relation to which the provider provides a regulated service;
and is specified as such in the service provider’s registration
NB In certain circumstances (see Regulation 89, not covered in this
guidance) the responsible individual may be designated by CIW (on
behalf of the Welsh Ministers) and not the service provider.
Service
commissioner
The local authority or NHS body which is responsible for making
arrangements with the provider for care and support to be provided
to an individual
Service provider (or
provider)
A person or organisation registered with CIW to provide a regulated
service
Staff • Persons employed by the service provider to work at the service
as an employee or worker (within the meaning of section 230 of
the Employment Rights Act 1996);
• Persons engaged by the service provider under a contract for
services;
• This does not include persons who are allowed to work as
volunteers.
The individual Unless the context indicates otherwise, the child or adult who is
receiving care and support
The individual’s
needs
The person’s care and support needs
The Regulations The Regulated Services (Service Providers and Responsible
Individuals) (Wales) Regulations 2017, as amended
The Service The regulated service which is provided by a service provider at,
from or in relation to a place specified in a condition to the service
provider’s registration
Accommodation-
based services
These include care home services, residential family centre services
and secure accommodation services.
Community-based
services
These include domiciliary support services.
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The service
regulator
Care Inspectorate Wales acting on behalf of the Welsh Ministers in
the exercise of their regulatory functions
Statement of
purpose
The statement of purpose for the place at, from or in relation to
which the service is provided
SCW Social Care Wales, the workforce regulator
Disclosure and
Barring Service
(DBS)
is responsible for:
• providing access to criminal records information through its
disclosure service;
• maintaining lists of individuals barred from working in regulated
activity with children or vulnerable adults; and
• making independent barring decisions about people who have
harmed or are considered to pose a risk of harm to a child or
vulnerable person within the workplace.
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Useful links
The Regulation and Inspection of Social Care (Wales) Act 2016
http://www.legislation.gov.uk/anaw/2016/2/contents/enacted
The Regulated Services (Service Providers and Responsible Individuals) (Wales)
Regulations 2017
http://www.legislation.gov.uk/wsi/2017/1264/made
The Social Services and Well-being (Wales) Act 2014
http://www.legislation.gov.uk/anaw/2014/4/contents
Welsh Government: Well-being Statement for People Who Need Care and Support
and Carers Who Need Support
https://www.gov.wales/well-being-statement-people-who-need-care-and-carers
Care Inspectorate Wales
http://careinspectorate.wales/?lang=en
Care Inspectorate Wales: Registration
https://www.careinspectorate.wales/register-provide-service
Care Inspectorate Wales: Compiling a Statement of Purpose
https://careinspectorate.wales/sites/default/files/2018-
03/180115statementofpurposeguideen.pdf
Care Inspectorate Wales: Securing Improvement and Enforcement policy
https://careinspectorate.wales/sites/default/files/2018-06/180601-securing-improvement-
enforcement-policy-en.pdf
Older People’s Commissioner for Wales
Home - Older People’s Commissioner for Wales
Children’s Commissioner for Wales
Home - Children’s Commissioner for Wales (childcomwales.org.uk)
Social Care Wales
https://www.socialcare.wales/
Social Care Wales: Information and Learning Hub
https://socialcare.wales/hub/home
Wales Safeguarding Procedures
https://safeguarding.wales/en/
Care Inspectorate Wales: Disclosure and Barring Service checks
https://www.careinspectorate.wales/disclosure-and-barring-service-dbs-checks
Disclosure and Barring Service
https://www.gov.uk/government/organisations/disclosure-and-barring-service
Disclosure and Barring Service: Guidance on duty to make barring referrals
https://www.gov.uk/guidance/barring-referrals
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Disclosure and Barring Service: Guidance leaflets
https://www.gov.uk/government/publications/dbs-guidance-leaflets
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Chapter 1: Requirements on Service Providers (Parts 3 to 15 of the Regulations)
1.1 General requirements on service providers (Part 3)
The intent of the general requirements within Part 3 of the Regulations is to ensure that service providers put in place governance
arrangements to support the smooth operation of the service and to ensure that there is a sound base for providing high quality care and
support for individuals using the service and to enable them to achieve their personal outcomes. This includes the following:
• setting clear organisational intent and direction by outlining in the statement of purpose the services provided and the
actions the service provider will undertake to ensure these services are delivered to the required standards.
• putting in place the underpinning policies and procedures to support managers and staff to achieve the aims of the service
and support individuals to achieve their personal outcomes.
• establishing sound management structures to oversee and monitor the service in order to ensure that it operates safely and
effectively for the individuals receiving care and support.
• establishing clear arrangements for an ongoing cycle of quality assurance and review to provide assurance that the service
operates in line with legal requirements and its statement of purpose and is supporting individuals appropriately. Information
obtained through monitoring is used for continued development and improvement of the service.
• maintaining oversight of financial arrangements and investment in the business to ensure financial sustainability so that
individuals using the service are supported to achieve their personal outcomes and are protected from the risk of unplanned
removal or change in the service provided due to financial pressures.
• promoting a culture of openness, honesty and candour at all levels.
Regulation 6
Guidance
Requirements in relation to the provision of the service
6. The service provider must ensure that the service is provided
with sufficient care, competence and skill, having regard to the
statement of purpose.
• Service providers have clear arrangements for the oversight
and governance of the service in order to establish, develop
and embed a positive and compassionate culture which
ensures that the best possible outcomes are achieved for
individuals using the service and to meet the requirements of
the Regulations.
10
• This includes but is not limited to:
o values, attitudes and behaviours of leaders and care
staff which enable individuals to lead confident, inclusive
and empowered lives;
o a rights-based approach where the individual’s rights,
including their human rights, are upheld;
o policies and procedures to achieve the aims of the
statement of purpose and to place people at the centre
of the service;
o systems for assessment, care planning, monitoring and
review which support evidence-based practice and
enable individuals to achieve their personal outcomes;
o processes to ensure care is delivered consistently and
reliably;
o safe staffing arrangements, underpinned by professional
development, to meet the care and support needs of
individuals;
o quality and audit systems to review progress and inform
the development of the service;
o a proactive approach to equal opportunities and
diversity;
o suitable and accessible premises, facilities and
equipment.
Regulation 7
Guidance
Requirements in relation to the statement of purpose
7.(1) The service provider must provide the service in
accordance with the statement of purpose.
(2) The service provider must—
• The statement of purpose is fundamental to the service. It
should:
o accurately describe the services provided;
o state where and how these services will be provided;
and
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(a) keep the statement of purpose under review, and
(b) where appropriate, revise the statement of purpose.
(3) Unless paragraph (4) applies, the service provider must
notify the persons listed in paragraph (6) of any revision to be
made to the statement of purpose at least 28 days before it is to
take effect.
(4) This paragraph applies in cases where it is necessary to
revise the statement of purpose with immediate effect.
(5) If paragraph (4) applies, the service provider must, without
delay, notify the persons listed in paragraph (6) of any revision
made to the statement of purpose.
(6) The persons who must be notified of any revision to the
statement of purpose in accordance with paragraph (3) or (5)
are—
(a) the service regulator,
(b) the individuals,
(c) the placing authority (where relevant), and
(d) any representative, unless it is not appropriate to do so or
would be inconsistent with the well-being of an individual.
(7) The service provider must provide the up to date statement of
purpose to any person on request, unless it is not appropriate to do
so or would be inconsistent with the well-being of an individual.
o state the arrangements to support the delivery of the
services.
• It includes the information set out in The Regulated Services
(Registration) (Wales) Regulations 2017, as amended2.
• In preparing a statement of purpose, the service provider takes
into account any statement of purpose guidance provided by
the service regulator.
• For accommodation-based services, a statement of purpose is
provided for each place/location at which a service will be
provided.
• For domiciliary support services, a statement of purpose is
provided for each place from, or in relation to which, services
are provided.
• Service providers review and update the statement of purpose
at least annually or when changes are being made to the
service provided.
• Where there is an intention to change the service being
provided, the statement of purpose is updated to reflect the
change. The provider notifies those persons set out in
regulation 7(6) at least 28 days prior to the changes being
made. Examples of this include:
o where a service which does not provide nursing care
intends to provide nursing care;
o provision of additional specialist services;
2 S.I. 2017/ 1098 (W.278) https://www.legislation.gov.uk/wsi/2017/1098/pdfs/wsi_20171098_mi.pdf
12
o where a specific service referred to in the statement of
purpose is to be withdrawn; or
o changes to the normal staffing arrangements or levels
as set out in the existing statement of purpose.
• Where there is an intention to change the service being
provided with immediate effect, i.e. within the 28 days
notification period (required by regulation 7(3)), for example in
response to an urgent request, the provider:
o notifies the service regulator immediately (and where
practicable, prior to implementing the change); and
o updates the statement of purpose to reflect the change
without delay and provides a copy to the service
regulator.
• Where a change to the statement of purpose is proposed, the
service provider satisfies the service regulator of their ability to
provide the services proposed by, for example, providing
additional information or receiving a visit from the service
regulator to the service (where appropriate).
• Where the statement of purpose is updated, a record is kept of
the version and date of amendment.
• A copy of the statement of purpose is readily available to
individuals who use the service, staff and any representative
who may request it.
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Regulation 8
Guidance
Requirements in relation to monitoring and improvement
8. (1) The service provider must ensure that there are effective
arrangements in place for monitoring, reviewing and improving the
quality of care and support provided by the service.
(2) Those arrangements must include arrangements for seeking
the views of—
(a) individuals,
(b) any representatives, unless this is not appropriate or would
be inconsistent with the individual’s well-being,
(c) in the case of an individual who is a child provided with
accommodation as part of a care home service, the placing
authority,
(d) service commissioners, and
(e) staff,
on the quality of care and support provided by the service and
how this can be improved.
(3) When making any decisions on plans for improvement of the
quality of care and support provided by the service, the service
provider must—
(a) take into account the views of those persons consulted in
accordance with paragraph (2), and
(b) have regard to the quality of care report prepared by the
responsible individual in accordance with regulation 80(4).
• Service providers have systems and processes in place to
monitor, review and improve the quality of care and support.
This will include identifying:
o who is responsible for ensuring this is done;
o how this will be done;
o how often this takes place;
o arrangements for the responsible individual to report to
the service provider.
• The outcome of any review is analysed and reviewed by
people with the appropriate knowledge, skills and competence
to understand its significance and take action to secure
improvement. Service providers seek professional/expert
advice as needed and in a timely manner to help secure
improvements.
• Service providers can demonstrate how they have:
o analysed and responded to the information gathered;
and
o used the information to make improvements.
• Service providers monitor progress against plans to improve
the quality and safety of services, and take appropriate action
immediately where progress is not achieved as expected.
• The systems and processes are continually reviewed to make
sure they enable the service provider to identify where the
quality and/or safety of services are being, or may be,
compromised and to enable an appropriate timely response.
• As part of the quality review process, service providers:
o encourage feedback;
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o regularly seek the views of the relevant people listed in
regulation 8(2) about the quality of care and support;
and
o are able to demonstrate they have done this and
provide an analysis of the feedback they have
received.
• The methods used to engage with and gain the views of those
listed in regulation 8(2) are appropriate to their age, level of
understanding and take into account their specific condition
and/or any communication impairment. Participation of children
is in line with national guidance.
• Information collated through quality and audit systems is used
to develop the review of quality of care review report in line
with regulation 80(4).
Regulation 9
Guidance
Requirements in relation to the responsible individual
9.(1) This regulation does not apply to a service provider who is
an individual.
(2) A service provider to whom this regulation applies must
ensure that the person who is designated as the responsible
individual—
(a) is supported to carry out their duties effectively, and
(b) undertakes appropriate training.
(3) In the event that the service provider has reason to believe
that the responsible individual has not complied with a
• Service providers have systems and processes in place for
regular formal discussion with, and support for, the responsible
individual.
• Service providers support the responsible individual to
undertake training which enables them to carry out their role
effectively and to meet the aims of the service as outlined in the
statement of purpose and in line with practice guidance
recommended by Social Care Wales. Training for responsible
individuals includes that which covers:
o legislative framework and requirements;
o specific duties of a responsible individual;
o service performance and quality management;
and
15
requirement imposed by the regulations in Parts 16 to 20, the
provider must—
(a) take such action as is necessary to ensure that the
requirement is complied with, and
(b) notify the service regulator.
(4) During any time when the responsible individual is unable
to fulfil their duties, the service provider must ensure that there
are arrangements in place for—
(a) the effective management of the service,
(b) the effective oversight of the service,
(c) the compliance of the service with the requirements of the
regulations in Parts 3 to 15, and
(d) monitoring, reviewing and improving the quality of the care
and support provided by the service.
(5) If the responsible individual is unable to fulfil their duties for
a period of more than 28 days, the service provider must—
(a) notify the service regulator, and
(b) inform the service regulator of the interim arrangements.
o shaping service culture, etc.
• Where a responsible individual has failed to fulfil their role the
service provider notifies the service regulator of any action
taken and, where relevant, advises on the arrangements to
designate a replacement.
• If there is no responsible individual or the responsible individual
is unable to fulfil their duties for any reason, for example they
are absent from their role due to illness, the service provider
ensures that the responsibility for oversight of the management
of the service, as set out in parts 16 to 20 of the Regulations, is
still being met under alternative arrangements.
Regulation 10
Guidance
Requirements in relation to the responsible individual where
the service provider is an individual
10.(1) This regulation applies where the service provider is an
individual.
(2) If this regulation applies, the individual must undertake
appropriate training for the proper discharge of his or her duties
as the responsible individual.
(3) During any time when the individual is absent, he or she
must ensure that there are arrangements in place for—
• The responsible individual undertakes training which enables
them to carry out their role effectively and to meet the aims of
the service as outlined in the statement of purpose and in line
with practice guidance recommended by Social Care Wales.
Training includes that which covers:
o legislative framework and requirements;
o specific duties of a responsible individual;
o service performance and quality management;
and
o shaping service culture, etc.
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(a) the effective management of the service,
(b) the effective oversight of the service,
(c) the compliance of the service with the requirements of the
regulations in Parts 3 to 15, and
(d) monitoring, reviewing and improving the quality of the care
and support provided by the service.
(4) If the individual is unable to fulfil their duties as a
responsible individual for a period of more than 28 days, he or
she must—
(a) notify the service regulator, and
(b) inform the service regulator of the interim arrangements.
• If the responsible individual is unable to fulfil their duties for any
reason, for example they are absent from their role due to
illness, the responsible individual ensures alternative
arrangements are put in place to ensure the requirements in
regulation 10(3) are met.
Regulation 11
Guidance
Requirements in relation to the financial sustainability of the
service
11. (1) The service provider must take reasonable steps to
ensure that the service is financially sustainable for the purpose of
achieving the aims and objectives set out in the statement of
purpose.
(2) The service provider must maintain appropriate and up to
date accounts for the service.
(3) The service provider must provide copies of the accounts to
the Welsh Ministers within 28 days of being requested to do so.
(4) The Welsh Ministers may require accounts to be certified by
an accountant.
• Systems are in place to ensure financial planning, budget
monitoring and financial control is carried out effectively.
• Systems are in place to ensure financial stability and consumer
protection in line with any national guidance and financial
regulations.
• Service providers have the financial resources needed to
provide, and continue to provide, the services described in the
statement of purpose and in order to meet the requirements of
the regulation.
• Service providers have appropriate insurance and suitable
indemnity arrangements in place to cover potential liabilities
arising from death, injury, or other causes, loss or damage to
property, and other financial risks.
17
• Where audited accounts are not available, annual accounts are
completed by a qualified accountant for the purpose of
regulation and inspection.
• The accounts demonstrate that the service is financially viable
and likely to have sufficient funding to continue to fulfil service
delivery as set out in its statement of purpose.
Regulation 12
Guidance
Requirements to provide the service in accordance with
policies and procedures
12. (1) The service provider must ensure that the following
policies and procedures are in place for the service—
Admissions and commencement of the service (see Part 4,
regulation 14)
Safeguarding (see Part 8, regulation 27)
Supporting individuals to manage their money (see Part 8,
regulation 28)
Use of control or restraint (see Part 8, regulation 29)
Staff support and development (see Part 10. regulation 36)
Staff discipline (see Part 10, regulation 39)
Infection control (see Part 14, regulation 56)
Medication (see Part 14, regulation 58)
Complaints (see Part 15, regulation 64)
Whistleblowing (see Part 15, regulation 65)
(2) Where the service includes the provision of accommodation
for children, the service provider must have a policy in place on
the prevention of bullying, procedures for dealing with an
• Service providers have the policies and procedures in place as
required by the Regulations, where it is appropriate and
relevant to the service.
• Policies and procedures are proportionate to the service being
provided in accordance with the statement of purpose.
• Policies and procedures:
o are aligned to any current legislation and national
guidance;
o provide guidance for staff and volunteers to
ensure that services are provided in line with the
statement of purpose; and
o set out requirements to inform individuals and
their representatives about how the service is
provided.
• Policies, procedures and practices are reviewed and updated,
in light of changes to practice, changing legislation and best
practice recommendations.
18
allegation of bullying and a procedure to be followed when any
child for whom accommodation is provided is absent without
permission (see regulation 27(5)).
(3) The service provider must have such other policies and
procedures in place as are reasonably necessary to support the
aims and objectives of the regulated service set out in the
statement of purpose.
(4) The service provider must ensure that the content of the
policies and procedures which are required to be in place by
virtue of paragraphs (1) to (3) is—
(a) appropriate to the needs of individuals for whom care and
support is provided,
(b) consistent with the statement of purpose, and
(c) kept up to date.
(5) The service provider must ensure that the service is provided
in accordance with those policies and procedures.
• Staff, individuals using the service and their representatives
have the opportunity to be involved in developing new, and
amending existing, policies and procedures.
• Where changes are made to the statement of purpose the
policies and procedures are reviewed and updated to reflect
the changes.
• Where changes are made to policies and procedures which
directly affect individuals and/or their representatives, these are
communicated to individuals and any representative in a timely
manner.
• Service providers ensure staff and volunteers have access to,
and knowledge and understanding of, the policies and
procedures which support them in their role in achieving the
best possible outcomes for individuals.
• All policies and procedures are available on request to the
individuals who use the service, their representatives and,
where appropriate, relevant placing authorities and
commissioners.
• Policies and procedures are in a format accessible to the
individual and support is provided to assist individuals’
understanding of these.
• Systems for monitoring and improvement include those which
ensure the service is being run effectively, in accordance with
the policies and procedures.
• Where the service includes the provision of accommodation for
children, the policy and procedures related to regulation 12(2)
includes:
19
o individual roles and responsibilities of staff and
others working at the service, in identifying,
receiving and reporting allegations of bullying.
o individual roles and responsibilities of staff and
others working for the service, in reporting when
a child is absent without permission.
o instructions for staff on actions to be taken, in
such instances, and mechanisms for referral to
relevant partners and agencies.
Regulation 13
Guidance
Duty of candour
13. The service provider must act in an open and transparent
way with—
(a) individuals who are receiving care and support,
(b) any representatives of those individuals, and
(c) in the case of a child who is provided with accommodation,
the placing authority.
• Service providers have policies and procedures in place to
support a culture of openness and transparency and ensure
that all staff and volunteers are aware of and follow them.
These policies and procedures are in line with, and take
account of, Social Care Wales’s guidance on the professional
duty of candour for social care professionals registered with
SCW.
• Service providers promote a culture of candour that includes:
o being open and honest when engaging with individuals
and their representatives when things go wrong;
o providing information about incidents which happen and
the outcome of any investigations that have taken place;
o offering an apology for what has happened, where it is
appropriate to do so.
• Service providers take action to prevent and appropriately
address bullying, victimisation and/or harassment in relation to
the duty of candour, and investigate any instances where a
20
board member, responsible individual or member of staff may
have obstructed another in exercising their duty of candour.
• Service providers have a system in place to identify and deal
with possible breaches of the duty of candour by staff who are
professionally registered, including the obstruction of another in
their professional duty of candour. Action taken to address
such breaches includes, where appropriate, a referral to the
professional regulator or other relevant body.
21
1.2 Requirements on service providers as to the steps to be taken before agreeing to provide care and
support (Part 4)
The intent of the requirements within Part 4 of the Regulations is to provide individuals with assurance that before a service provider
offers care and support they have considered a wide range of information to confirm the service is able to meet the individual’s needs
and support them to achieve their personal outcomes. This includes the individual’s wishes and preferences and consultation with
relevant persons and professionals.
Regulation 14
Guidance
Suitability of the service
14.(1) The service provider must not provide care and support
for an individual unless the service provider has determined that
the service is suitable to meet the individual’s care and support
needs and to support the individual to achieve their personal
outcomes.
(2) The service provider must have in place a policy and
procedures on admissions and commencement of the service.
(3) The determination under paragraph (1) must take into
account—
(a) the individual’s care and support plan,
(b) if there is no care and support plan, the service provider’s
assessment under paragraph (4),
(c) any health or other relevant assessments,
(d) the individual’s views, wishes and feelings,
(e) any risks to the individual’s well-being,
(f) any risks to the well-being of other individuals to whom
care and support is provided,
• Service providers have an admissions and commencement of
the service policy and procedure. This includes but is not
limited to:
o arrangements for confirming that the service can or
cannot support the individuals to achieve their personal
outcomes;
o who will be consulted as part of the process;
o the information to be considered;
o the assessment processes (including for emergency
admissions) and who will undertake the assessment;
o the circumstances where a service will not be provided;
o opportunities to visit the service (in relation to
accommodation-based services); and
o the arrangements for commencing the service.
• A summary of the admission procedure is included in the
statement of purpose and the service provider’s written guide
to the service.
• Before agreeing to provide a service the service provider
makes an informed decision as to whether or not they can
meet an individual’s care and support needs. In making this
decision the service provider:
22
(g) any reasonable adjustments which the service provider
could make to enable the individual’s care and support
needs to be met, and
(h) the service provider’s policy and procedures on admissions
and commencement of the service.
(4) In a case where the individual does not have a care and
support plan, the service provider must—
(a) assess the individual’s care and support needs, and
(b) identify their personal outcomes.
(5) The assessment required by paragraph (4) must be carried
out by a person who—
(a) has the skills, knowledge and competence to carry out the
assessment, and
(b) has received training in the carrying out of assessments.
(6) In making the determination in paragraph (1), the service
provider must involve the individual, the placing authority (if
applicable) and any representative. But the service provider is not
required to involve a representative if—
(a) the individual is an adult or a child aged 16 or over and the
individual does not wish the representative to be involved,
or
(b) involving the representative would not be consistent with
the individual’s well-being.
o takes into account the requirements set out within
regulation 14(3);
o consults with the individual, the placing authority (if
applicable) and/or their representative to determine
what matters to them;
o obtains copies of and gives consideration to any
existing care and support plan, integrated care and
multidisciplinary assessments for adults;
o in the case of a child looked after, obtains a copy of and
considers the Part 6 care and support plan, and works
with the placing authority in planning the child’s
placement;
o in the case of a child looked after aged 16 or over, or a
care leaver up to the age of 21 (or 25 if undertaking a
programme of education or training), obtains a copy of
and considers the young person’s pathway plan;
o considers any risks to the individual or to others using
the service and staff;
o obtains information relating to the individual’s specialist
needs and requirements in order to confirm these can
be met in line with the statement of purpose.
• Service providers ensure there is relevant information and
support for individuals to understand the choices available to
them (including provision from alternative service providers,
where appropriate), in a format accessible to the individual and
suitable to their age and level of understanding.
• Information obtained is sufficient to enable smooth transition
for the individual to receive the service.
• Where the individual lacks the mental capacity to make
specific decisions about their care and support and no lawful
representative is appointed, their best interests are established
23
and acted upon in accordance with the Mental Capacity Act
2005.
• In accommodation-based services consideration is given to
compatibility, the potential impact on the individual and the
service provided to others using the service.
• In domiciliary support services consideration is given to the
ability of the service to meet demand and ensure additional
contracts do not impact on individuals who are already using
the service, for example preferred/required call times.
• People making these decisions on behalf of the service
provider are competent in carrying out assessments and have
sufficient responsibility and authority within the organisation to
be able to decide whether the service can meet the individual’s
care and support needs.
• In the case of adults, confirmation is provided in writing to the
individual that the service can meet the individual’s care and
support needs including health, personal care, emotional,
social, cultural, religious and spiritual needs. Confirmation in
writing is provided where the service is unable to meet the
individual’s care and support needs.
• In addition to consultation with the individual and/or their
representative wider consultation with other relevant partners
takes place. This is essential where there is shared
responsibility for care.
• Where an individual does not have existing assessments and
care and support plans – for example individuals who are self-
funding their care – an assessment is undertaken prior to
agreeing to provide a service. This assessment includes
health, personal care and support needs, any specialist
24
support required, communication, emotional, educational,
social, cultural, religious and spiritual needs and establishes
their personal outcomes and aspirations.
• Where a placement is made on an emergency basis, every
effort is made to secure relevant assessments prior to
placement and to ensure that the service can meet the
individual’s needs.
• Where short stays are provided, updated care and support
plans are reviewed and personal plans amended to reflect any
changes prior to each admission to assure that the service
provider can still meet the individual’s needs.
25
1.3 Requirements on service providers as to the steps to be taken on commencement of the provision of care
and support (Part 5)
The intent of Part 5 of the Regulations is to ensure that individuals can feel confident that service providers have an up to date, accurate
plan (referred to as personal plan) for how their care is to be provided.
The provider develops an initial personal plan before the service begins using existing information, assessments and any care and
support plans in place. The personal plan is then developed further during the first week of using the service through a full assessment
undertaken by the provider (provider assessment) with the individual and their representative. The provider assessment considers their
personal wishes, aspirations and care and support needs. The information from this is used to further develop the personal plan.
The personal plan:
• provides information for individuals and their representatives of the agreed care and support and the manner in which this will
be provided;
• provides a clear and constructive guide for staff about the individual, their care and support needs and the outcomes they
would like to achieve;
• provides the basis for ongoing review; and
• enables individuals, their representatives and staff to measure progress and whether their personal outcomes are met.
Regulation 15
Guidance
Personal plan
15. (1) The service provider must prepare a plan for the
individual which sets out—
(a) how on a day-to-day basis the individual’s care and support
needs will be met,
(b) how the individual will be supported to achieve their
personal outcomes,
• When a decision is made that the service can meet an
individual’s care and support needs an initial personal plan is
developed, co-produced with the individual, the placing
authority (if applicable) and any representative (if appropriate)
before the individual begins to receive care and support.
• In the case of an emergency, the initial personal plan will be in
place within 24 hours of the service commencing.
26
(c) the steps which will be taken to mitigate any identified risks
to the individual’s well-being, and
(d) the steps which will be taken to support positive risk-taking
and independence, where it has been determined this is
appropriate.
(2) The plan which is required to be prepared under paragraph
(1) is referred to in these Regulations as a personal plan.
(3) The personal plan must be prepared prior to commencement
of the provision of care and support to the individual, unless
paragraph (4) applies.
(4) This paragraph applies in a case where the individual is in
urgent need of care and support and there has been no time to
prepare a personal plan prior to the commencement of the
provision of care and support to the individual.
(5) If paragraph (4) applies, the personal plan must be prepared
within 24 hours of the commencement of the provision of care and
support to the individual.
(6) When preparing a personal plan, the service provider must
involve the individual, the placing authority (if applicable) and any
representative. But the service provider is not required to involve a
representative if—
(a) the individual is an adult or a child aged 16 or over and the
individual does not wish the representative to be involved,
or
(b) involving the representative would not be consistent with
the individual’s well-being.
(7) In preparing the personal plan, the service provider must take
into account—
(a) the individual’s care and support plan,
(b) if there is no care and support plan, the service provider’s
assessment under regulation 14(4),
• The initial personal plan is reviewed and updated during the
first 7 days of commencement of service in line with the
outcome of the provider’s assessment (regulation 18).
• The personal plan will set out:
o the actions required to meet the individual’s well-being,
care and support needs on a day-to-day basis. This
includes the details of their care needs (including self
medication), their personal preferences and routines for
how this will be provided;
o how the individual will be supported to achieve their
personal outcomes;
o how the individual’s wishes, aspirations, and religious
beliefs will be supported;
o steps to identify risks to the individual’s well-being and
how this will be managed;
o steps to support positive risk taking;
o steps to maintain, re-able and/or achieve independence.
• When a personal plan is being revised it is co-produced with
the individual receiving care and support, the placing authority
(if applicable) or any representative.
• A copy of the personal plan is provided to the person receiving
the service and in a language and format appropriate to their
needs, age and level of understanding. If there is a reason for
not doing so this is documented.
• The personal plan is accessible and in a clear format to inform
staff about how they should provide care and support on a
daily basis to meet an individual’s needs and support them to
achieve their personal outcomes.
27
(c) any health or other relevant assessments,
(d) the individual’s views, wishes and feelings,
(e) any risks to the individual’s well-being, and
(f) any risks to the well-being of other individuals to whom
care and support is provided.
• The personal plan takes into account any care and support
plan prepared by a local authority for the person under section
54 of the 2014 Act.
• The personal plan takes into account any health or other
relevant assessments and/or plans such as person-centred
behavioural support plans.
• In drawing up a personal plan for a child looked after, the
service provider works with the placing authority to ensure the
plan takes into account the child’s Part 6 care and support plan
(including the health plan, personal education plan and
placement plan for the child).
• For a child looked after aged 16 or over and care leavers up to
age 21 (or 25 if undertaking a programme of education or
training), the provider takes into account the young person’s
pathway plan.
• For a residential family centre service, a personal plan relates
to the individual or the family.
Regulation 16
Guidance
Review of personal plan
16. (1) The personal plan must be reviewed as and when
required but at least every three months.
(2) In the case of a child who is looked after by a local authority,
any review of the personal plan must be aligned with the reviews
required to be carried out by the local authority under the Care
• The personal plan is kept under review and is amended and
developed to reflect changes in the individual’s care and
support needs and personal outcomes.
• The plan is reviewed every three months or sooner, if there is
a change in the individual’s needs, and in line with any reviews
undertaken by the placing authority.
28
Planning, Placement and Case Review (Wales) Regulations
2015(3).
(3) Reviews of a personal plan must include a review of the
extent to which the individual has been able to achieve their
personal outcomes.
(4) When carrying out a review under this regulation, the service
provider must involve the individual, the placing authority (if
applicable) and any representative. But the service provider is not
required to involve a representative if—
(a) the individual is an adult or a child aged 16 or over and the
individual does not wish the representative to be involved,
or
(b) involving the representative would not be consistent with
the individual’s well-being.
(5) Following the completion of any review required by this
regulation, the service provider must consider whether the personal
plan should be revised and revise the plan as necessary.
• In the case of a child looked after, the provider ensures that
the three-monthly reviews aligns with the child’s ‘children
looked after’ review undertaken by the child’s placing authority.
A review of the personal plan is undertaken after every
‘children looked after’ review.
• Reviews are undertaken involving the individual and, where
appropriate, with the agreement of the individual, their
representative.
• Reviews take into account the information recorded on a daily
basis relating to the individual achieving their personal
outcomes. Where this differs significantly from any
commissioning body’s assessment and care and support plan,
the relevant commissioner is notified.
• Where applicable, reviews take into account the latest, up to
date control and restraint records in relation to the individual.
Regulation 17
Guidance
Records of personal plans
17. The service provider must—
(a) keep a record of—
i. the personal plan and any revised plan, and
ii. the outcome of any review, and
(b) give a copy of the personal plan and any revised plan to—
• A copy of the personal plan is provided in a format and
language appropriate to the person’s needs.
• Individuals, the placing authority (if applicable) and any
representatives are informed about how they can access the
personal plan.
3 S.I. 2015/1818 (W. 261) https://www.legislation.gov.uk/wsi/2015/1818/pdfs/wsi_20151818_mi.pdf
29
i. the individual,
ii. any representative, unless this is not appropriate or
would be inconsistent with the individual’s well-being,
and
iii. where a child is provided with accommodation as
part of a care home service, the placing authority.
Regulation 18
Guidance
Provider assessment
18.(1) Within 7 days of the commencement of the provision of
care and support for an individual, the service provider must—
(a) assess how the individual’s care and support needs can
best be met,
(b) assess how the individual can best be supported to achieve
their personal outcomes,
(c) ascertain the individual’s views, wishes and feelings,
(d) assess any risks to the individual’s well-being, and
(e) assess any risks to the well-being of other individuals to
whom care and support is provided.
(2) The assessment under paragraph (1) is referred to in these
Regulations as a provider assessment.
(3) A provider assessment must be carried out by a person
who—
(a) has the skills, knowledge and competence to carry out the
assessment, and
(b) has received training in the carrying out of assessments.
(4) A provider assessment must take into account—
• A provider assessment builds on the information which has
informed the decision to provide a service for the individual,
including any existing care and support plan. The assessment
is proportionate to the nature of the placement and the
individual’s particular circumstances.
• The provider assessment identifies:
o the individual’s personal outcomes;
o the care and support needed to support individuals to
achieve their personal outcomes;
o their personal preferences (taking into account any
religious or philosophical beliefs or cultural background)
in how these can be achieved;
o any risks to the individual’s well-being or risks to the
well-being of others and how these will be mitigated;
and
o areas which require more in depth or specialist
assessment.
• The assessment is coproduced with the individual intending to
or currently using the service and/or their representative.
30
(a) the individual’s care and support plan, if available,
(b) the service provider’s assessment under regulation 14(4), if
applicable,
(c) any health or other relevant assessments,
(d) the individual’s views, wishes and feelings,
(e) any risks to the individual’s well-being, and
(f) the service provider’s policy and procedures on admissions
and commencement of the service.
(5) When carrying out or revising a provider assessment, the
service provider must involve the individual, the placing authority
(if applicable) and any representative. But the service provider is
not required to involve a representative if—
(a) the individual is an adult or a child aged 16 or over and the
individual does not wish the representative to be involved,
or
(b) involving the representative would not be consistent with
the individual’s well-being.
(6) A provider assessment must be kept under review and
revised as necessary.
(7) Following the completion of the provider assessment and any
revised assessment, the personal plan must be reviewed and
revised as necessary.
(8) The service provider must keep a record of a provider
assessment and give a copy of the assessment to the individual,
any representative and, where the child is provided with
accommodation by a care home service, the placing authority.
• The outcome of the provider assessment informs the
development of the personal plan within the first 7 days of the
individual commencing the service.
• Persons undertaking the provider assessment on behalf of the
service provider:
o are competent and experienced in undertaking
assessments; and
o have experience and training in the provision of care for
the individuals they are assessing.
• Where individuals have complex and specialist needs the
person undertaking the assessment has training relevant to
those needs or seeks the advice and guidance of a relevant
specialist.
• Where individuals have nursing needs the assessment is
undertaken by a registered nurse with the relevant skills.
• Where individuals are supported by a range of service
providers there is collaboration to ensure that all partners are
clear about their responsibilities in relation to that individual for
the purposes of the assessment and the review of their needs.
• Tools for assessment reflect up to date good practice guidance
and legislation.
• Assessments are reviewed and revised whenever there is a
significant change in an individual’s needs or where the
personal plan is not supporting the individual to achieve their
personal outcomes.
• The personal plan is revised and updated as required following
any provider assessment.
31
1.4 Requirements on service providers as to the information to be provided to individuals on commencement
of the provision of care and support (Part 6)
The intent of Part 6 of the Regulations is to ensure that individuals are provided with information about the service to enable them to
have:
• a clear understanding of the culture and ethos of the service;
• an outline of the services they can expect to receive;
• an understanding of the manner in which services will be provided; and
• the terms and conditions of the service.
This should enable individuals, placing authorities and any representatives to have a good understanding of how the service operates in
providing care and support. The written guide also contains the information they need to raise concerns and make complaints to service
providers when they are dissatisfied with the service and informs them of how to escalate concerns if they are not satisfied with the
response.
Regulation 19
Guidance
Information about the service
19.(1) The service provider must prepare a written guide to the
service.
(2) The guide must be—
(a) dated, reviewed at least annually and updated as
necessary,
(b) in an appropriate language, style, presentation and format,
having regard to the statement of purpose for the service,
(c) given to all individuals who are receiving care and support,
(d) in the case of child who is looked after by a local authority,
given to the placing authority, and
• A written guide is available to individuals, the placing authority
and any representatives, which provides information about the
service.
• The guide is in plain language and in a format that reflects the
needs, age and level of understanding for whom the service is
intended. The guide is made available in formats and media
accessible and appropriate to the audience. For example,
preferred and appropriate language, large print, audio,
computerised, visual aids. When required it is explained in the
individual’s preferred method of communication.
• Where required individuals are supported to understand the
contents of the guide and what it means for them.
32
(e) made available to others on request, unless this is not
appropriate or would be inconsistent with the well-being of
an individual.
(3) The guide must contain the following information—
(a) information about how to raise a concern or make a
complaint;
(b) information about the availability of advocacy services.
(4) The service provider must ensure that all individuals receive
such support as is necessary to enable them to understand the
information contained in the guide.
• The guide sets out the areas required by regulation 19(3) and
in addition includes the following:
o arrangements for welcoming and supporting individuals;
o the ethos, culture and priorities of the regulated service
including a summary of the statement of purpose;
o how to access the most recent inspection report
completed by the service regulator;
o how to access the most recent annual return for the
service;
o key staff who will be supporting the individual;
o how to contact the responsible individual;
o the opportunities and mechanisms for the involvement
of families, carers, volunteers and the community;
o the complaints procedure and how to make a complaint;
o contact details and role of the Public Services
Ombudsman for Wales, service regulator, Citizen Voice
Body (Llais), Children’s Commissioner for Wales and
Older People’s Commissioner for Wales (as
appropriate);
o access to, and support to access, relevant advocacy
services and other agencies or services, such as
primary healthcare services (GP, Dentist, Optometrist,
Pharmacist, Chiropodist, Hospital visits);
o access to, and support to access, relevant digital
communication devices and/or assistive technology
o arrangements for contributing views and participation in
the running of the service;
o fees – range, any additional fees or costs payable by
the individual, method of payment, notice of increase;
and
o terms and conditions including circumstances in which
the service may cease to be provided and notice
periods; and
33
o how individuals can access their own records.
• Additional requirements for accommodation-based services:
o policy on accommodating personal preferences, e.g.
pets, furniture etc;
o availability of, and support to access, telephone,
Wi fi, internet etc;
o activities, including support to access community
services and activities;
o facilities available as part of the service; and
o information about health and safety including any fire
safety and evacuation procedures.
Regulation 20
Guidance
Service agreement
20. (1) The service provider must ensure that every individual is
given a signed copy of any agreement relating to—
(a) the care and support provided to the individual;
(b) any other services provided to the individual.
(2) The service provider must ensure that individuals receive
such support as is necessary to enable them to understand the
information contained in any such agreement.
• Individuals using the service are given a copy of the agreement
/contract which details the individual service to be provided
and, where applicable:
o information about any costs payable by the individual
and what they cover;
o information about any costs payable by the placing
authority and what they cover;
o arrangements for how payments are to be made;
o any late payment charges;
o terms and conditions of the service including termination
of contract and notice period;
o arrangements and timescales for notifying individuals of
contractual changes; and
o the rooms to be used in accommodation-based
services.
so that they can make decisions about their care and support.
34
• Service providers give individuals or their representatives a
written estimate of the costs of the care and support payable
by the individual, in a format accessible to the individual and
suitable to their age and level of understanding. This includes
details of any likely additional costs and charges.
• In the case of children looked after, this information will also be
provided to the placing authority.
• Service agreements and contracts are in line with consumer
law.
35
1.5 Requirements on service providers as to the standard of care and support to be provided (Part 7)
The intent of Part 7 of the Regulations is to ensure that individuals are provided with the quality of care and support they need to achieve
the best possible well-being outcomes. The service is designed in consultation with the individual and considers their personal wishes,
aspirations and outcomes and any risks and specialist needs which inform their needs for care and support
This includes:
• ensuring care and support enables an individual to meets their personal outcomes;
• provision of staff with the knowledge, skills and competency to meet an individual’s well-being needs;
• ensuring staff have the appropriate language and communication skills;
• planning and deploying staff to provide continuity of care; and
• consultation with and seeking support from relevant agencies and specialists where required.
Regulation 21
Guidance
Standards of care and support – overarching requirements
21.(1) The service provider must ensure that care and support is
provided in a way which protects, promotes and maintains the
safety and well-being of individuals.
(2) The service provider must ensure that care and support is
provided to each individual in accordance with the individual’s
personal plan.
(3) The service provider must ensure that care and support is
provided in way which—
(a) maintains good personal and professional relationships
with individuals and staff; and
(b) encourages and assists staff to maintain good personal
and professional relationships with individuals.
• The service provider’s approach to standards of care and
support, including any person-centred positive behaviour
support, is clearly set out in the statement of purpose.
• Achievement of an individual’s personal outcomes are
supported by policies and procedures.
• Policies and procedures include the management of specific
needs that are in line with any current legislation, national
guidance and reflect evidence-based practice.
• Service providers ensure the service is responsive and
proactive in identifying and mitigating risks, and in supporting
positive risk-taking and independence where it has been
determined this is appropriate.
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(4) If, as a result of a change in the individual’s assessed needs,
the service provider is no longer able to meet those needs, even
after making any reasonable adjustments, the provider must
immediately give written notification of this to the individual, any
representative, the service commissioner and the placing
authority.
• Service providers ensure medical advice and professional help
for an individual is sought (where appropriate) or a referral to
commissioners is made in a timely manner. Where
accommodation is not provided arrangements are in place for
referral to specialist services for support and advice, where
appropriate
• Service providers ensure care and support is delivered in a
dignified and respectful manner in which staff and volunteers
have meaningful interactions and positive and caring attitudes
towards individuals.
• Service providers ensure care and support is provided in
keeping with any assessment and personal plan, meets the
individual’s needs and supports them to achieve their personal
outcomes in relation to their:
o physical, mental and emotional well-being;
o cultural, religious, social or spiritual preferences;
o education, training and recreation needs;
o family and personal relationships;
o control over everyday life and where relevant
participation in work;
o intellectual, emotional and behavioural development;
o rights and entitlements, in particular with regard to the
United Nations Convention on the Rights of the Child,
o protection from abuse, neglect and improper treatment.
• Personal plans include sufficient detail to inform and enable
staff to meet the individual’s care and support needs and
support individuals to achieve the best possible outcomes.
This is based on relevant guidance, information or prescribed
practice.
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• Where the service provider can no longer meet an individual’s
assessed needs, the written notification is in accordance with
consumer law.
Examples of this include:
Individuals are supported to have independence, choice and
control in their day-to-day life and with their personal
development
• Individuals are supported to fulfil their potential and do things
that matter to them and make them happy. This can include
being involved in everyday decisions such as choosing their
own meals, the activities they take part in and their routines,
and being supported to participate in or complete education or
lifelong learning, developing and maintaining hobbies, joining
community activities and volunteering.
• Individuals are involved in decisions about their care options,
adaptations to their environment and the equipment they use.
• Children and young people are supported to be healthy and
active and undertake activities that support them to be healthy.
• Children and young people are encouraged to develop daily
routines that promote their well-being, such as mealtimes and
bed times.
• Individuals are encouraged and supported to be as
independent as possible, to do what they can for themselves,
including support for self-care such as self-medication.
• Children and young people receive support to develop
independent living skills.
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• Individuals are supported in their choices to have visits from
family, friends and others and to meet with them in private if
that is their preference.
• Individuals are supported in their choices to go out unless it is
not appropriate or would be inconsistent with the well-being of
an individual.
• Service providers work with the individual, their representatives
and other professionals involved in the individual’s life to
ensure support is available if the individual leaves the service,
such as pathway planning, in line with national guidance.
• Individuals are supported and prepared for moving on.
• Individuals are supported and prepared if they leave the
service, both when this is planned or in an emergency.
Individuals are supported with their emotional and mental
well-being
• Where individuals are at risk of emotional and well-being
difficulties, service providers support individuals to:
o feel they are respected as individuals and that their
identity is recognised and valued;
o feel they have choice and control and are listened to;
o feel secure and safe;
o feel they belong and matter to others;
o enjoy safe and healthy relationships with family and
friends and to develop new relationships; and
o experience continuity.
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• Service providers recognise and respond positively to
individual’s emotional needs especially when they are
experiencing difficulty, for example when individuals are lonely,
distressed, experiencing transition or loss, or experiencing
anxiety, depression or other forms of mental illness.
• Staff receive appropriate training to understand behaviours
and adopt strategies to support individuals with their
behaviours to achieve positive well-being and outcomes.
• Policy and procedures include the individual roles and
responsibilities of staff or others working at the service in
relation to person-centred positive behaviour support. This is
aligned with any current national guidance and evidence-
based practice.
Individuals are supported to maintain a healthy diet and fluid
intake
• Where food and/or drink is provided for individuals, there is a
choice which meets their needs and preferences as far as is
reasonably practical.
• Healthy choices of food are available and are promoted.
• Mealtimes are a positive experience and, where required,
individuals are supported sensitively to eat and drink.
• Where assessments are undertaken this includes the
identification, using nationally recognised tools and evidence-
based guidance, of where an individual’s nutritional or fluid
intake could be compromised.
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• Where individuals are identified as being at risk of weight loss
or dehydration there is effective monitoring of weight,
nutritional and fluid intake, and remedial action is taken when
concerns arise or persist.
• Where necessary, additional specialist advice is sought to
support care. Prescribed treatments and support, including
specialist diets and food and drink preparation, is adhered to.
Individuals are supported to manage skin integrity
appropriately
• Where skin integrity assessments are needed, they are only
undertaken using assessment tools approved by Public Health
Wales. Individuals assessed as being at risk are put on the
SKIN bundle (Public Health Wales).
• Staff completing the skin integrity assessment have the
required skills and knowledge in both skin assessment,
management and treatment of pressure ulcers/wounds.
• Pressure relieving equipment is appropriate, in good working
order and relevant to the risk assessment rating.
• Where necessary, additional specialist advice is sought to
support care.
Individuals are supported with maintaining and managing
continence
• Where appropriate, individuals are supported to maximise their
independence with personal toileting routines.
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• Care and support is provided with continence management
and is provided in a way which protects the individual’s dignity
and privacy.
• Service providers ensure that an assessment of individuals’
continence is undertaken, where relevant. This is undertaken
using recognised tools, and additional expert support and
advice is sought where necessary.
• Recommendations for managing continence, including the use
of specialist aids and products, are outlined in the personal
plan and are followed by staff.
Individuals are supported to identify and manage sensory
impairment appropriately
• Where appropriate, service providers ensure individuals
receive relevant checks and provide support to access ongoing
reviews.
• Where individuals have been provided with aids such as
hearing aids and glasses, staff understand their importance
and are proactive in supporting individuals to use them.
• Service providers ensure that any aids are appropriately
maintained so they may be used effectively.
• Service providers consider the potential impact on individuals
with sensory impairment when planning the environment, for
example, the effects of noise in communal areas on individuals
who have a hearing impairment.
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Individuals are supported with their cognitive impairment
• Service providers recognise and understand the specialist
needs of individuals who have been identified as having a
cognitive impairment. The service provider provides individual
therapy activities and specific programmes to prevent or
manage a particular condition or behaviour and to enhance the
quality of life for individuals.
• Care and support is based on recognised evidence-based
guidance and frameworks relevant to the individual’s
impairment and in line with the service provider’s statement of
purpose.
• Staff receive appropriate training to understand cognitive
impairment. This includes pain recognition and pain
management, and how to communicate with, and employ
strategies to support, individuals with cognitive impairment to
help them achieve positive well-being and outcomes.
• Individuals are given ongoing support and encouragement to
motivate or enable them to take part in daily life.
• Service providers seek expert assessments and advice, where
appropriate, for individuals who have ongoing difficulties and/or
cognitive deterioration. The outcome of any assessment
prompts a review of the personal plan and of the support
provided to the individual.
Individuals are supported to have effective oral hygiene and
dental health
• Individuals are encouraged to care for their teeth and mouth
and, where necessary, are provided with support to do so.
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• Appropriate oral healthcare supplies are readily available and
kept in good condition.
• Oral healthcare is monitored as part of daily care and remedial
action is taken where issues are identified.
• Where appropriate, individuals are assisted to access regular
dental heath checks or to visit a dentist if pain or decay is
suspected.
Individuals are supported appropriately during their last days
of life
• Where appropriate, as part of the provider assessment, service
providers ascertain the individual’s wishes and preferences
regarding their end-of-life care and support.
• Their personal plan reflects advance statements and advance
decision making including details of any legal lasting power of
attorney for health and welfare.
• The care and support provided reflects any current national
guidance.
• Individuals are able to spend their last days of life at the
service if that is their wish, or at home, unless there is a
medical reason why this should not occur.
• Individuals are supported in their own room and are able to
have significant others with them as they wish.
• Service providers work collaboratively with other agencies to
provide end of life care and any palliative intervention.
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• Service providers communicate effectively with family
members and representatives regarding palliative care
arrangements and end of life care.
Regulation 22
Guidance
Continuity of care
22. The service provider must put arrangements in place to
ensure that individuals receive such continuity of care as is
reasonable to meet their needs for care and support.
• Service providers have the staff and resources available to
provide a service in line with the statement of purpose and to
meet an individual’s care and support needs.
• Individuals know staff at the service. They are told about staff
changes which affect them and new workers are routinely
introduced to them.
• Staffing arrangements provide consistency of care and
support. Where replacement staff are used they are familiar
with, and have a good understanding of, the individuals to
whom they are providing care and support.
Regulation 23
Guidance
Information
23.(1) The service provider must ensure that individuals have the
information they need to make or participate in assessments,
plans and day to day decisions about the way care and support is
provided to them and how they are supported to achieve their
personal outcomes.
(2) Information provided must be available in the appropriate
language, style, presentation and format, having regard to—
• Service providers ensure that individuals are able to make
decisions about their lives and are supported where necessary
to do this.
• Individuals are offered the opportunity and are enabled to
contribute their views about the day to day running of the
service.
• Service providers put in place arrangements to enable
individuals to access relevant advocacy services or self
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(a) the nature of the service as described in the statement of
purpose;
(b) the level of the individual’s understanding and ability to
communicate;
(c) in the case of a child, the child’s age.
(3) The service provider must ensure that the individual receives
such support as is necessary to enable them to understand the
information provided.
advocacy groups (if they wish) and support for their
communication needs to enable them to make decisions about
their lives.
Regulation 24
Guidance
Language and communication
24. (1) The service provider must take reasonable steps to meet
the language needs of individuals.
(2) The service provider must ensure that individuals are
provided with access to such aids and equipment as may be
necessary to facilitate the individual’s communication with others.
• Service providers have arrangements in place to assist
individuals with their specific communication and language
needs in line with the statement of purpose. Where necessary
this will include putting measures in place to ensure that
individuals can communicate meaningfully. This includes:
o the individual’s language of need and choice;
o additional means of communication such as Picture
Exchange Communication System (PECS),
Treatment and Education of Autistic and related
Communication handicapped Children (TEACCH),
Makaton, British Sign Language (BSL) where
appropriate.
• Service providers identify an individual’s communication
needs as part of their determination as to whether the service
can meet their needs.
• Individuals can understand staff when they communicate with
them.
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• Service providers ensure that aids and equipment required to
support individual’s communication needs are in place,
accessible, well maintained and that staff know how to use
them.
• Service providers evidence their commitment to deliver or
work towards actively offering a service in the Welsh language
to individuals whose first language is Welsh.
Regulation 25
Guidance
Respect and sensitivity
25. (1) The service provider must ensure that individuals are
treated with respect and sensitivity.
(2) This includes, but is not limited to,—
(a) respecting the individual’s privacy and dignity;
(b) respecting the individual’s rights to confidentiality;
(c) promoting the individual’s autonomy and independence;
(d) having regard to any relevant protected characteristics (as
defined in section 4 of the Equality Act 2010) of the
individual.
• Service providers ensure that individuals are:
o listened to, and communicated with, in a courteous and
respectful manner with their care and support being the
main focus of staff’s attention; and
o treated with respect and feel valued.
• Individuals requiring intimate personal care have this provided
in a dignified way with their personal preferences respected.
This is agreed with the individual and recorded in their
personal plan.
• Individuals are encouraged to take part in everyday tasks and
contribute their views, if they choose to, on the way the in
which the service is run.
• Technology and specialist equipment are provided or made
accessible to enable individuals to call for assistance and to
enable people to manage their own needs.
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1.6 Requirements on service providers – safeguarding (Part 8)
The intent of Part 8 of the Regulations is to ensure that service providers have in place effective mechanisms to safeguard individuals to
whom they provide care and support.
This includes arrangements that:
• promote the safety and well-being of individuals using the service;
• support and underpin staff and volunteers’ knowledge, understanding and skill in identifying risks and action to take where
abuse, neglect or improper treatment is identified or suspected; and
• ensure the service provider works collaboratively with partners to prevent and take action where abuse, neglect or improper
treatment is identified or suspected.
The arrangements recognise that risks may arise from within the service itself or from others.
Regulation 32 sets out the definitions of ‘abuse’, ‘neglect’ and ‘improper treatment’. It explains that in relation to a child, ‘abuse’ also
includes any other form of ‘harm’ within the meaning of section 197(1) of the 2014 Act.
Regulation 26
Guidance
Safeguarding – overarching requirement
26. The service provider must provide the service in a way which
ensures that individuals are safe and are protected from abuse,
neglect and improper treatment.
• When they begin using the service, individuals and their
representatives are given information about safeguarding, how
to raise a safeguarding concern and the support available to
enable them to do so (including how to access advocacy
services).
• Staff and volunteers have access to up-to-date safeguarding
policies and procedures and are supported to act in
accordance with them.
• Staff receive training relevant to their role at induction to
enable them to understand their responsibility to safeguard
and protect individuals. This includes both internal and local
safeguarding arrangements including how to raise a
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safeguarding concern and how the service provider’s
whistleblowing policy supports raising a concern about a
member of staff or volunteer.
• Staff training is ongoing at regular intervals in line with local
safeguarding arrangements, and in accordance with Social
Care Wales’ safeguarding training, learning and development
standards.
• Staff and volunteers are aware of their individual
responsibilities for raising safeguarding concerns to ensure the
safety and well-being of individuals.
• Service providers make provision to support staff and
volunteers raising safeguarding concerns (including in line with
their whistleblowing policy).
• Service providers work in partnership with other relevant
professionals and agencies to assess and manage risks to
individuals using the service and to participate in the
safeguarding process.
• Records of safeguarding referrals and outcomes are
maintained to enable oversight and scrutiny of safeguarding
within the service. Protection of individuals is overseen by the
manager and responsible individual and within the governance
structure, with arrangements made for oversight at board level.
• The service provider ensures outcomes arising from any
safeguarding referral are communicated to the individual in a
method appropriate to their age and level of understanding
taking into account their specific condition and any
communication impairment. This is also communicated to any
representatives (if appropriate).
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Regulation 27
Guidance
Safeguarding policies and procedures
27.(1) The service provider must have policies and procedures in
place—
(a) for the prevention of abuse, neglect and improper
treatment, and
(b) for responding to any allegation or evidence of abuse,
neglect or improper treatment.
(2) In this regulation, such policies and procedures are referred
to as safeguarding policies and procedures.
(3) The service provider must ensure that their safeguarding
policies and procedures are operated effectively.
(4) In particular, where there is an allegation or evidence of
abuse, neglect or improper treatment, the service provider must—
(a) act in accordance with their safeguarding policies and
procedures,
(b) take immediate action to ensure the safety of all individuals
for whom care and support is provided,
(c) make appropriate referrals to other agencies, and
(d) keep a record of any evidence or the substance of any
allegation, any action taken and any referrals made.
(5) Where the service includes the provision of accommodation
for children, the service provider must have the following policies
and procedures in place—
(a) a policy on the prevention of bullying;
(b) procedures for dealing with an allegation of bullying;
• There is an up to date safeguarding policy and procedures in
place.
• Safeguarding policies and procedures are aligned to current
legislation, national guidance and local adult and children’s
safeguarding procedures. They should reflect and align with
the Wales Safeguarding Procedures.
• Safeguarding policies and procedures include the individual
roles and responsibilities of staff and others working at the
service in identifying, responding to, and reporting on
allegations of abuse, neglect or improper treatment or any
suspected abuse, neglect or improper treatment. This will
include instruction for staff and volunteers on actions to be
taken to refer concerns to the local authority, and other
relevant partners and agencies.
• Staff supervision processes regularly revisit safeguarding
procedures and seek to identify and address any gaps in staff
knowledge.
• Where there is any allegation or evidence of abuse, neglect or
improper treatment, arising within the service or otherwise, the
service provider ensures that immediate action is taken to
ensure the safety of individuals for whom care and support is
provided and makes appropriate referrals to other relevant
agencies (which may include a local authority) to ensure that
individuals are safe and protected.
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(c) the procedure to be followed when any child for whom
accommodation is provided is absent without permission.
• Service providers ensure that individuals are informed of their
right to independent professional advocacy services in raising
a safeguarding concern.
Regulation 28
Guidance
Supporting individuals to manage their money
28. (1) The service provider must have a policy and procedures
in place about supporting individuals to manage their money and
must ensure that the service is provided in accordance with such
policy and procedures.
(2) The policy and procedures which are required by this
regulation to be in place must set out the steps which are to be
taken to enable and support people to manage their own money
and to protect individuals from financial abuse.
(2A) Where a service provides accommodation for children, the
policy and procedures required by this regulation must set out the
steps which the service provider will take to ensure adequate
oversight and monitoring of savings made by or on behalf of
children including arrangements for keeping records of savings
(and expenditure from savings) and passing on these records
when a placement comes to an end.
(3) Where an individual’s money is held by the service provider
for any purpose (apart from moneys held for the purpose of paying
charges payable by the individual in accordance with any
agreement with the service provider), the policy and procedures
required by this regulation must provide—
(a) that the money is held in an account in the individual’s
name or in an account which enables clear demarcation of
each individual’s money;
• Policy and procedures set out arrangements for supporting
individuals to manage their money. This includes:
o how individuals are encouraged and supported to
handle their own financial affairs as they wish/where
possible;
o how individuals will be supported, including opening and
managing individual bank accounts, budgeting and
making spending decisions;
o how individuals are supported to understand and
manage any associated risks; and
o how the service provider ensures that those staff not
required to support the individual to manage their
money or others working in or connected with the
service are precluded from involvement with individuals'
financial affairs.
• Where accommodation is provided to children, service
providers ensure arrangements are in place to oversee and
monitor the savings of a child.
• Where accommodation is provided to children, policy and
procedures set out:
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(b) any such account is not used in connection with the
management of the service.
(4) The service provider must ensure so far as practicable that
persons working at the service do not act as the agent of an
individual.
o how children will be supported to understand and
access any financial allowances they may be entitled to,
where applicable to the child; and
o how records and receipts of expenditure related to a
child’s savings will be dealt with when a placement ends
• Where individuals are not able to manage their own finances,
records and receipts are maintained of any financial
transactions undertaken on their behalf.
• Where staff are supporting individuals to manage their money,
this is recorded in the individual’s personal plan.
• Arrangements are in place for oversight and review of
management of finances by the service provider.
• Where the service handles individuals’ money, the service
provider ensures that the personal finances of the individuals
are not pooled with the finances of the service.
• Money is held in an account in the individual’s name (or an
account with clear demarcation of the individual’s money) and
is spent as they wish. Appropriate records and receipts are
kept.
• There are arrangements in place for the safe storage of money
and valuables. Records are be maintained of any possessions
handed over for safekeeping.
• Arrangements are in place for individuals to access
independent support and advice (including advocacy, where
appropriate) concerning their financial affairs, including in
relation to Wills, bequests, or legacies.
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• Staff or others working at the service or involved with the
service do not act as agents (to act on behalf of the individual)
unless they have the lawful authority to do so.
• Service providers ensure that money donated to or collected
specifically for the benefit of the individuals using the service is
not used for routine expenditure.
Regulation 29
Guidance
The appropriate use of control and restraint
29.(1) Care and support must not be provided in a way which
includes acts intended to control or restrain an individual unless
those acts—
(a) are necessary to prevent a risk of harm posed to the
individual or another individual, and
(b) are a proportionate response to such a risk.
(2) Control or restraint must not be used unless it is carried out
by staff who are trained in the method of control or restraint used.
(3) The service provider must have a policy on the use of control
or restraint and ensure that any control or restraint used is carried
out in accordance with this policy.
(4) A record of any incident in which control or restraint is used
must be made within 24 hours.
(5) For the purposes of this regulation, a person controls or
restrains an individual if that person—
(a) uses, or threatens to use, force to secure the doing of an
act which the individual resists, or
• Service providers ensure a positive and constructive approach
is adopted to support an individual’s behaviour. This is
informed by person-centred planning to reduce the likelihood
of situations arising where restrictive practices are absolutely
necessary.
• Any strategies or measures taken to support the individual’s
behaviour are consistent with:
o meeting the individual’s needs for care and support;
o the well-being of other individuals for whom care and
support is provided.
• There is a policy in place for the appropriate use of control,
restraint or restrictive practice which reflects current national
guidance.
• Staff are aware of and understand and follow the policy and
procedures on the appropriate use of control, restraint or
restrictive practice.
• As part of their induction, staff receive positive behaviour
support training that is relevant to their role. Any control,
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(b) restricts the individual’s liberty of movement, whether or not
the individual resists, including by the use of physical,
mechanical or chemical means.
restraint or restrictive practices are only used when absolutely
necessary, in line with current national guidance.
• Staff are kept up to date on the policy and procedures in line
with any changes to guidance and legislation.
• Service providers ensure that if using forms of control, restraint
or restrictive practice, they are able to check it:
o is proportionate to the risk of harm and the seriousness
of that harm to the person using the service or another
person;
o takes account of the assessment of the person’s needs
and their capacity to consent to such treatment; and
o follows current legislation and guidance.
• Where an individual lacks mental capacity to consent to the
arrangements for their care and support, service providers
follow the statutory principles and provisions of the Mental
Capacity Act 2005 and the Deprivation of Liberty Safeguards,
where appropriate. Service providers ensure acts of care and
support are in the person’s best interest and there is lawful
authority in place where required.
• Service providers and staff regularly monitor and review the
approach to, and use of control, restraint or restrictive practice
and report on this within their governance framework. This
includes:
o the details of the incident and actions taken in response;
and
o sufficient detail to enable analysis and review of the
individual’s care and support needs as well as to inform
wider review of service provision.
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• Records of the use of control, restraint and restrictive practice
are reviewed and reported upon within the quality-of-care
review.
• Secure accommodation providers act in accordance with the
terms of the Secure Accommodation Order made by the court.
Regulation 30
Prohibition on the use of corporal punishment
30. (1) A service provider who provides a care home service, a secure accommodation service or a residential family centre service
must ensure that persons working at the service use no form of corporal punishment at any time against any child to whom
accommodation is provided.
(2) A service provider who provides a domiciliary support service must ensure that persons working at the service use no form of
corporal punishment at any time against any child to whom care and support is provided.
Regulation 31
Guidance
Deprivation of liberty
31. An individual must not be deprived of their liberty for the
purpose of receiving care and support without lawful authority.
• Service providers act at all times in accordance with the Mental
Capacity Act 2005 and Deprivation of Liberty Safeguards as
well as the Code of Practice to the Mental Capacity Act 2005
and supplementary Code of Practice for Deprivation of Liberty
Safeguards.
• Staff are trained at appropriate intervals and in line with any
changes to guidance and legislation to understand their
responsibility under the Mental Capacity Act and the
Deprivation of Liberty Safeguards.
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Regulation 32
Interpretation of Part 8
32. In this Part—
“abuse” (“camdriniaeth”) means physical, sexual, psychological, emotional or financial abuse and, in relation to a child, any other
harm.
For the purposes of this definition—
(a) “financial abuse” (“camdriniaeth ariannol”) includes—
i. having money or other property stolen;
ii. being defrauded;
iii. being put under pressure in relation to money or other property;
iv. having money or other property misused;
(b) “harm” (“niwed”) has the same meaning as in section 197(1) of the 2014 Act;
“improper treatment” (“triniaeth amhriodol”) includes discrimination or unlawful restraint, including inappropriate deprivation of liberty
under the terms of the Mental Capacity Act 2005(4);
“neglect” (“esgeulustod”) has the same meaning as in section 197(1) of the 2014 Act.
4 2005 c. 9. https://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf
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1.7 Requirements on service providers which only apply where accommodation is provided (Part 9)
The intent of Part 9 of the Regulations is to ensure that where accommodation is provided, individuals are
supported to access healthcare and other services to maintain their ongoing health, development and well-
being.
Regulation 33
Guidance
Access to health and other services
33. (1) This regulation applies to a service provider in respect of
a care home service, a secure accommodation service or a
residential family centre service which the provider is registered to
provide.
(2) A service provider to whom this regulation applies must put
arrangements in place for individuals—
(a) to be registered with a general practitioner,
(b) to be placed under the care of a registered dental
practitioner,
(c) to be able to access treatment, advice and other services
from any health care professional as necessary, and
(d) to be supported to access such services.
(3) In the case of a care home service which provides
accommodation wholly or mainly for children or in the case of
secure accommodation service, the service provider must
designate a member of staff to be the “link worker” for each child
and must ensure that—
(a) a child’s link worker participates in any review involving
consideration of the child’s educational progress, whether
conducted under regulations made under section 102 of
• Where individuals are relocating to a new address service
providers assist them to register with a general practitioner of
the individual’s choice.
• Where required, assistance is provided to access additional
services from health and allied health professionals and is
undertaken in a timely manner. This includes seeking
assistance on behalf of individuals or supporting them to
access the services.
• Individuals are assisted and supported to attend and
participate in health checks and activities related to health
promotion, where appropriate.
• Staff are aware of their role in health promotion.
• Individuals are assisted and supported to access appointments
with health and allied professionals. This includes specifically
but not exhaustively: dentistry, ophthalmology, speech and
language services, physiotherapy, psychology, podiatry,
mental health or therapeutic services and any palliative care
services.
• Records relating to professional consultations are kept
(including, where possible, any resulting actions) and, where
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the 2014 Act, the Care Planning, Placement and Case
Review (Wales) Regulations 2015 or otherwise;
(b) a child’s link worker participates in any review involving
consideration of any aspect of a child’s health, whether
conducted under regulations made under section 102 of
the 2014 Act, the Care Planning, Placement and Case
Review (Wales) Regulations 2015, or otherwise.
(4) In paragraph (3) of this regulation “link worker” means a staff
member of a care home service for children who is of appropriate
seniority with particular responsibility for protecting and promoting
the health and educational welfare of an individual child and for
liaison with education and health care providers on that child’s
behalf.
available, relevant correspondence maintained to provide a
clear health record for the individual.
• Where there are multiple professionals involved in an
individual’s care and support the service provider establishes
roles and responsibilities for referral and advice. This is
recorded and is clear for the individual and staff involved in
their care and support.
• Individuals are supported to access additional facilities, where
available, to promote health and well-being or support them to
achieve their personal outcomes, for example, access to
leisure centres, fitness classes or other therapeutic activities.
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1.8 Requirements on service providers as to staffing (Part 10)
The intent of Part 10 of the Regulations is to ensure that individuals are supported by appropriate numbers of staff who have the
knowledge, competence, skills and qualifications to provide the levels of care and support required to enable the individual to achieve
their personal outcomes.
Service providers have in place:
• policies and procedures for recruitment;
• rigorous practices for recruiting and vetting staff;
• a structure of management and staffing that supports the statement of purpose which is relevant to individual’s needs; and
• a management structure, systems and processes for induction, ongoing supervision, training and development of staff.
Regulation 34
Guidance
Staffing – overarching requirements
34. (1) The service provider must ensure that at all times a
sufficient number of suitably qualified, trained, skilled, competent
and experienced staff are deployed to work at the service, having
regard to—
(a) the statement of purpose for the service;
(b) the care and support needs of the individuals;
(c) supporting individuals to achieve their personal outcomes;
(d) the requirements of the regulations in Parts 3 to 15.
(2) In the case of a care home service where any individual to
whom accommodation is provided has been assessed as needing
24 hour nursing care, the service provider must ensure that there
is a sufficient number of suitably qualified registered nurses
deployed to work at the service at all times.
• Service providers have a demonstrable, measurable and
systematic approach to determining the number of staff and
range of skills/qualifications required for the reliable provision
of care and support to meet individuals’ needs and support
them to achieve their personal outcomes. This considers, but is
not limited to:
o the statement of purpose;
o the assessed needs and dependency levels of
individuals;
o the environment, facilities and equipment provided; and
o in domiciliary support services this includes
consideration of geographical locations of individuals
using the service and staff travel time required.
o the different levels of knowledge, skills and competence
required to meet the specific needs of individuals on a
collective and individual basis. This includes the
management arrangements and the number of
registered professional and social care workers needed.
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(3) The service provider must be able to demonstrate the way in
which the determination has been made as to—
(a) the types of staff deployed, and
(b) the numbers of staff of each type deployed.
(4) The service provider must ensure that arrangements are
made for the support and development of staff.
(5) The service provider must ensure that the employment or
engagement of any persons on a temporary basis or on a non-
guaranteed hours contract does not prevent individuals receiving
such continuity of care as the provider has determined in
accordance with regulation 22 is reasonable to meet their needs
for care and support.
(6) In paragraph (5) of this regulation, “non-guaranteed hours
contract” has the same meaning as in regulation 42.
• In care home services where individuals are identified as
having nursing care needs, sufficient numbers of registered
nurses with a relevant qualification, experience, competency
and relevant skills are deployed to work at the service to
supervise and provide for the needs of those individuals.
• In care home services where individuals are assessed as
requiring 24-hour nursing care (due to the intensity, complexity
and/or acuity of their needs), the provider:
o ensures sufficient numbers of qualified, competent
and experienced registered nurses are responsible,
accessible and present for meeting the nursing care
needs of individuals at all times;
o demonstrates the way in which the number and
competency of registered nurses deployed has been
determined.
• Staffing levels and skill mix are reviewed continuously and
adapted to respond to the changing needs and circumstances
of individuals using the service.
• Arrangements are in place to cover staff sickness or absence
to ensure care and support needs are met and individuals are
supported to achieve their personal outcomes.
• There are procedures to follow in the case of in an emergency
that make sure sufficient and suitable staff are deployed to
cover both the emergency and the routine work of the service.
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Regulation 35
Guidance
Fitness of staff
35. (1) The service provider must not—
a) employ a person under a contract of employment to work at
the service unless that person is fit do so;
b) allow a volunteer to work at the service unless that person
is fit to do so;
c) allow any other person to work at the service in a position in
which he or she may in the course of his or her duties have
regular contact with individuals who are receiving care and
support or with other persons who are vulnerable unless
that person is fit to do so.
(2) For the purposes of paragraph (1), a person is not fit to work
at the service unless—
a) the person is of suitable integrity and good character;
b) the person has the qualifications, skills, competence and
experience necessary for the work he or she is to perform;
c) the person is able by reason of their health, after
reasonable adjustments are made, of properly performing
the tasks which are intrinsic to the work for which he or she
is employed or engaged;
d) the person has provided full and satisfactory information or
documentation, as the case may be, in respect of each of
the matters specified in Part 1 of Schedule 1 and this
information or documentation is available at the service for
inspection by the service regulator;
e) subject to paragraph (10) of this regulation where the
person is employed by the service provider to manage the
• Service providers have rigorous selection and vetting systems
in place to enable them to make a decision on the appointment
or rejection of all staff and volunteer applicants. This includes
the information set out in Schedule 1 of the Regulations. This
also includes checking the veracity of references and
employment.
• Where agency staff are deployed service providers ensure that
they are subject to the same checks as permanently employed
staff and have evidence to demonstrate that the checks have
been undertaken. This may include confirmation and
checklists supplied by any agency.
• The service provider has a process in place to assure
themselves the agency is reliable and robust in carrying out
these checks.
• Positive consideration is given to involving individuals using
the service in the recruitment of new staff.
• Service providers have a process in place to check that staff
have appropriate and current registration with a professional
regulator where required or, where applicable, an accredited
voluntary register.
• Having considered all the information available service
providers will determine whether the individual has the
necessary skills, qualifications and good character to
undertake the role for which they are employed/deployed.
• Service providers ensure any person who is not required to
register with Social Care Wales but who will be involved in the
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service, the person is registered as a social care manager
with Social Care Wales;
f) subject to paragraph (11) of this regulation, where the
person is employed by the service provider (whether as an
employee or worker) other than as a manager in order to
provide care and support to any person in connection
with—
i. a care home service,
ii. a secure accommodation service,
iii. a domiciliary support service in order to
provide care and support to a person referred
to in paragraph 8(1) of Schedule 1 to the Act,
or
iv. a residential family centre service,
the person is registered as a social care worker with Social Care
Wales no later than the relevant date (see paragraph (8) for the
meaning of “the relevant date”);
g) subject to paragraph (11) of this regulation, where the
person is engaged under a contract for services, other than
as a manager, to provide care and support to any person in
connection with—
i. a care home service,
ii. a secure accommodation service,
iii. a domiciliary support service in order to
provide care and support to a person referred
to in paragraph 8(1) of Schedule 1 to the Act,
or
iv. a residential family centre service,
the person is registered as a social care worker with Social Care
Wales no later than the relevant date (see paragraph (8A) for
meaning of “the relevant date”).
care and support of a service user, for example an
occupational therapist has been checked in line with the
requirements set out within regulation 35(2)(a)-(d).
• Where staff (including volunteers) no longer meet the required
fitness criteria set out in regulation 35(2), service providers
take appropriate and timely action to ensure that individuals
are not placed at risk. For example, this may include:
o coaching and mentoring;
o providing additional training and supervision;
o the use of disciplinary procedures.
• Service providers ensure staff comply with the requirements of
their professional codes of practice and, where appropriate,
providers make referrals to the relevant professional bodies for
persons whose fitness to practise is brought into question.
• Where there are concerns that a person working at the service
has abused or caused harm to an individual or placed an
individual at risk of abuse or harm, the Disclosure and Barring
Service (DBS) and any relevant professional registration body
are notified by the service provider without delay.
• Service providers have a legal duty under the Safeguarding
Vulnerable Groups Act 2006 to refer a staff member or
volunteer to the DBS if the staff member or volunteer has been
removed from working at the service (or an employee has
resigned before they could be dismissed) and the staff
member or volunteer has harmed or is considered to pose a
risk of harm to a child or vulnerable adult.
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(3) The certificate referred to in paragraphs 2 and 3 of Schedule 1
(referred to in this regulation as a DBS certificate) must be applied
for by, or on behalf of the service provider, for the purpose of
assessing the suitability of a person for the post referred to in
paragraph (1). But this requirement does not apply if the person
working at the service is registered with the Disclosure and Barring
Service update service (referred to in this regulation as the DBS
update service).
(4) Where a person being considered for a post referred to in
paragraph (1) is registered with the DBS update service, the
service provider must check the person’s DBS certificate status for
the purpose of assessing the suitability of that person for that post.
(5) Where a person appointed to a post referred to in paragraph
(1) is registered with the DBS update service, the service provider
must check the person’s DBS certificate status at least annually.
(6) Where a person appointed to a post referred to in paragraph
(1) is not registered with the DBS update service, the service
provider must apply for a new DBS certificate in respect of that
person within three years of the issue of the certificate applied for
in accordance with paragraph (3) and thereafter further such
applications must be made at least every three years.
(7) If any person working at the service is no longer fit to work at
the service as a result of one or more of the requirements in
paragraph (2) not being met, the service provider must—
a) take necessary and proportionate action to ensure
that the relevant requirements are complied with;
b) where appropriate, inform—
i. the relevant regulatory or professional
body;
ii. the Disclosure and Barring Service.
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(8) In paragraph (2)(f) of this regulation, “the relevant date” is
either—
a) six months from the date on which the person commenced
their employment, or
b) such later date as the service regulator may in exceptional
circumstances agree.
(8A) In paragraph (2)(g) of this regulation, “the relevant date” is
either—
a. six months from the date a person is first
engaged under a contract for services to
provide care and support in connection with–
i. a care home service,
ii. a secure accommodation service,
iii. a domiciliary support service in order to
provide care and support to a person
referred to in paragraph 8(1) of
Schedule 1 to the Act, or
iv. a residential family centre service, or
b. such later date as the service regulator may in
exceptional circumstances agree.
(9) In this regulation, “the Disclosure and Barring Service” (“y
Gwasanaeth Datgelu a Gwahardd ”) and “DBS” (“GDG”) mean the
body established by section 87(1) of the Protection of Freedoms Act
2012
(10) Until 1 April 2020, the requirement under paragraph (2)(e ) for
a manager to be registered with Social Care Wales does not apply
to a manager who is appointed to manage an undertaking—
a. in respect of which a person is registered, or has
applied to register, as the provider of a domiciliary
support service, and
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b. in respect of which a person was registered as
carrying on a nurses agency under Part 2 of the
Care Standards Act 2000 immediately before 2 April
2018 but was not also registered as carrying on a
domiciliary care agency
(11) The requirement that a person is registered as a social care
worker with Social Care Wales in accordance with paragraph (2)(f)
and (g), does not apply where the person is employed (whether as
an employee or worker) or engaged under a contract for services
to work as a—
a. nurse, or
b. registered professional.
Regulation 36
Guidance
Supporting and developing staff
36.(1) The service provider must have a policy in place for the
support and development of staff.
(2) The service provider must ensure that any person working at
the service (including a person allowed to work as a volunteer)—
(a) receives an induction appropriate to their role;
(b) is made aware of his or her own responsibilities and those
of other staff.
(c) receives appropriate supervision and appraisal;
(d) receives core training appropriate to the work to be
performed by them;
(e) receives specialist training as appropriate;
• Service providers ensure they have an induction programme
that equips all new staff and volunteers to be confident in their
roles and practice and enables them to make a positive
contribution to the well-being and safety of individuals using
the service.
• Social care workers complete the relevant induction
programme required by Social Care Wales within the defined
timescale alongside any service-specific induction
programmes.
• Staff have access to copies of any relevant codes of
professional practice and practice guidance, including any
issued by Social Care Wales. The standards specified in these
codes and practice guidance are actively promoted.
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(f) receives support and assistance to obtain such further
training as is appropriate to the work they perform.
(3) The service provider must ensure that any person employed
to work at the service is supported to maintain their registration
with the appropriate regulatory or occupational body.
• Where agency staff are deployed an introduction to the service
is provided which includes, but is not limited to:
o the statement of purpose;
o core policies and procedures; and
o management and supervision arrangements.
• Staff are aware of, and understand, their responsibilities and
accountabilities when delegating an activity or having an
activity delegated to them. This includes registered nurses who
maintain accountability for any delegation of activity to other
workers.
• Staff undertaking delegated healthcare activities are aware of,
and adhere to, any code of practice and guidance issued in
relation to undertaking delegated activities.
• Service providers respect the professional autonomy of
registered professionals in relation to the delegation of
activities.
• Staff receive supervision in their role to help them reflect on
their practice and to make sure their professional competence
is maintained. This includes feedback about their performance
from individuals using the service.
• Staff meet for one-to-one supervision with their line manager
or equivalent officer, or a more senior member of staff, no less
than quarterly.
• Registered nursing staff have the opportunity to receive clinical
supervision.
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• All staff have an annual appraisal which provides feedback on
their performance and identifies areas for training and
development in order to support them in their role.
• Additional training, learning and development needs of
individual staff members are identified within the first month of
employment and reviewed through the supervision and
appraisal process.
• Staff are supported to undertake training, learning and
development to enable them to fulfil the requirements of their
role and meet the needs of individuals using the service. This
includes training to operate any specialist equipment.
• Service providers undertake an annual (or more frequently if
required) training needs analysis to ensure that staff have the
relevant skills and competence to meet the needs of
individuals in accordance with the statement of purpose for the
service.
• Service providers maintain a written record of all training and
supervision undertaken or to be undertaken by staff.
• Service providers support all staff to complete, where
appropriate:
o core training, for example, manual handling and
safeguarding training;
o necessary qualifications that would enable them to
continue to perform their role;
o training and activities required for continuing
professional development and to meet the
requirements for registration of professional
regulatory bodies, where this is relevant to their role;
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o other training deemed appropriate by the service
provider;
o core and specialist training identified for their role by
Social Care Wales.
Regulation 37
Guidance
Compliance with employer’s code of practice
37. The service provider must adhere to the code of practice on
the standards of conduct and practice expected of persons
employing or seeking to employ social care workers, which is
required to be published by Social Care Wales under section
112(1)(b) of the Act.
• Service providers have a clear understanding of their role and
responsibilities in relation to the Code of Practice for
Employers of Social Care Staff (Social Care Wales publication)
and/or other codes of practice applicable to employers which
may be issued by Social Care Wales from time to time.
Regulation 38
Guidance
Information for staff
38. (1) The service provider must ensure that all persons
working at the service (including any person allowed to work as a
volunteer) are provided with information about the service and the
way it is provided.
(2) The service provider must ensure that there are
arrangements in place to make staff aware of any codes of
practice about the standards of conduct expected of social care
workers, which is required to be published by Social Care Wales
under section 112(1)(a) of the Act.
• Service providers compile and make available information for
staff and volunteers in line with the statement of purpose. This
includes information about the following matters—
o the ethos and culture of the service;
o the conduct expected of staff and others working at the
service;
o the roles and responsibilities of staff and others working
at the service;
o the policies and procedures of the service;
o record keeping requirements;
o confidentiality and data protection requirements;
o disciplinary procedures;
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o arrangements for ensuring that individuals are safe and
are protected from abuse, neglect and improper
treatment (including reporting safeguarding concerns);
and
o arrangements for lone working.
• Service providers ensure staff and volunteers have access to
and understand up to date copies of all relevant policies,
procedures and codes of practice. Service providers ensure
staff have read these during the induction period and assess
staff members’ ongoing understanding through supervision and
performance reviews.
• Service providers ensure staff and volunteers undertake their
duties in line with the requirements of the policies and
procedures.
• All staff and volunteers are provided with a written job
description which states clearly their responsibilities, the duties
currently expected of them and their line of accountability.
• Regular staff meetings take place (a minimum of six meetings
per year), the issues discussed are recorded and appropriate
actions are taken as a result.
Regulation 39
Guidance
Disciplinary procedures
39.— (1) The service provider must put in place and operate a
disciplinary procedure.
(2) The disciplinary procedure must include—
• Service providers have a disciplinary policy and procedure, in
line with employment law, to deal with employee performance
and conduct. This includes:
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(a) provision for the suspension, and the taking of action short
of suspension, of an employee, in the interests of the
safety or well-being of people using the service;
(b) provision that a failure on the part of an employee to report
an incident of abuse, or suspected abuse, to an
appropriate person, is grounds on which disciplinary
proceedings may be instituted.
(3) For the purpose of paragraph (2)(b), an appropriate person
is—
(a) the service provider,
(b) the responsible individual,
(c) an officer of the service regulator,
(d) an officer of the local authority for the area in which the
service is provided,
(e) in the case of an incident of abuse or suspected abuse of a
child, an officer of the National Society for the Prevention of
Cruelty to Children, or
(f) a police officer.
o information about what is acceptable and unacceptable
behaviour and what action will be taken if there are
concerns about staff behaviour.
o the arrangements for a member of staff to be
suspended (or transferred to other duties) pending the
investigation of any allegations of serious misconduct,
including allegations of abuse or serious concerns
relating to the safety or well-being of individuals.
o the actions to be taken to address concerns about
volunteers’ behaviour.
• Where the service provider is undertaking disciplinary action
against any employee and the employee leaves prior to the
completion of the disciplinary process, consideration is given to
whether a referral to the police, Disclosure and Barring
Service, Social Care Wales or any other professional body is
appropriate.
• Where a volunteer’s fitness to practise is in question due to
any alleged misconduct/lack of capability of a concerning
nature, the service provider takes appropriate and timely
action. For example, this may include:
o providing additional training and supervision;
o termination of the volunteer arrangements;
o referral to the Disclosure and Barring Service (DBS)
or police, where required.
• Service providers ensure staff are aware of and understand the
disciplinary procedures and any grievance procedures.
• A written report of any disciplinary investigations and action
taken is kept on the employee’s file in line with employment
and data protection legislation.
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1.9 Requirements on service providers in respect of domiciliary support services (Part 11)
The intent of Part 11 of the Regulations set out the requirements for a domiciliary support service which the provider is registered to
provide.
This includes:
• a “schedule of visits” which delineates the time allowed for each visit and the time allowed for travel between each visit;
• the offer to domiciliary care workers on non-guaranteed hours contracts the choice of alternative contractual
arrangements.
Regulation 40
Application of regulations in this Part
40. The regulations in this Part only apply to a service provider in respect of the provision of a domiciliary support service which the
provider is registered to provide.
Regulation 41
Guidance
Delineation of travel time and care time
41.—(1) A service provider to whom this regulation applies
must—
(a) prepare a schedule of visits in respect of each domiciliary
care worker working at the service; and
(b) provide a copy of the relevant schedule of visits to the
domiciliary care worker to whom that schedule relates.
(2) The schedule of visits must delineate the time allocated for
travel time, the time allocated for each visit and (if applicable) the
time allocated for rest breaks.
• Service providers ensure systems are in place for the
provision of a schedule of visits for each domiciliary care
worker in line with the requirements of regulation 41.
For travel time
Service providers ensure that allocated times:
• Provide a realistic consideration of the distance between
one location and the next; and
• Take account of other factors that might reasonably affect
travel time (e.g. traffic congestion at specific times of the
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(3) The time allocated for travel time must be sufficient having
regard to—
(a) the distance between the location of one scheduled visit
and the next scheduled visit; and
(b) any other factors which might reasonably be expected to
affect travel time, such as traffic congestion and the
availability of parking at the location of the scheduled visits.
(4) The time allocated for each visit—
(a) must be sufficient to enable care and support to be
provided to the individual in accordance with their personal
plan; and
(b) must not be less than 30 minutes unless either condition A,
B or C, as described in section 8 of the Act, is met.
(5) A service provider to whom this regulation applies must
ensure that a record is kept of the time spent by each domiciliary
care worker on travel time, visits and rest breaks.
(6) For the purposes of this regulation—
“domiciliary care worker” (“gweithiwr gofal cartref”) means a
person who provides care and support to individuals as part of
a domiciliary support service and includes—
(a) a person employed by the service provider as an employee
or a worker; and
(b) a person engaged by the service provider under a contract
for services.
For the purposes of this definition, the terms “employed” (“a
gyflogir”), “employee” (“cyflogai”) and “worker” (“gweithiwr”)
have the same meanings as in section 230 of the Employment
Rights Act 1996;
day or parking restrictions) and factor in a reasonable
allowance to provide adequate time to permit domiciliary
care workers to work around them.
For care time
Service providers ensure that:
• Allocated times are sufficient to enable care and support
to be provided to an individual in accordance with their
personal plan.
• The delivery of care is not less than 30 minutes unless it
meets either condition A, B or C as set out in section 8 of
the Act.
For example:
• For the purposes of this guidance, condition A relates to the
period of care to deliver the activity stated within the
individual’s personal plan or the carer’s support plan. The
first visit or the first visit by every new support worker within
that same period of care is at least 30 minutes. Subsequent
visits should also be at least 30 minutes, unless conditions
B or C apply. Rotas only need to show sufficient time to
meet those tasks.
• Condition B relates to where the visit is consistent with the
terms of any arrangement to provide the service; or is for
the sole purpose of checking whether a person is safe and
well; or that the tasks performed are completed to a
standard that meets the requirements set out within these
regulations. Where condition B applies, the rotas do not
need to be revised but a clear record is kept.
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“schedule of visits” (“amserlen ymweliadau”) means a schedule
of the visits which a domiciliary care worker is required to make
during the course of a day or a week;
“travel time” (“amser teithio”) includes the time spent travelling
between the location of one scheduled visit and the location of
the next scheduled visit but does not include any time spent
travelling from the home of the domiciliary care worker to the
location of the first scheduled visit or any time spent travelling
from the location of the last scheduled visit to the home of the
domiciliary care worker;
“visit” (“ymweliad”) means a visit to an individual for the
purpose of providing a domiciliary support service.
• Condition C takes account of a visit being cut short at the
request of the individual. Where condition C applies, the
rotas do not need to be revised but a clear record is kept.
Regulation 42
Guidance
Offering domiciliary care workers on non-guaranteed hours
contracts the choice of alternative contractual arrangements
42.—(1) If the conditions in paragraph (2) are met, a service
provider to whom this regulation applies must offer a domiciliary
care worker the choice of continuing to be employed under either
of the following types of contractual arrangement—
(a) a contract of employment where the number of hours
required to be worked per week is at least the average
number of hours worked per week during the preceding
three months;
(b) a contract of employment where the number of hours
required to be worked per week is less than the average
number of hours worked per week during the preceding
three months.
• Service providers ensure domiciliary care workers employed
by them are offered a choice of continued employment in line
with the requirements of regulation 42.
• For the purposes of 42(2)(b) regular hours are the hours that
a worker consistently works over a three-month period, be
they a weekly or monthly quota (i.e. 37 hours a week or 148
hours a month).
• Service providers ensure contractual arrangements are
reviewed, after a further three-month period, for any
domiciliary care worker who opts to remain upon a non-
guaranteed hours contract.
• Services providers ensure a record is kept of the contract
discussion.
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But this requirement does not prevent the service provider
employing a domiciliary care worker on any other type of
contractual arrangement which has been agreed between the
provider and the worker, including a further non-guaranteed hours
contract.
(2) The conditions referred to in paragraph (1) are—
(a) the domiciliary care worker has been employed by the
service provider under a non-guaranteed hours contract for
the qualifying period,
(b) the domiciliary care worker has worked regular hours
during the three months preceding the end of the qualifying
period,
(c) the provider has decided that there is a continuing need for
the hours to be worked on an ongoing basis, and
(d) the domiciliary care worker has performed satisfactorily
during the qualifying period.
(3) For the purposes of this regulation—
“domiciliary care worker” (“gweithiwr gofal cartref”) means a
person who provides care and support to individuals as part of
a domiciliary support service and includes a person employed
by the service provider as an employee or a worker but does
not include a person engaged by the service provider under a
contract for services;
“non-guaranteed hours contract” (“contract oriau heb eu
gwarantu”) means a contract of employment or other worker’s
contract under which—
(a) the undertaking to do work or perform services is an
undertaking to do so conditionally on the employer making
work or services available to the worker, and
(b) there is no certainty that any such work or services will be
made available to the worker.
For the purpose of this definition, an employer makes work or
services available to a worker if the employer requests or requires
the worker to do the work or perform the services;
• Service providers conduct contract reviews as part of staff
appraisal practices or other management reviews, where
applicable or appropriate.
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“the qualifying period” (“y cyfnod cymhwysol”) is—
(a) in any case where the worker has commenced employment
after the relevant date, the period of three months from the
date the employment commenced;
(b) in any case where the worker commenced employment
before the relevant date, the period of three months ending
with the commencement date;
(c) in any case where the worker has previously been offered
the choice of an alternative contractual arrangement in
accordance with the requirements of this regulation and
has chosen to remain on a non-guaranteed hours contract,
the period of three months from the date any such choice
was made.
For the purposes of this definition—
“the commencement date” (“y dyddiad cychwyn”) is the
date on which this regulation comes into force;
“the relevant date” (“y dyddiad perthnasol”) is the date
which falls three months before the commencement date.
(4) For the purposes of this regulation—
(a) the terms “contract of employment” (“contract cyflogaeth”),
“employer” (“cyflogwr”), “employee” (“cyflogai”),
“employment” (“cyflogaeth”) and “employed” (“cael ei
gyflogi”, “wedi ei gyflogi”, “a gyflogir”) have the same
meanings as in section 230 of the Employment Rights Act
1996;
“(b) worker” (“gweithiwr”) has the same meaning as in section 230
of the Employment Rights Act 1996, except that a person
engaged under a contract for services is not a worker for the
purpose of this regulation. Any reference to a worker's contract is
to be construed accordingly.
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1.10 Requirements on service providers as to premises, facilities and equipment (Part 12)
The intent of Part 12 of the Regulations set out the requirements for service providers to ensure that individuals’ care and support is
provided in a location and environment with facilities and, where relevant, equipment that promotes achievement of their personal
outcomes. The requirements of Part 12 apply to all providers of care home services, secure accommodation services or residential family
centre services.
This includes:
• ensuring that systems and processes are in place which promote a safe and high-quality environment in which the
services are provided;
• ensuring the physical environment provides individual and communal space to meet their care and support needs; and
• facilities and equipment which are well maintained and appropriate to the individuals using the service.
Regulations 43 and 44
Guidance
Overarching requirement
43. The service provider must ensure that the premises, facilities
and equipment are suitable for the service, having regard to the
statement of purpose for the service.
Premises – accommodation-based services only
44.(1) The requirements in this regulation only apply to service
providers who are registered to provide a care home service,
secure accommodation service or residential family centre
service.
(2) The service provider must ensure that the physical design,
layout and location of the premises used for the provision of the
service is suitable to—
• The location, design and size of the premises are suitable for
the service as described in the statement of purpose.
• The premises are located, designed and equipped to meet the
needs of the individuals for which the service is intended and
reflect national guidance. This includes ensuring that:
o individuals’ needs and, where possible, their views are
taken into account when premises are designed, built,
maintained, renovated or adapted;
o in determining the location from which the service will
be delivered, the service provider takes into account the
need for individuals to have easy access to the local
community and relevant facilities, such as those relating
to education, health, employment and leisure, as well as
good access to public transport. Where access to public
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(a) achieve the aims and objectives set out in the statement of
purpose;
(b) meet the care and support needs of the individuals;
(c) support individuals to achieve their personal outcomes.
(3) In particular, the service provider must ensure that the
premises used for the provision of the service meet the
requirements of paragraphs (4) to (6) of this regulation.
(4) Premises must be—
(a) accessible, adequately lit, heated and ventilated;
(b) secure from unauthorised access;
(c) suitably furnished and equipped;
(d) of sound construction and kept in good structural repair
externally and internally;
(e) fitted and adapted as necessary, in order to meet the
needs of individuals;
(f) organised so that equipment used for the provision of the
service is appropriately located;
(g) free from hazards to the health and safety of individuals
and any other persons who may be at risk, so far as is
reasonably practicable;
(h) properly maintained;
(i) kept clean to a standard which is appropriate for the
purpose for which they are being used.
(5) Premises must have bedrooms which—
(a) include appropriate facilities to meet the care and support
needs of the individual (if the room is single occupancy) or
individuals (if the room is shared) occupying the bedroom;
(b) are of an adequate size, having regard to —
i. whether the room is shared or single occupancy;
transport is limited, this is facilitated by the service
provider;
o the privacy, dignity and confidentiality of individuals is
not compromised unless it is in keeping with their
personal plan, for example the use of any surveillance;
o individuals’ safety is maintained, including their ability to
enter and exit the premises and find their way around
easily;
o there is safe access to all fixed / wall mounted
equipment, such as the hoisting system; and
o there is independent access to all appropriate areas of
the service and, where required, the premises are
adapted to achieve this.
• Service providers have security arrangements in place which
ensure individuals are safe and secure without compromising
their rights, privacy and dignity. The level of security used is
appropriate to the individual and to the service being provided.
This includes:
o protecting personal property and/or money;
o providing appropriate access to and from the premises
which does not unnecessarily restrict an individual’s
freedom of movement;
o discussion with relevant partners, for example crime
prevention officers about the level of security that may
be appropriate.
• Service providers have a written policy in relation to the use of
CCTV both by the service and by individuals, families and
staff.
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ii. the layout and furniture;
iii. the equipment required to meet the needs of the
individual (if the room is single occupancy) or
individuals (if the room is shared);
iv. the number of staff required to meet the needs of the
individual (if the room is single occupancy) or
individuals (if the room is shared);
(c) are comfortable for the individual (if the rooms is single
occupancy) or individuals (if the room is shared);
(d) allow the individual (if the room is single occupancy) or
individuals (if the room is shared) both freedom of
movement and privacy.
(6) Premises must have sitting, recreational and dining space
which is provided separately from the individual’s own private
rooms and any such space must be—
(a) suitable and sufficient, having regard to the statement of
purpose;
(b) located so as to enable all persons using the space to
access any such space easily and safely.
(7) Any communal space used for the provision of the service
must be suitable for the provision of social, cultural and religious
activities appropriate to the circumstances of the individuals.
(8) Suitable facilities must be provided for individuals to meet
visitors in private in a space which is separate from the individual’s
own private rooms.
(9) Premises must have toilets, bathrooms and showers which
are—
(a) of sufficient number and of a suitable type to meet the
needs of the individuals;
(b) appropriately equipped;
• The use of surveillance in regulated services is overt,
purposeful, lawful and clearly indicated within the building and
user guide.
• The use of surveillance complies with the requirements under
the Regulations in relation to privacy, dignity and respect. It
also complies with all other legal requirements e.g. under the
Data Protection Act 1998.
• Where children are accommodated premises are not marked
to distinguish this.
• Service providers ensure that the building has natural
ventilation and is heated to reflect the needs of the individuals
living at the place.
• Furnishings and equipment are provided to achieve the aims
and objectives set out in the statement of purpose and to meet
the needs and, where possible, the preferences of individuals
receiving care and support. This includes:
o specialist beds and mattresses, call systems, moving
and handling equipment, signage, handrails and/or
equipment to support individual’s physical, cognitive
and sensory needs;
o the provision of suitable equipment and furnishings to
support learning, for example computers and desks;
o providing sports and leisure equipment;
o access to a telephone (and the opportunity to use a
telephone in private), email and internet facilities which
are suitable for the individual’s needs.
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(c) located so as to enable all persons to access them easily
and safely.
(10) Premises must have external grounds which are accessible,
suitable for, and safe for use by, individuals and appropriately
maintained.
(11) Premises must have suitable facilities for staff which must
include—
(a) suitable storage facilities, and
(b) where appropriate, suitable sleeping accommodation and
changing facilities.
• Arrangements are made to obtain additional specialist advice,
aids and equipment to meet individuals’ needs in liaison with
relevant statutory agencies.
• Policies and procedures are in place to ensure that buildings’
mechanical and electrical systems are sound and operationally
safe.
• There is a system of monitoring and auditing in place which
supports a planned maintenance schedule and renewal
programme for the fabric and decoration of the premises.
• There are arrangements to ensure that any immediate repairs
and works arising are identified, reported and action
undertaken in response to the level of urgency. This will
support the safety and well-being of individuals using the
service, visitors, volunteers and staff.
• Service providers allocate available budget to ensure the
ongoing maintenance of premises, facilities, furnishings and
equipment.
• Service providers ensure bedrooms are equipped to meet the
needs of the individual in line with the statement of purpose.
• Service providers consider individuals’ wishes and preferences
in the way their rooms are furnished and decorated.
• Individuals’ own rooms suit their needs and lifestyles and
promote their independence.
• Lighting in individuals’ accommodation is in line with their
needs and any relevant health and safety requirements.
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• Individuals are able to adjust the heating in their own
bedrooms and, where relevant, additional ventilation systems
and lighting are installed to meet their needs, in line with
national standards for inclusive access.
• Bedrooms, whether for a single occupant or shared, have
sufficient space and furnishings to:
o enable the safe use of equipment without impinging
upon staff, individuals or furnishings and personal
items;
o enable staff to meet the individual’s care and support
needs in a safe and dignified manner;
o provide privacy;
o provide space for independent activity, for example,
undertaking homework, pursuing hobbies and
spending time alone.
• Doors to bedrooms are fitted with locks suitable to their
capabilities and individuals are provided with keys unless their
risk assessment indicates otherwise.
• Staff are able to open the doors to bedrooms from the outside
in case of emergency.
• Individuals have safe and secure storage facilities for their
personal belongings including money, valuables and where
appropriate medication.
• Communal spaces are available to meet the needs of
individuals accommodated, in keeping with the statement of
purpose, and are easily and independently accessible in
accordance with the Equality Act 2010 and other current
legislation and guidance. This includes provision for individuals
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to meet privately with visitors, take part in activities, play and
recreation, in a way that does not impact on the routines or
privacy of other individuals using the service.
• In considering the layout, access, design/decor, signage and
adaptations for communal areas, service providers take into
account the needs and dependencies of individuals living at
the place such as those relating to dementia, physical and
sensory impairments. The service provider ensures communal
spaces are based on recognised evidence-based guidance.
• Independence is promoted and maintained by ensuring
individuals have appropriate access to facilities and
equipment, for example accessible kitchen/cooking and
laundry facilities.
• Baths or showers are available for individuals to use, in
accordance with their needs and in line with the statement of
purpose.
• Bathrooms, showers and toilets are located and designed to
take account of the privacy, dignity, safety and needs and
abilities of individuals, in line with requirements of the Equality
Act 2010.
• Bathrooms, showers and toilets have aids and equipment
provided to meet the needs of individuals accommodated, for
example grab rails, sinks located at an accessible height and
emergency call systems.
• Facilities are readily accessible from sleeping and recreational
areas of the home.
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• Staff are able to open the doors to bathrooms, showers and
toilets from the outside in case of an emergency.
• Grounds are kept tidy, safe, attractive, and accessible to
individuals.
• Service providers regularly review the safety and condition of
the grounds as part of the maintenance programme.
• Outdoor space is designed to meet the needs of all individuals
including those with physical, sensory and cognitive
impairments.
• Where accommodation is provided for staff, this is located
within the service and enables them to respond easily to
individuals’ needs.
• Suitable sleeping accommodation and changing facilities are
provided for staff where appropriate.
• Staff are provided with a safe place to store personal
belongings.
Regulation 45
Guidance
Single occupancy and shared rooms - adults
45. (1) Where the service provider is providing a care home
service which includes the provision of accommodation for
individuals who are adults, the service provider must ensure that
all adults are accommodated in single rooms. But this requirement
does not apply if either—
• Single bedrooms are provided in all accommodation-based
services.
• Bedrooms are only shared when regulation 45(2) and 45(3)
applies.
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(a) the conditions in paragraph (2) are met, or
(b) paragraph (3) applies.
(2) The conditions are —
(a) an adult agrees to sharing a room with another adult;
(b) sharing a room is consistent with the well-being of both
adults;
(c) the personal plans of both adults have been reviewed and
revised as necessary;
(d) the number of adults who are accommodated in shared
rooms does not exceed 15% of the total number of adults
accommodated by the service.
(3) This paragraph applies if the following conditions are met—
(a) the care home service was registered as a care home
under the Care Standards Act 2000;
(b) the number of adults accommodated in shared rooms at
the relevant time exceeded 15% of the total number of
adults accommodated by the service at the relevant time;
(c) all the adults who are accommodated in shared rooms
were sharing a room with another adult at the relevant time.
(4) In paragraph (3) of this regulation, “the relevant time” means
the time the service provider was registered under the Act as the
provider of the care home service.
• Service providers ensure shared rooms are managed in line
with the requirements of the Regulations.
• In circumstances where sharing a room is under consideration,
the discussion with the individuals concerned or their
representatives, and the decision made, is documented by the
service provider.
Regulation 46 Guidance
Single occupancy and shared rooms – children
46.(1) This regulation applies where the service provider is
providing—
• Single bedrooms are provided in all accommodation-based
services.
• Bedrooms are only shared when regulation 46(3) applies.
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(a) a care home service which includes the provision of
accommodation for individuals who are children, or
(b) a secure accommodation service.
(2) If this regulation applies, the service provider must ensure
that each child is accommodated in a single room. But this
requirement does not apply if the conditions in paragraph (3) are
met.
(3) The conditions are—
(a) the accommodation is provided in a care home service
which was registered as a children’s home under the Care
Standards Act 2000,
(b) the accommodation provided was occupied at the time the
service provider was registered under the Act,
(c) the child is sharing a room with no more than one other
child,
(d) (except in the case of siblings) the other child is not of the
opposite sex or of a significantly different age to him or her,
and
(e) sharing a room will promote the child’s well-being, is
provided for in the child’s care and support plan and
wherever practicable is agreed with the child.
• In the circumstances where sharing a room is under
consideration, the discussion with the individuals concerned or
their representatives, and the decision made, is documented
by the service provider.
Regulation 47 Guidance
Premises – all services
47. The service provider must ensure that the premises used for
the operation of the service have adequate facilities for—
(a) the supervision of staff;
• Service providers have a suitable space within the premises,
such as a shared meeting room, to provide privacy for the
supervision of staff.
• Records are stored securely in line with legislative
requirements.
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(b) the secure storage of records.
Regulation 48 Guidance
Facilities and equipment
48. The service provider must ensure that the facilities and
equipment used for the provision of the service are—
(a) suitable and safe for the purpose for which they are
intended to be used;
(b) used in a safe way;
(c) properly maintained;
(d) kept clean to a standard which is appropriate for the
purpose for which they are being used;
(e) stored appropriately.
For all services:
• Service providers ensure there are suitable facilities for the
storage of equipment, which are easily accessible to staff and
do not present a risk to individuals using or working at the
service.
• Facilities, fittings, adaptations and equipment are available to
achieve the aims and objectives of the statement of purpose,
help to meet the care and support needs of individuals using
the services, and support them to achieve their personal
outcomes.
• Arrangements are in place to purchase, service, maintain,
renew, and replace equipment where appropriate. These
arrangements meet the requirements of any current legislation
and guidance, manufacturers' instructions and the service
provider's policies or procedures.
• All equipment is used, stored and maintained in line with the
manufacturers’ instructions.
• Equipment is used for its intended purpose and solely for the
individual for whom is it provided.
• Staff and others who operate the equipment are trained to use
it appropriately prior to use.
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• Individuals using the service are consulted about the facilities,
services and equipment provided by the service on their behalf
and, where possible, individual choices and preferences are
respected and acted upon.
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1.11 Additional requirements on service providers in respect of premises – new accommodation (Part 13)
The intent of Part 13 of the Regulations is to develop accommodation-based services to provide consistently high quality environments
for individuals receiving care and support. This is to provide choice and support for individuals to maintain their privacy and dignity and
independence. The requirements of Part 13 apply to service providers registered to provide care home services, secure accommodation
services or residential family centre services.
Regulation 49
Guidance
Application of Part 13
49. (1) This Part applies to service providers who are registered
to provide an accommodation-based service where -
(a)(i) the service involves the provision of accommodation to five
or more individuals, and
(ii) the premises used for the provision of the service fall within
one of the categories in paragraph (2); or
(b) the service providers are persons to whom regulation 49A(1)
or regulation 49B(1) applies.
(2) The categories are—
Category A: The premises used for the provision of the
service consist of a new building or an existing building
which has been converted for the purpose of providing the
service, and, in either case, the building has not previously
been used for the purpose of providing an accommodation-
based service.
Category B: The premises consist of a building or buildings
to which an extension is added and the extension is used
for the purpose of providing the service at a place specified
as a condition to the service provider’s registration.
• Accommodation-based services where additional requirements
apply are defined in regulations 45 and 46.
• Category A relates a new or converted building for the purpose
of providing a regulated service.
• Category B relates to a new extension to an existing building
included within the service provider’s registration. The
requirements set out under Part 13 apply to the extension only,
under Category B.
• Category C relates to an unoccupied building, that was
previously registered under one service provider but which
now forms part of an application being made by a new service
provider.
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Category C: The premises consist of a building which was
unoccupied immediately prior to the service provider's
registration but was previously used for any of the following
purposes—
a) for the purpose of providing an accommodation-
based service at a place specified as a condition to
the registration of another service- provider;
b) as an establishment in respect of which a person was
registered under Part 2 of the Care Standards Act
2000 to provide accommodation in a children's home,
a care home, or a residential family centre;
c) as an establishment in respect of which a person was
registered under Part 1 or 2 of the Registered Homes
Act 1984 to provide residential accommodation for
persons in need of personal care (by reason of old
age, disablement, drug or alcohol dependence or
mental disorder);
d) as an establishment in respect of which a person was
registered in a register kept for the purposes of
section 60 of the Children Act 1989, or under Part 8
of that Act, to provide residential accommodation for
children.
(3) If this Part applies, the service provider must ensure that the
requirements of regulations 50 to 54 are complied with but in the
case of Category B premises, the requirements only apply to the
part of the premises comprising the extension (or in the case of
regulation 53, to any parts of the external grounds developed in
conjunction with the extension).
(4) (a) In this regulation, “accommodation-based service” means
a care home service, a secure accommodation service or a
residential family centre service;
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(b) "children's home", "care home" and residential family
centre" have the meanings respectively given in sections 1, 3
and 4 of the Care Standards Act 2000 as it had effect in Wales
immediately before 1 April 2017.
Reconfiguration of premises
49A.—(1) This regulation applies to a service provider—
(a) who is registered to provide an accommodation-based
service at a place specified as a condition to the service
provider’s registration, and
(b) to whom Part 13 did not apply in relation to that place
during a period when the service involved the provision
of accommodation to four or fewer individuals.
(2) Subject to paragraph (3), where a service provider to whom this
regulation applies has been granted a variation to their conditions
of registration on or after 31 March 2024 as a result of the
reconfiguration of premises used in relation to the place, and the
effect of the variation is that accommodation can be provided at that
place to five or more individuals, the service provider must comply
with the requirements of regulations 50 to 54 in respect of that
place.
(3) The requirement to comply with regulations 50 and 51 in relation
to that place only applies to any additional bedrooms for individuals.
(4) In this regulation and regulation 49B—
“reconfiguration of premises” means rearranging or altering the
existing physical layout of the premises to increase the number of
individuals who can be accommodated at the service.
49B.—(1) This regulation applies to a service provider—
(a) who is registered to provide an accommodation -based
service at a place specified as a condition to the service
provider’s registration; and
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(b) to whom Part 13 did not apply in relation to that place during
a period when the premises used by the service did not fall
within Category A, B or C and involved the provision of
accommodation to five or more individuals.
(2) Subject to paragraph (3), where a service provider to whom this
regulation applies—has been granted a variation to their conditions
of registration on or after 31 March 2024 as a result of the
reconfiguration of premises used in relation to the place and the
effect of the variation is that the number of individuals for which
accommodation can be provided at that place is increased , the
service provider must comply with the requirements of regulations
50 to 54 in respect of that place.
(3)The requirement to comply with regulations 50 and 51 in
relation to that place only applies to any additional bedrooms for
individuals.
Regulation 50 Guidance
Additional requirements – en-suite bathrooms
50. All bedrooms used for the provision of the service must have
an en-suite bathroom which includes an accessible wash hand
basin, lavatory and shower.
• En-suite facilities are accessible to meet individuals’ needs.
For example, wet rooms, showers or baths.
Regulation 51
Additional requirements – room sizes
51.— (1) All bedrooms used for the provision of the service must have a minimum of 12 square metres of useable floor space unless
paragraph (2) or (3) applies.
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(2) This paragraph applies where the person living in the room has to use a wheelchair on a permanent and constant basis.
(3) This paragraph applies where a bedroom is shared.
(4) If paragraph (2) applies, the bedroom must have a minimum of 13.5 square metres of useable floor space.
(5) If paragraph (3) applies, the bedroom must have a minimum of 16 square metres of useable floor space.
Regulation 52
Guidance
Additional requirements – communal space
52.(1) Subject to paragraph (2), the amount of sitting,
recreational and dining space which is used for the provision of
the service in accordance with regulation 44(6) must be at least—
(a) 4.1 square metres for each individual;
(b) 5.1 square metres for wheelchair users.
(2) For Category B premises, this regulation applies so that the
space requirement must be met in relation to any additional rooms
for individuals
• Service providers ensure communal space adheres to the
requirements set out under regulation 52.
Regulation 53
Guidance
Additional requirements – outdoor space
53. The external grounds (or, in the case of Category B premises,
any part of the external grounds developed in conjunction with the
building of the extension) which are used for the provision of the
service in accordance with regulation 44(10) must—
(a) be accessible to individuals in wheelchairs or with other
mobility problems,
• Service providers ensure that the layout, design and access to
outdoor areas is in line with the statement of purpose and
individuals’ needs.
• Outdoor areas can be accessed independently and/or with
support if required. Consideration is given to the need for:
o adaptations to provide access;
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(b) have sufficient and suitable seating, and
(c) be designed to meet the needs of all individuals including
those with physical, sensory and cognitive impairments.
o pathways and paving suitable for wheelchair users and
mobility scooters/equipment;
o the safety and security of individuals while outside;
o sufficient seating to enable individuals to rest /enjoy
being outdoors;
o play and recreational equipment; and
therapeutic and sensory areas.
Regulation 54
Guidance
Additional requirements – passenger lift
54. Where the accommodation used for the provision of the
service is on more than one floor and this is consistent with the
statement of purpose for the service, there must be a passenger
lift.
• Service providers ensure that passenger lifts are accessible
and include audio alerts and signage appropriate to the
age, level of understanding, the condition and any
communication impairment of, the individuals accessing the
lift.
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1.12 Requirements on service providers as to supplies, hygiene, health and safety and medicines (Part 14)
The intent of Part 14 of the Regulations is to ensure that individuals are supported by a service that:
• has sufficient quantities of supplies for their care and support needs;
• has safe systems for medicines management;
• identifies and mitigates risks to health and safety; and
• promotes hygienic practices and manages the risk of infection.
Regulation 55
Guidance
Supplies
55. The service provider must ensure that supplies are available
of a sufficient quantity and of a suitable type to deliver the service
effectively and to meet the care and support needs of the
individuals.
• Service providers ensure supplies are of a sufficient level to
meet the high quality of care required to support individuals to
achieve their personal outcomes.
• Individuals are supported to access personal supplies where
relevant.
• Arrangements are in place for the oversight and review of
supplies required by the service. This includes contingency
plans in case of an emergency.
Regulation 56
Guidance
Hygiene and infection control
56.—(1) The service provider must have arrangements in place
to ensure—
• Policies and procedures are in place that promote hygiene and
take into account current legislation and guidance, for example
those which relate to:
o food handling;
o hand washing; and
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(a) satisfactory standards of hygiene in the delivery of the
service;
(b) the appropriate disposal of general and clinical waste.
(2) The service provider must have policies and procedures in
place for the control of infection and to minimise the spread of
infection and must ensure that the service is provided in
accordance with these policies and procedures.
o cleaning and laundering arrangements (where relevant).
• Staff and volunteers are aware of the policies and procedures
relevant to their role and have training to understand safe
working practices concerning hygiene and the prevention of
infection.
• In accommodation-based services:
o cleaning programmes are in place, with appropriate staff
and equipment for the care and support provided, to
ensure that standards of hygiene are maintained;
o systems are established to monitor levels of cleanliness
and to take action where shortfalls are identified.
o systems are in place for the oversight and monitoring of
standards of hygiene.
• Equipment relevant to the statement of purpose is provided to
maintain high standards of hygiene, for example:
o in care homes, laundering facilities and hand washing
facilities which are easily accessible and appropriately
sited;
o in all services, access to protective clothing, gloves and
aprons.
• The service provider has policies and procedures in place that
meet the requirements of the relevant regulatory authorities to
ensure the health and safety of individuals using the service,
staff, volunteers, and visitors.
• Procedures for the management of hazardous waste meet the
requirements of relevant Health and Safety legislation and
guidance.
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• There are policies and procedures to prevent infection and the
spread of infection which are aligned to any current legislation
and national guidance. This includes, but is not limited to:
o the safe handling and disposal of clinical waste;
o dealing with spillages;
o the provision of protective clothing including personal
protective equipment (PPE);
o hand washing.
• Equipment provided for cleaning and decontamination is
suitable to meet the requirements of current legislation and
guidance and relevant to the statement of purpose. It is:
o easily accessible; and
o cleaned and decontaminated after each use in line
with current legislation, guidance and manufacturers'
instructions.
Regulation 57 Guidance
Health and safety
57. The service provider must ensure that any risks to the health
and safety of individuals are identified and reduced so far as
reasonably practicable.
• Service providers ensure the premises comply with current
legislation and national guidance in relation to health and
safety, fire safety, environmental health and any standards set
by the Food Standards Agency. Examples include:
o required safe water temperatures;
o fitting and maintenance of window restrictors;
o fire evacuation and drills;
o safe disposal of clinical waste;
o safe storage, preparation of food; and
o regular health and safety risk assessments of the premises
which include the grounds and equipment.
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• Improvements identified are acted upon according to the level
of risk.
• Where relevant, service providers act on the views of external
bodies such as the fire service, Health and Safety Executive,
Environmental Health and other bodies that provide best
practice guidance.
Regulation 58
Guidance
Medicines
58.(1) The service provider must have arrangements in place to
ensure that medicines are stored and administered safely.
(2) These arrangements must include the arrangements for—
(a) maintaining a sufficient supply of medicines;
(b) the effective ordering, re-ordering, recording, handling and
disposal of medicines;
(c) regular auditing of the storage and administration of
medicines.
(3) The service provider must have a policy and procedures in
place in relation to the safe storage and administration of
medicines and must ensure that the service is provided in
accordance with this policy and these procedures.
• There is a medication policy and procedure in place which is
aligned to any current legislation and national guidance. This
includes the systems in place for the management and
oversight of ordering, reordering, storage (of both controlled
and non-controlled medication), administration (including
covert administration), reconciliation, recording, and disposal
of medicines.
• Medication storage and administration adheres to statutory
and non-statutory national guidance.
• Arrangements are in place to support and promote the
individual’s independent management of their medication
including liaison with relevant professionals to enable this.
• Where covert medication is provided, it is administered in line
with current best practice guidance.
• Staff receive training and are competent before managing,
administering or supporting individuals to manage their own
medication.
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• Systems are in place to ensure the oversight and audit of
medicines management.
• Where staff are taking on delegated activities from other
professionals relating to medicine management this is in
keeping with any current national guidance and/or
professional codes of practice.
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1.13 Other requirements on service providers (Part 15)
The intent of Part 15 of the Regulations is to ensure that individuals are protected by a service that works proactively to secure their care
and support and safeguard their rights and well-being by:
• maintaining accurate records which are available to them and their representatives;
• communicating with the relevant regulatory bodies and statutory agencies where there are concerns (including safeguarding
concerns) and significant events affecting individuals;
• promoting an open and transparent service by publishing an accessible complaints policy and procedure;
• supporting staff and volunteers to raise any concerns about the service through whistleblowing procedures;
• demonstrating learning from all concerns and complaints to improve the service.
Regulation 59
Guidance
Records
59.(1) The service provider must keep and maintain the records
specified in Part 1 of Schedule 2 in respect of each place at, from
or in relation to which the service is provided.
(2) Where the service provider is registered to provide a care
home service, a secure accommodation service or a residential
family centre service, the service provider must in addition keep
and maintain the records specified in Part 2 of Schedule 2 in
respect of each place at which such a service is provided.
(3) The service provider must—
(a) ensure that records relating to individuals are accurate and
up to date;
(b) keep all records securely;
(c) make arrangements for the records to continue to be kept
securely in the event the service closes;
• There is a policy and procedures for the management of
records. This includes, for example, records relating to an
individual’s specialist assessment, mental capacity test,
Deprivation of Liberty Safeguards, etc.
• Staff are aware of the policy and have a clear understanding of
the procedures for managing records. This includes training in
information security and action to be taken where personal
information is compromised.
• Service providers maintain all the records required for the
protection of individuals and the efficient running of the service
as specified by schedule 2 of the Regulations.
• In care homes services which accommodate children:
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(d) in the case of records about a child accommodated in a
care home service provided wholly or mainly for children,
ensure that the records are delivered to the placing
authority when the service ceases to be provided in respect
of the child to whom the records relate;
(e) make the records available to the service regulator on
request;
(f) retain records relating to adults for three years from the
date of the last entry;
(g) retain records relating to children for fifteen years from the
date of the last entry, unless the records are returned to the
placing authority in accordance with sub-paragraph (d);
(h) ensure that individuals who use the service—
i. can have access to their records; and
ii. are made aware they can access their records.
o a permanent, private and secure record of the child’s
history, educational plans, progress and achievements,
any statement of special educational needs is
maintained; and
o can be seen by the child and by the child’s parents as
appropriate and in keeping with any current legal
requirements or court orders in place.
• All records are secure, up to date and in good order. They are
prepared, maintained and used in accordance with the data
protection legislation and other statutory requirements and are
kept for the required length of time as set out in regulation
59(3)(f) &(g).
• Records are stored securely including electronic records which
are password protected.
• Individuals, their carers or their representatives, and staff are
given access to any records and information about them held
by service providers in accordance with current legal
requirements.
Regulation 60
Guidance
Notifications
60.(1) The service provider must notify the service regulator of
the events specified in Parts 1 and 2 of Schedule 3.
(2) Where the service provider is providing a care home service
for children, the provider must—
• Service providers have appropriate arrangements in place for
the notification of the events listed Schedule 3 of the
Regulations to be made to the relevant authority.
• Notifications are made without delay, usually within 24 hours of
the event occurring.
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(a) notify the placing authority of the events specified in Part 3
of Schedule 3;
(b) notify the local authority for the area in which the home is
situated of the events specified in Part 4 of Schedule 3;
(c) notify the appropriate police officer of the events specified
in Part 5 of Schedule 3;
(d) notify the health board in whose area the home is situated
of the events specified in Part 6 of Schedule 3.
(3) The notifications required by paragraphs (1) and (2) must
include details of the event.
(4) Unless otherwise stated, notifications must be made without
delay and in writing.
(5) Notifications must be made in such manner and in such form
as may be required by the service regulator.
• The following applies in relation to Schedule 3 (17). Service
providers notify the regulator of any accident or injury to an
individual which, in the reasonable opinion of a health care
professional, requires treatment by that, or another, health care
professional and has or may have resulted in—
o damage or impairment (either permanent or likely to last
for more than 28 days) of the sensory, motor or
intellectual functions of the individual,
o changes to the structure of the individual’s body,
o the individual experiencing prolonged pain or prolonged
psychological harm, or
o the death or shortening of the life expectancy of the
individual.
• The following applies in relation to Schedule 3 (33). Service
providers notify the placing authority of any accident or injury to
a child which, in the reasonable opinion of a health care
professional, requires treatment by that, or another, health care
professional and has or may have resulted in—
o damage or impairment (either permanent or likely to last
for more than 28 days) of the sensory, motor or
intellectual functions of the individual,
o changes to the structure of the individual’s body,
o the individual experiencing prolonged pain or prolonged
psychological harm, or
o the death or shortening of the life expectancy of the
individual.
• The following applies in relation to Schedule 3 (20). Service
providers notify the regulator of any events which prevent, or
could prevent, them from continuing to provide the service
safely. This includes but is not limited to:
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o an insufficient number of suitably qualified, trained,
skilled, competent and experienced staff deployed to
work at the service,
o an interruption in the supply, to premises owned or used
by the service provider for the purposes of providing the
regulated service, of electricity, gas, water or sewerage
where that interruption has lasted for longer than a
continuous period of 24 hours,
o physical damage to premises owned or used by the
service provider for the purposes of providing the
regulated service which has, or is likely to have, a
detrimental effect on the care and support provided to
individuals,
o the failure or malfunction of the heating system in
premises owned or used by the service provider for the
purposes of providing the regulated service where that
failure or malfunctioning has lasted for longer than a
continuous period of 24 hours; and
o the failure or malfunctioning of fire alarms or other
safety devices in premises owned or used by the
service provider for the purposes of providing the
regulated service where that failure or malfunctioning
has lasted for longer than a continuous period of 24
hours.
• The following applies in relation to Schedule 3
(30)(42)(44)(46). Service providers notify the relevant
authorities of any incident of child sexual exploitation (CSE) or
child criminal exploitation (CCE) or suspected child sexual or
criminal exploitation. This includes but is not limited to:
o where a child identified as at risk of CSE or CCE goes
missing;
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o where a child reports an incident that indicates they may
be a victim of CSE or CCE; or
o where there is reason to believe a child may be subject
to CSE or CCE.
• Where a child identified as at risk of CSE or CCE goes
missing, only one notification is made under Schedule 3
(30)(42)(44)(46).
• The following applies in relation to Schedule 3 (31)(40)(45).
Service providers notify the relevant authorities of any incident
where an accommodated child goes missing or has an
unexplained absence. This includes but is not limited to:
o Where a child’s location or reason for their absence is
unknown and there is cause for concern for them
because of their vulnerability or risk to self or others.
The point at which the home is concerned and will take
action, including reporting the child missing to the
police, will vary according to the child’s individual risk
assessment.
Regulation 61
Notification with respect to children admitted into, or discharged from, a place at which accommodation is provided to
children
61.(1) This regulation applies where the service provider is registered to provide—
(a) a care home service which provides accommodation to children (referred to in this regulation as “a children’s care home
service”), or
(b) a secure accommodation service.
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(2) In this regulation, references to “the accommodation” are references to the place at which a children’s care home service or a
secure accommodation service is provided.
(3) The service provider must notify, without delay, the local authority for the area in which the accommodation is located of every
admission of a child into the accommodation and every discharge of a child from the accommodation.
(4) The service provider is not required to notify the local authority in paragraph (3) if that local authority is also the placing authority
for the child in question.
(5) A notification under this regulation must be in writing and must state—
(a) the child's name and date of birth;
(b) whether the child is provided with accommodation under section 76 or 77 of the 2014 Act or, in the case a child placed by a
local authority in England, whether the child is provided with accommodation under section 20 or 21 of the Children Act 1989;
(c) whether the child is subject to a care or supervision order under section 31 of the Children Act 1989;
(d) the contact details for—
i. the child's placing authority; and
ii. the independent reviewing officer appointed for the child's case; and
(e) whether the child has a statement of special educational needs or an EHC plan and, if so, details of the local authority with
responsibility for maintaining the statement of special educational needs or for the EHC plan.
(6) In this regulation, “EHC plan” has the meaning given in section 37(2) (education, health and care plans) of the Children and
Families Act 2014(5).
Regulation 62 Guidance
Notification with respect to the death of a child
accommodated in a secure children's home
62.(1) This regulation applies where a child to whom a secure
accommodation service(6) is provided dies.
• Service providers notify the relevant authorities of the death of
a child accommodated in a secure children’s home in
accordance with regulation 62.
5 2014 c. 6. https://www.legislation.gov.uk/ukpga/2014/6/pdfs/ukpga_20140006_en.pdf
6 A secure accommodation service is a regulated service under the Act (see section 2(1)(b) of the Act). Paragraph 2 of Schedule 1 to the Act defines “a secure
accommodation service” as the provision of accommodation for the purpose of restricting the libert y of children at residential premises in Wales where care and
support is provided to those children.
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(2) Any requirements imposed by this regulation apply to the
service provider of the secure accommodation service which was
providing accommodation to the child at the time of the death.
(3) If this regulation applies, the service provider must without
delay notify—
(a) the appropriate office of the service regulator;
(b) the placing authority;
(c) the local authority in whose area the secure
accommodation service is located;
(d) the Local Health Board in whose area the secure
accommodation service is located;
(e) the Prisons and Probation Ombudsman for England and
Wales (“the PPO”); and
(f) the child's parent or person who has parental responsibility
for the child.
(4) The service provider must allow the PPO to investigate the
death by—
(a) granting the PPO access to—
i. the premises of the service, and
ii. the service's documents and records;
(b) allowing the PPO to take away from the premises copies of
any documents or records accessed under sub-paragraph
(a)(ii) provided that the PPO has secure arrangements for
doing so; and
(c) if they consent, allowing the PPO to interview in private any
children, parents (or persons with parental responsibility) or
relatives, or persons working at the service.
(5) A notification under this regulation—
(a) must include details of—
• This notification regulation applies to service providers of
secure accommodation services and care homes where
children are accommodated.
• When a child moves in or leaves the service, service providers
notify the local authority for the area in which the secure
accommodation or care home is located.
• This notification includes the information set out in regulation
62(5).
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i. the circumstances of the death;
ii. the other persons, bodies or organisations (if any)
who or which the service provider has notified or
proposes to notify; and
iii. any actions the service provider has taken or
proposes to take as a result of the death;
(b) must be made or confirmed in writing.
(6) In this regulation, references to PPO include a person
appointed by, or working on behalf of, the PPO for the purposes of
an investigation under paragraph (2).
Regulation 63
Guidance
Conflicts of interest (including prohibitions)
63.(1) The service provider must have effective arrangements in
place to identify, record and manage potential conflicts of interest.
(2) The service provider must ensure that a person having a
financial interest in the ownership of a care home service does not
act as a medical practitioner for any individual for whom that
service is provided.
• Service providers maintain appropriate systems and take all
reasonable steps to make sure actual or perceived conflicts of
interests are identified, prevented and recorded in an open
way.
• Where a medical practitioner has a financial interest in a care
home service, that practitioner does not act as the medical
practitioner for an individual receiving care from the service. A
financial interest includes:
o being the owner, partner or director in the provider
organisation;
o being a share holder or holding stocks in the provider
organisation.
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Regulation 64
Guidance
Complaints policy and procedure
64.(1) The service provider must have a complaints policy in
place and ensure that the service is operated in accordance with
that policy.
(2) The service provider must have effective arrangements in
place for dealing with complaints including arrangements for—
(a) identifying and investigating complaints;
(b) giving an appropriate response to a person who makes a
complaint, if it is reasonably practicable to contact that
person;
(c) ensuring that appropriate action is taken following an
investigation;
(d) keeping records relating to the matters in sub-paragraphs
(a) to (c).
(3) The service provider must provide a summary of complaints,
responses and subsequent action to the service regulator within
28 days of being requested to do so.
(4) The service provider must—
(a) analyse information relating to complains and concerns;
and
(b) having regard to that analysis, identify any areas for
improvement.
• Service providers have an accessible complaints policy which
includes, where appropriate, the use of an informal resolution
stage and explains –
o who to approach to discuss a concern/complaint;
o how individuals can be supported to make a complaint;
o information about accessing independent advocacy,
where available, including the Citizen Voice Body
(Llais);
o how complaints will be dealt with; and
o the stages and timescales for the process
• The policy and procedures are in an easy-to-read format, well
publicised, readily available and accessible to individuals using
the service, their families, significant others, visitors, staff and
others working at the service.
• Information about other avenues for complaint is included to
support complainants if they are not satisfied with the service
provider’s action. For example, information about the
complaints procedure of the commissioning authority, the
Public Services Ombudsman for Wales, Citizen Voice Body
(Llais) and, in the case of children, the Children’s
Commissioner for Wales.
• Individuals are able to make their complaint in writing or
verbally to staff and these are acknowledged unless
complaints are made anonymously.
• Staff are aware of the complaints policy and understand how to
respond appropriately to complaints.
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• Service providers ensure any representation or complaint is
confirmed, addressed promptly and the complainant is kept
informed of progress.
• A written report is provided to the complainant setting out the
outcome of the complaint and any action to be taken.
• Wherever practicable consent is gained to the disclosure of the
details of a complaint, where necessary, to enable an effective
investigation to take place.
• Confidentiality is maintained during the complaints process
unless there are professional or statutory obligations which
would not make this possible, such as those in relation to
safeguarding.
• Individuals do not suffer victimisation or any other
disadvantage, or the withdrawal or reduction of a service as a
result of making representations or complaints.
• Systems are in place to make sure that all complaints are
investigated in accordance with the timescales set out in the
service provider’s complaints policy. This includes the
following:
o undertaking a review to establish the level of
investigation and immediate action required, including
whether there is a requirement for a referral to
appropriate authorities for investigation. This may
include the service regulator or local authority
safeguarding teams.
o where areas for improvement or service failures are
identified, acting upon these immediately.
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• Staff and others involved in the investigation of complaints
have the right level of knowledge and skill to do this. They
understand the service provider's complaints process and are
knowledgeable about any current related guidance.
• Records of complaints are maintained and monitored to identify
trends and areas of risk which may require pre-emptive action.
• Actions taken in response to complaints are reported on as
part of the governance arrangements for the service.
Regulation 65
Guidance
Whistleblowing
65.(1) The service provider must have arrangements in place to
ensure that all persons working at the service (including any
person allowed to work as a volunteer) are able to raise concerns
about matters that may adversely affect the health, safety or well-
being of individuals for whom the service is provided.
(2) These arrangements must include—
(a) having a whistleblowing policy in place and acting in
accordance with that policy, and
(b) establishing arrangements to enable and support people
working at the service to raise such concerns.
(3) The provider must ensure that the arrangements required
under this regulation are operated effectively.
(4) When a concern is raised, the service provider must ensure
that—
(a) the concern is investigated;
• There is an accessible whistleblowing policy and procedure in
place. This includes:
o the procedure for raising a concern;
o the safeguards in place for staff who raise a concern;
and
o how concerns will be investigated.
• Staff are aware of, and have had training in, how to raise
concerns (including safeguarding concerns) and there are
mechanisms and support available to enable them to do this.
• Wherever practicable consent is gained to the disclosure of the
details of a complaint, where necessary, to enable an effective
investigation to take place.
• Confidentiality is maintained during the complaints process
unless there are professional or statutory obligations which
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(b) appropriate steps are taken following an investigation;
(c) a record is kept of both the above.
would not make this possible, such as those in relation to
safeguarding.
• Individuals do not suffer victimisation or any other
disadvantage as a result of making their concerns known.
• All allegations, incidents or evidence of abuse, neglect or
improper treatment are followed up promptly in line with the
service provider’s safeguarding policy and procedures and
local safeguarding arrangements.
• Systems are in place to make sure that all safeguarding
concerns are considered without delay in line with the service
provider’s safeguarding policy and procedures. This includes:
o undertaking a review to establish the level of
investigation and immediate action required, including
referral to appropriate authorities for investigation (this
may include seeking advice from the service regulator
or local authority safeguarding staff).
o where areas for improvement or service failures are
identified, acting upon these without delay.
o ensuring staff and others involved in the investigation
understand the processes relating to safeguarding and
responding to concerns.
• Records of concerns are maintained and monitored to identify
trends and areas of risk which may require pre-emptive action.
Actions taken as a response to whistleblowing are subject to
reporting within governance arrangements.
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Chapter 2: Requirements on Responsible Individuals (Parts 16 to 20 of the Regulations)
The intent of Parts 16 to 20 of the Regulations is to ensure that a designated person at an appropriately senior level holds accountability,
for both service quality and compliance. The Regulations place specific requirements upon the responsible individual (RI) and will enable
the service regulator to take action not only against the service provider but also against the RI in the event that regulatory requirements
are breached. The regulations in these Parts are made under section 28 of the Act.
The responsible individual is responsible for overseeing the management of the service and for providing assurance that the service is
safe, well run and complies with the Regulations. The responsible individual is responsible for ensuring the service has a manager,
sufficient resources and support. The responsible individual is not responsible for the day-to-day management of the service (unless they
are also the manager); this rests with the manager.
2.1 Requirements on responsible individuals for ensuring effective management of the service (Part 16)
Regulation 66
Guidance
Supervision of management of the service
66. The responsible individual must supervise the management
of the service, which includes taking the steps described in
regulations 64, 72 and 73.
• The responsible individual follows the service provider’s
prescribed policies, processes, and systems to enable proper
oversight of the management, quality, safety and effectiveness
of the service. This includes, but is not limited to, ensuring the
service:
o focuses on individuals’ well-being and personal
outcomes;
o listens to individuals;
o responds positively to any concerns or complaints;
o does not place individuals at unnecessary risk;
o achieves best possible outcomes for individuals;
o fulfils the statement of purpose;
o has sufficient numbers of staff who are trained,
competent and skilled to undertake their role;
o has sufficient resources, facilities and equipment.
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• The responsible individual has systems in place to review and
assess the way in which the manager implements actions from
the findings of internal quality assurance and external
inspection reports, within required timescales.
• There are clear lines of accountability, delegation and
responsibility set out in writing between the responsible
individual and the manager (unless the manager is also the
responsible individual).
• Arrangements are in place for the manager to have direct
access to the responsible individual in addition to the
opportunity to meet formally as part of the responsible
individual’s quality reviews (unless the manager is also the
responsible individual).
• Arrangements are in place to ensure that the manager is
supported by supervision and training, and has opportunities to
gain skills for professional development that will support them
in their role.
Regulation 67 Guidance
Duty to appoint a manager
67.(1) The responsible individual must appoint a person to
manage the service. But this requirement does not apply if the
conditions in paragraph (2) or (3) apply.
(2) The conditions are—
(a) the service provider is an individual;
(b) the service provider proposes to manage the service;
• The responsible individual ensures a manager who is
registered with Social Care Wales is appointed and in place to
manage the delivery of the service on a day-to-day basis for
each place at, from, or in relation to which services are
provided.
• The responsible individual takes responsibility and
accountability for the appointment of the manager regardless
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(c) the service provider is fit to manage the service;
(d) the service provider is registered as a social care manager
with Social Care Wales; and
(e) the service regulator agrees to the service provider
managing the service.
(3) The conditions are—
(a) the service provider is a partnership, body corporate or
unincorporated body;
(b) the service provider is registered to provide a care home
service or residential family centre service at no more than
two locations or is registered to provide a domiciliary
support service in relation to no more than two areas;
(c) the service provider proposes that the individual designated
as the responsible individual for the service is to be
appointed to manage the service;
(d) that individual is fit to manage the service;
(e) that individual is registered as a social care manager with
Social Care Wales; and
(f) the service regulator agrees to that individual managing the
service.
(4) For the purposes of paragraph (2)(c), the service provider is
not fit to manage the service unless the requirements of regulation
35(2) (fitness of staff) are met in respect of the service provider.
(5) The duty in paragraph (1) is not discharged if the person
appointed to manage the service is absent for a period of more
than three months.
of whether they are directly involved in the recruitment
process.
• The responsible individual is assured that the person
appointed as the manager for the service has the appropriate
knowledge, skills and competence to manage the service
safely in accordance with the requirements of the Regulations.
• The responsible individual demonstrates that the appointment
of the manager has been undertaken with due diligence and in
line with the requirements of regulation 35 (fitness of staff).
• Where a manager is absent for a period more than three
months, the service provider ensures there is an appropriately
qualified, experienced and competent manager, registered with
Social Care Wales in place to manage the service.
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Regulation 68
Guidance
Fitness requirements for appointment of manager
68. (1) The responsible individual must not appoint a person to
manage the service unless that person is fit to do so.
(2) For the purposes of paragraph (1), a person is not fit to
manage the service unless the requirements of regulation 35(2)
(fitness of staff) are met in respect of that person.
• The responsible individual has suitable arrangements in place
to ensure the manager is fit and is capable of running the
service in line with its statement of purpose. This includes
ensuring:
o the manager is appropriately qualified;
o the manager is registered with Social Care Wales;
o the manager is experienced in managing care services
and in the provision of the type of care being provided;
o the vetting of prospective managers includes the
relevant checks required by regulations to assure the
responsible individual that the person is fit and able to
work with vulnerable individuals.
Regulation 69
Guidance
Restrictions on appointing manager for more than one
service
69.(1) The responsible individual must not appoint a person to
manage more than one service, unless paragraph (2) applies.
(2) This paragraph applies if—
(a) the service provider has applied to the service regulator for
permission to appoint a manager for more than one
service, and
(b) the service regulator is satisfied that the proposed
management arrangements—
i. will not have an adverse impact on the health or well-
being of individuals, and
• Where a manager is appointed to manage more than one
service, this is agreed in advance with the service regulator.
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ii. will provide reliable and effective oversight of each
service.
Regulation 70
Guidance
Duty to report the appointment of manager to service
provider
70. On the appointment of a manager in accordance with
regulation 67(1), the responsible individual must give notice to the
service provider of—
(a) the name of the person appointed, and
(b) the date on which the appointment is to take effect.
• The responsible individual has suitable arrangements in place
to:
o inform the service provider of the details of the
appointment of the manager;
o provide the information specified by the Regulations
concerning the individual; and
o notify the service regulator and Social Care Wales when
a new manager is appointed.
Regulation 71
Duty to report appointment of manager to the workforce and service regulators
71.(1) On the appointment of a manager in accordance with regulation 67(1), the responsible individual must give notice to the
workforce and service regulators of—
(a) the name, date of birth and Social Care Wales registration number of the person appointed, and
(b) the date on which the appointment is to take effect.
(2) In a case where the service provider is an individual and the service regulator has agreed to the service provider managing the
service, the service provider must give notice to the workforce regulator of—
(a) the name, date of birth and Social Care Wales registration number of the service provider, and
(b) the date from which the service provider is to manage the service.
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Regulation 72 Guidance
Arrangements when manager is absent
72.(1) The responsible individual must put suitable
arrangements in place to ensure that the service is managed
effectively at any time when there is no manager or when the
manager is not present at the service.
(2) If there is no manager or the manager is not present at the
service for a period of more than 28 days, the responsible
individual must—
(a) notify the service provider and the service regulator, and
(b) inform them of the arrangements which have been put in
place for the effective management of the service.
• The responsible individual has structures in place which
ensure that where the manager is not available or is absent for
any reason there is an effective and competent deputising
system to provide leadership on a day to day basis which:
o continues to support individuals to achieve their
personal outcomes;
o maintains the safety, quality and effectiveness of the
service;
o ensures minimal disruption to individuals receiving the
service;
o ensures compliance with Regulations; and
o maintains staff professional development.
• Where the manager, registered with Social Care Wales, is
unavailable or absent for any reason for more than 28 days the
responsible individual will inform the service regulator in writing
and without delay of the reason for the absence and the
arrangements for cover.
Regulation 73
Guidance
Visits
73.(1) In the case of care home services, secure
accommodation services and residential family centre services(7),
the responsible individual must—
• The responsible individual visits the service in person to
monitor the performance of the service in relation to its
statement of purpose and to inform the quality of care review.
The visit includes the following:
7 See Schedule 1 to the Act for further provision about the meaning of care home services, secure accommodation services and re sidential family centre services.
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(a) visit each place in respect of which the responsible
individual is designated, and
(b) meet with staff and individuals at each such place.
(2) In the case of a domiciliary support service (8), the
responsible individual must—
(a) meet with members of staff who are employed to provide a
regulated service at, from or in relation to each place in
respect of which the responsible individual is designated,
and
(b) meet with individuals for whom a regulated service is being
provided at, from or in relation to each such place.
(3) The frequency of such visits and meetings is to be
determined by the responsible individual having regard to the
statement of purpose but must be at least every three months.
o talking to, with consent and in private, individuals using
the service and their representatives (if applicable) and
staff. For domiciliary support services, this may include
visiting a representative sample of individuals in their
own home.
o inspecting the premises, a selection of records of events
and any complaints records.
• The responsible individual ensures visits are documented
including evidence of:
o the date of the visit
o details of discussions with staff and individuals using the
service
o details of the records reviewed, and
o details of the outcome of the visit such as actions taken
to make any improvements required.
8 See section 2(1) of the Act for the services included within the definition of “regulated service”.
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2.2 Requirements on responsible individuals for ensuring effective oversight of the service (Part 17)
Regulation 74
Guidance
Oversight of adequacy of resources
74.(1) The responsible individual must report to the service
provider on the adequacy of the resources available to provide the
service in accordance with the requirements on service providers
in Parts 3 to 15 of these Regulations.
(2) Such reports must be made on a quarterly basis.
(3) But this requirement does not apply where the service
provider is an individual.
• The responsible individual ensures that systems and
processes are in place which enable them to collate
information about the service and any areas that may need
closer observation/consideration and/or improvement. This
includes, but is not limited to:
o staff turnover;
o staff sickness levels;
o complaints;
o safeguarding issues;
o inspection reports by the service regulator,
o inspection outcomes and or reports from other relevant
agencies i.e. Health and Safety Executive (HSE), Food
Standards Agency (FSA) and fire service.
• The responsible individual has suitable arrangements in place
to alert the service provider immediately where the service is:
o not complying with polices and procedures;
o failing or unable to meet or address issues raised in
inspection reports; and
o being provided in a way which is contrary to the
statement of purpose.
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Regulation 75
Guidance
Other reports to the service provider
75.(1) The responsible individual must, without delay, report to
the service provider—
(a) any concerns about the management or provision of the
service;
(b) any significant changes to the way the service is managed
or provided;
(c) any concerns that the service is not being provided in
accordance with the statement of purpose for the service.
(2) But this requirement does not apply where the service
provider is an individual.
• The responsible individual ensures suitable arrangements are
in place to report to the service provider in line with the
requirements of regulations 75 and 80(4).
• The responsible individual has a system in place to submit
reports to the service provider that accurately reflect overall
service quality and performance. This includes arrangements
for the responsible individual to feed back and communicate
any urgent matters requiring immediate action. This includes,
but is not limited to:
o any allegation, incident or evidence of abuse, neglect or
improper treatment;
o sudden or unexplained death of individuals using the
service;
o natural disaster;
o financial irregularities;
o significant outbreak of infection;
o significant concerns raised by the service regulator or
commissioners; and
o any event, which affects staff availability.
Regulation 76
Guidance
Engagement with individuals and others
76.(1) The responsible individual must put suitable
arrangements in place for obtaining the views of—
(a) the individuals who are receiving care and support,
(b) any representatives of those individuals,
• The responsible individual has suitable arrangements in place
to enable feedback on all aspects of service provision and
ensure that these arrangements are accessible to, and take
into account the views of, all those listed under regulation
76(1).
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(c) in the case of a child who is provided with accommodation,
the placing authority,
(d) service commissioners, and
(e) staff employed at the service,
on the quality of care and support provided and how this
can be improved.
(2) The responsible individual must report the views obtained to
the service provider so that these views can be taken into account
by the service provider when making any decisions on plans for
improvement of the quality of care and support provided by the
service.
• The responsible individual ensures the methods used to
engage with and gain the views of individuals using the service
are appropriate to their age, level of understanding and take
into account any specific condition or communication need.
• The responsible individual has positive relationships with, and
is accessible to, people outside the service. This includes but
is not limited to:
o families or nominated representation;
o commissioners;
o regulators;
o professional bodies.
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2.3 Requirements on responsible individuals for ensuring the compliance of the service (Part 18)
Regulation 77
Guidance
Duty to ensure there are systems in place to record incidents
and complaints
77. The responsible individual must ensure that there are effective
systems in place to record incidents, complaints and matters on
which notifications must be made in accordance with regulations
60 to 62 and 84.
• The responsible individual ensures there are suitable
arrangements in place for the recording of the matters set out
in regulations 77.
• The responsible individual has systems and processes in place
to ensure that any records made are legible, accurate and kept
securely.
Regulation 78
Guidance
Duty to ensure there are systems in place for keeping of
records
78. The responsible individual must ensure that there are effective
systems in place in relation to the keeping of records, which
include systems for ensuring the accuracy and completeness of
records which are required to be kept by regulation 59.
• Where records are stored electronically, they are secure and
staff have individual access codes which provide a clear audit
trail which shows who has made any entries and amendments.
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Regulation 79
Guidance
Duty to ensure policies and procedures are up to date
79. The responsible individual must put suitable arrangements in
place to ensure that the service provider’s policies and procedures
are kept up to date, having regard to the statement of purpose.
• The responsible individual ensures suitable arrangements are
in place to review policies and procedures in line with
regulation 12 and 79.
• The responsible individual ensures suitable arrangements are
in place to ensure staff and volunteers have access to, and
knowledge and understanding of, the policies and procedures
which support them in their role in achieving the best possible
outcomes for individuals.
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2.4 Requirements responsible individuals for monitoring, reviewing and improving the quality of the
regulated service (Part 19)
Regulation 80
Guidance
Quality of care review
80.(1) The responsible individual must put suitable
arrangements in place to establish and maintain a system for
monitoring, reviewing and improving the quality of care and
support provided by the service.
(2) The system established under paragraph (1) must make
provision for the quality of care and support to be reviewed as
often as required but at least every six months.
(3) As part of any review undertaken, the responsible individual
must make arrangements for—
(a) considering the outcome of the engagement with
individuals and others, as required by regulation 76;
(b) analysing the aggregated data on incidents, notifiable
incidents, safeguarding matters, whistleblowing, concerns
and complaints;
(c) reviewing any action taken in relation to complaints;
(d) considering the outcome of any audit of the accuracy and
completeness of records.
(4) On completion of a review of the quality of care and support
in accordance with this regulation, the responsible individual must
prepare a report to the service provider which must include—
(a) an assessment of the standard of care and support
provided, and
(b) recommendations for the improvement of the service.
• The responsible individual has suitable arrangements in place
to assess, monitor and improve the quality and safety of the
service. This includes, but is not limited to:
o the collation and analysis of feedback from those listed
under regulation 76(1);
o issues and lessons learned in the analysis of complaints
and safeguarding matters:
o patterns and trends identified through the analysis of
incidents or near misses, for example, falls or
medication errors, safeguarding risks, records of control
or restraint, etc;
o the outcome of any inspection reports from the service
regulator;
o the outcome of visits to monitor the service by the
responsible individual; and
o audits of records, including personal plans.
• The responsible individual ensures that the audit systems and
processes for monitoring the service give assurance that the
service provides high quality care, achieves the best possible
outcomes for individuals and improves their well-being.
• The responsible individual has suitable arrangements in place
to ensure systems and processes are continually reviewed to
enable the responsible individual to identify where the quality
and/or safety of services is being, or may be, compromised,
and to respond appropriately without delay.
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(5) But the requirement in paragraph (4) does not apply where
the service provider is an individual.
• The responsible individual has suitable arrangements in place
to ensure all feedback is acknowledged, recorded and
responded to as appropriate.
• The responsible individual has suitable arrangements in place
to ensure areas of learning from complaints, safeguarding and
whistleblowing are shared with staff to improve the service and
encourage safe, compassionate care practices.
• The responsible individual ensures areas of learning are
analysed and that recommendations are made to the service
provider as to how and where the quality and safety of the
service can be improved. The report, which includes the
information that has informed it (relating to those areas set out
above) will inform or form part of the statement of compliance
to be included in the service provider’s annual return.
Regulation 81
Guidance
Statement of compliance with the requirements as to
standards of care and support
81.(1) The responsible individual must prepare the statement
required to be included in the annual return under section 10(2)(b)
of the Act, in so far as it relates to the place or places in respect of
which the responsible individual has been designated.
(2) When preparing the statement, the responsible individual
must have regard to the assessment of the standard of care and
support which is contained in a report prepared in accordance
with regulation 80(4).
• The responsible individual has prepared and is accountable for
the quality and accuracy of the information provided in the
statement of compliance and service provider’s annual return.
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2.5 Other requirements on responsible individuals (Part 20)
Regulation 82
Guidance
Support for staff raising concerns
The responsible individual must ensure that the provider’s
whistleblowing policy is being complied with and that the
arrangements to enable and support people working at the service
to raise such concerns are being operated effectively.
• The responsible individual ensures suitable arrangements are
in place for:
o staff and volunteers to be aware of and understand
the whistleblowing policy;
o staff and volunteers to understand there is zero
tolerance for poor care or for a failure to safeguard the
well-being of individuals;
o ensuring staff and volunteers are encouraged and
supported to report issues; and
o ensuring staff and volunteers understand that
concerns are welcomed and sought out, not ignored.
Regulation 83
Guidance
Duty of candour
The responsible individual must act in an open and transparent
way with—
a) individuals who are receiving care and support;
b) any representatives of those individuals;
c) in the case of a child who is provided with
accommodation, the placing authority.
• The responsible individual acts in an open and transparent
way ensuring suitable arrangements are in place to ensure
compliance with the requirements of regulation 83.
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Regulation 84
Guidance
Notifications
(1) The responsible individual must notify the service regulator of
the events specified in Schedule 4.
(2) The notifications required by paragraph (1) must include
details of the event.
(3) Unless otherwise stated, notifications must be made without
delay and in writing.
(4) Notifications must be made in such manner and in such form
as may be required by the service regulator.
• The responsible individual has suitable arrangements in place
to notify the service regulator of events specified in Schedule 4
of the Regulations
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Annex A: Parts of the Regulations not the subject of this Guidance
PART 1
General
Title, commencement, application and interpretation
1 (1) The title of these Regulations is the Regulated Services (Service Providers and Responsible
Individuals) (Wales) Regulations 2017.
(2) These Regulations come into force on 2 April 2018 and apply in relation to Wales.
(3) In these Regulations—
“the Act” (“y Ddeddf”) means the Regulation and Inspection of Social Care (Wales) Act 2016;
“the 2014 Act” (“Deddf 2014”) means the Social Services and Well-being (Wales) Act 2014(9);
“care and support plan” (“ cynllun gofal a chymorth ”) means a plan under section 54 or section
83 of the 2014 Act;
“child” (“plentyn”) means a person who is aged under 18;
“child who is looked after by a local authority” (“plentyn sy’n derbyn gofal gan awdurdod lleol”)
has the same meaning as in section 74 of the 2014 Act;
“general practitioner” (“ ymarferydd cyffredinol ”) means a registered medical practitioner( 10)
who—
(a) provides primary medical services under Part 4 of the National Health Service (Wales) Act
2006(11), or
(b) provides services which correspond to services provided under Part 4 of the National Health
Service (Wales) Act 2006, otherwise than in pursuance of that Act;
“health care professional” (“ proffesiynolyn gofal iechyd ”) means a person who is registered as a
member of any profession to which section 60(2) of the Health Act 1999(12) applies;
"nurse" (""nyrs") means a qualified nurse or qualified midwife registered with the Nursing and
Midwifery Council in accordance with article 5 of the Nursing and Midwifery Order 2001
“personal outcomes” (“canlyniadau personol”)—
(a) in relation to an adult, means the outcomes that the adult wishes to achieve in day to day life;
(b) in relation to a child, means—
i. the outcomes that the child wishes to achieve, or
ii. the outcomes that any persons with parental responsibility wish to achieve in relation to
the child;
(9) 2014 anaw 4.
(10) The definition of a “registered medical practitioner” in Schedule 1 to the Interpretation Act 1978 (c. 30) was substituted by S.I. 2002/3135, Schedule
1, paragraph 10 with effect from 16 November 2009.
(11) 2006 c. 42.
(12) 1999 c. 8.
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“personal plan” (“ cynllun personol ”) means the plan required to be prepared in accordance with
regulation 15(1);
“placing authority” (“awdurdod lleoli”) in relation to a child provided with accommodation as part
of a care home service or a secure accommodation service, means—
(a) in the case of a child who is looked after by a local authority or local authority in England, that
local authority;
(b) in the case of a child who is not looked after by a local authority or local authority in England—
i. if the child is being provided with accommodation by a voluntary organisation, that
voluntary organisation;
ii. if the child is accommodated in a qualifying school under arrangements made by a local
authority (whether in the exercise of education functions within the meaning of section
579(1) of the Education Act 1996(13) or otherwise), that local authority;
iii. in any other case, the child’s parent;
and for the purposes of this definition “qualifying school” (“ ysgol gymhwysol ”) means a school
which is a care home service by virtue of the application of paragraph 1(3) of Schedule 1 to the Act;
“provider assessment” (“asesiad darparwr”) means the assessment which is required to be carried
out by the service provider under regulation 18;
“reasonable adjustments” (“addasiadau rhesymol”) means such reasonable adjustments as would be
required under the Equality Act 2010(14);
“registered dental practitioner” (“ymarferydd deintyddol cofrestredig”) means a person registered in
the dentists register kept under the Dentists Act 1984(15) who—
(a) provides primary dental services under Part 5 of the National Health Service (Wales) Act 2006,
or
(b) provides services which correspond to services provided under Part 5 of the National Health
Service (Wales) Act 2006, otherwise than in pursuance of that Act;
“registered professional" ("proffesiynolyn cofrestredig") has the meaning given in paragraph 1 of
Schedule 3 to the Health Professions Order 2001
"regulated services" ("gwasanaethau rheoleiddiedig") means care home services, domiciliary support
services, secure accommodation services or residential family centre services
“representative” (“cynrychiolydd”) means any person having legal authority, or the consent of the
individual to act on the individual’s behalf;
“service commissioner” (“ comisiynydd y gwasanaeth ”) means the local authority or NHS body
which is responsible for making arrangements with the provider for care and support to be provided
to an individual;
“service provider” (“darparwr gwasanaeth”) has the same meaning as in section 3(1)(c) of the Act;
“staff” (“staff”) includes—
(a) persons employed by the service provider to work at the service as an employee or a worker, and
(b) persons engaged by the service provider under a contract for services,
but does not include persons who are allowed to work as volunteers.
(13) 1996 c. 56.
(14) 2010 c. 15.
(15) 1984 c. 24.
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For the purpose of this definition, “employee” (“ cyflogai”) and “worker” (“ gweithiwr”) have the
same meanings as in section 230 of the Employment Rights Act 1996(16);
“the individual” (“yr unigolyn”) means, unless the context indicates otherwise, the child or adult who
is receiving care and support;
“the responsible individual” (“yr unigolyn cyfrifol”) has the same meaning as in section 21(1) of the
Act;
“the service” (“y gwasanaeth”) means—
(a) in relation to a care home service, a secure accommodation service or a residential family centre
service, the service which is provided at a specified location;
(b) in relation to a domiciliary support service, the service which is provided in relation to a specified
area.
For the purpose of this definition—
i. “specified location” (“ lleoliad penodedig”) means a location specified in a condition to
the service provider’s registration as a place at which the service is to be provided(17);
ii. “specified area” (“ardal benodedig”) means an area specified in a condition to the service
provider’s registration as a place in relation to which the service is to be provided.
But this definition does not apply to references to “the service” (“y gwasanaeth”) in Part 22;
“the service regulator” (“y rheoleiddiwr gwasanaethau”) means the Welsh Ministers in the exercise
of their regulatory functions(18);
“the statement of purpose” (“y datganiad o ddiben”) means the statement of purpose for the place at,
from or in relation to which the service is provided(19);
“the workforce regulator” (“rheoleiddiwr y gweithlu”) means Social Care Wales.
PART 2
Exceptions
Care home services
2.—(1) The following things are not to be treated as a care home service, despite paragraph 1 of
Schedule 1 to the Act (regulated services: definitions, care home services)—
(a) the provision of accommodation, together with nursing or care, to an adult—
i. in the course of a family or personal relationship, and
ii. for no commercial consideration;
(16) 1996 c. 18.
(17) Section 7(3)(a)(i) of the Act provides that the grant of an application under section 6 of the Act must be subject to a condition specifying the places at,
from or in relation to which the service provider is to provide a regulated service.
(18) “Regulatory functions” is defined in section 3(1)(b) of the Act.
(19) Regulation 3 of the Regulated Services (Registration) (Wales) Regulations 2017 requires a person who wants to provide a care home service, secure
accommodation service or residential family centre service to provide a statement of purpose for each place at which the service is to be provided; a
person who wants to provide an adoption service, a fostering service, an adult placement services or an advocacy service must provide a statement of
purpose for each place from which the service is to be provided; a person who wants to provide a domiciliary support service must provide a statement
of purpose for each place in relation to which the service is to be provided.
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(b) the provision of accommodation, together with nursing or care, to adults for a period of less than
28 days in any 12 month period or for a number of periods which in total are less than 28 days
in any 12 month period;
(c) the provision of accommodation, together with nursing, where the accommodation is vested—
i. in the Welsh Ministers for the purposes of their functions under the National Health
Service (Wales) Act 2006;
ii. in an NHS trust;
iii. in a Local Health Board.
(d) the provision of accommodation, together with care, where the accommodation is provided—
i. by an institution within the further education sector; or
ii. by a university.
But this exception does not apply if the number of persons to whom such accommodation is
provided is more than one tenth of the number of students to whom it provides both education
and accommodation.
For the purposes of this paragraph, “further education sector” (“sector addysg bellach”) has the
same meaning as in section 91(3) of the Further and Higher Education Act 1992(20);
(e) the provision of accommodation, together with care, where the care provided constitutes child
minding within the meaning of section 19(2), or day care within the meaning of section 19(3) of
the Children and Families (Wales) Measure 2010(21) but this exception does not apply if—
i. in any 12 month period there are 28 or more periods of 24 hours during which more than
15 hours of child minding or day care are provided in relation to any one child; or
ii. the accommodation is provided wholly or mainly for disabled children.
(f) the provision of accommodation, together with care, where the accommodation is provided for
children aged 16 and over only for the purposes of enabling the children to undergo training or
an apprenticeship.
But this exception does not apply if the accommodation is provided wholly or mainly for disabled
children;
(g) the provision of accommodation, together with care, where the accommodation is provided to
children at an approved bail hostel or approved probation hostel;
(h) the provision of accommodation, together with care, where the accommodation is an institution
for young offenders provided under or by virtue of section 43(1) of the Prison Act 1952(22);
(i) the provision of accommodation, together with care, where the accommodation is provided to
children for the purposes of—
i. a holiday;
ii. a leisure, recreational, sporting, cultural or educational activity;
But this exception does not apply—
i. care is provided wholly or mainly for disabled children unless the service provider has
first notified the Welsh Ministers of the arrangements in writing;
ii. if the accommodation is provided to any one child for more than 28 days in any 12 month
period, unless the accommodation is only provided to children over the age of 16;
(20) 1992 c. 13.
(21) 2010 nawm 1.
(22) 1952 c. 52.
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(j) the provision of accommodation, together with care, to a single child or to a sibling group by a
person in that person’s own home and where care and accommodation are not provided by that
person for a total of more than 28 days in any 12 month period.
(2)For the purposes of paragraph (1)(e), (f) and (i) of this regulation, a child is “disabled” if the child
has a disability for the purposes of the Equality Act 2010.
(3) See regulation 5 for the meaning of family or personal relationship.
(4) In subparagraph (1)(j) of this regulation “sibling group” includes both brothers and sisters, and half-
brothers and half-sisters
Domiciliary support services
3. (1) The following things are not to be treated as a domiciliary support service, despite paragraph 8
of Schedule 1 to the Act (regulated services: definitions, domiciliary support services)—
(a) the provision of support only;
(b) the provision of care and support to four or fewer individuals at any one time;
(c) the provision of care and support for an adult—
i. in the course of a family or personal relationship, and
ii. for no commercial consideration;
(d) the provision of care and support for a child by a parent, relative or foster parent;
(e) the provision of care and support by a carer where such care and support is provided without
the involvement of an undertaking acting as an employment agency or employment business
(within the meaning given to those expressions by section 13 of the Employm ent Agencies
Act 1973(23)), and where the carer works wholly under the direction and control of a related
third party;
(f) arrangements for the supply of carers to a service provider by an undertaking acting as an
employment agency or employment business for the purpose of the provision of a regulated
service by the service provider;
(g) the provision of care and support where the care and support is provided by a person
managing a prison or other similar custodial establishment;
(h) the provision of nursing care by a registered nurse;
(i) the provision of care and support by a Local Health Board to meet needs which are related to
the needs of individuals for nursing care
(2) In paragraph (1)(e) and (f), “carer” means an individual who provides care to a person referred to in
paragraph 8(1) of Schedule 1 to the Act.
(3) In paragraph (1)(e), “related third party” means—
(a) an individual with parental responsibility (within the meaning of
section 3 of the Children Act 1989( 24)) for a child to whom care and
support is to be provided;
(b) an individual with power of attorney or other lawful authority to make
arrangements on behalf of the individual to whom care and support is
to be provided;
(23) 1973 c. 35.
(24) 1989 c. 41.
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(c) a group of individuals mentioned in either of sub-paragraphs (a) or (b)
making arrangements on behalf of no more than four named
individuals to whom care and support is to be provided;
(d) a trust established for the purpose of providing services to meet the
care and support needs of a named individual.
(4) See regulation 5 for the meaning of family or personal relationship.
Residential family centre services
4. The following things are not to be treated as a residential family centre service, despite paragraph 3
of Schedule 1 to the Act (regulated services: definitions, residential family centre services)—
(a) the provision of accommodation for children and their parents where the
accommodation is provided in a hospital(25);
b) the provision of accommodation for children and their parents where the
accommodation is provided in a hostel or a domestic violence refuge;
c) in any other case, the provision of accommodation for children and their parents the
main purpose of which is the provision of accommodation together with other
services and facilities to adult individuals and the fact that those individuals may be
parents, or may be accompanied by their children, is incidental to the main purpose
of the provision of the accommodation.
Meaning of family or personal relationship
5. For the purposes of this Part—
(a) a family relationship includes a relationship between two persons
who—
i. live in the same household, and
ii. treat each other as though they were members of the same
family;
(b) a personal relationship is a relationship between or among friends;
(c) a friend of a person (A) includes a person who is a friend of a member
of A’s family.
PART 21
Offences
Offences – service providers
85.—(1) It is an offence for a service provider to fail to comply with a requirement of any of the
provisions specified in paragraph (2)(26).
(25) “Hospital” is defined in paragraph 9 of Schedule 1 to the Act and includes an independent clinic.
(26) For penalties upon conviction for an offence under this regulation, see section 51(1) of the Act.
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(2) The provisions specified for the purposes of paragraph (1) are the provisions of regulations 7(3),
7(5), 11(3), 12(1), 12(2), 19(1), 19(2), 19(3), 20(1), 35(1), 38(1), 59(1), 59(2), 59(3), 60(1), 60(2), 60(4),
61(3) and 62(3).
(3)A service provider commits an offence if the provider fails to comply with a requirement of any of
the provisions specified in paragraph (4) and such failure results in—
a) avoidable harm (whether of a physical or psychological nature) to an individual,
b) an individual being exposed to a significant risk of such harm occurring, or
c) in a case of theft, misuse or misappropriation of money or property, any loss by an
individual of the money or property concerned.
(4) The provisions specified for the purposes of paragraph (3) are the provisions of regulations 6, 7(1),
12(5), 14(1), 14(3), 15(1), 15(3), 15(5), 16(1), 16(5), 18(1), 18(6), 18(7), 21(1), 21(2), 22, 26, 33( 2),
34(1), 34(2) and 34(3).
Offences – responsible individuals
86(1)It is an offence for the responsible individual to fail to comply with a requirement of any of the
provisions specified in paragraph (2)(27).
(2) The provisions specified for the purposes of paragraph (1) are the provisions of regulations 67(1),
68(1), 71(1), 71(2), 73(1), 73(2), 73(3), 74(1), 74(2), 75(1), 80(4), 81(1), 84(1) and 84(3).
PART 22
Service providers who are liquidated etc. or who have died
Appointment of liquidators etc.
87. An appointed person must—
a) without delay, give written notification to the service regulator of their appointment
and the reasons for their appointment;
b) within 28 days of their appointment, notify the service regulator of their intentions
regarding the future operation of the service.
(2) In this regulation—
“appointed person” (“person a benodir”) has the same meaning as in section 30 of the Act;
“the service” (“y gwasanaeth”) means the regulated service or services which the service provider to
which the appointment relates is registered to provide.
Death of service provider
88.Where a service provider who is an individual has died, the personal representatives of the individual
must—
(a) without delay, give written notification of the death to the service
regulator;
(b) within 28 days of the death, notify the service regulator of their
intentions regarding the future operation of the service.
(27) For penalties upon conviction for an offence under this regulation, see section 51(1) of the Act.
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(2) The personal representatives of the individual may act in the capacity of the service provider for a
period not exceeding 28 days or for such longer period (not exceeding one year) as the service regulator
may agree.
(3) Where the personal representatives are acting in the capacity of the service provider in accordance
with paragraph (2), Part 1 of the Act applies with the following modifications—
(a) section 5 (requirement to register) does not apply;
(b) in section 21(2) (responsible individuals) after paragraph (a) insert—
“(aa) where the personal representatives of a service provider who has died are acting in the
capacity of the service provider, be one of the personal representatives;”.
(4) In this regulation, “the service” means the regulated service or services which the service provider
who has died was registered to provide at the time of their death.
PART 23
Regulations under section 21(5) of the Act
Designation of responsible individual by Welsh Ministers
89.The Welsh Ministers (instead of a service provider) may designate an individual to be a responsible
individual, despite the requirements of section 21(2) of the Act not being met in respect of the individual,
in the following circumstances—
a) the service provider is an individual who has died and the personal representatives of
the service provider have notified the service regulator that they do not intend to make
an application under section 11(1)(c) of the Act;
b) the service provider is an individual and they have notified the service regulator—
i. that they are no longer able to comply with their duties as a responsible
individual, and
ii. the reasons for this being the case;
c) the service provider is a corporate body or partnership and they have notified the
service regulator—
i. that the individual designated by the service provider as the responsible
individual is no longer able to comply with their duties as a responsible
individual,
ii. the reasons for this being the case, and
iii. that there is no other individual who is eligible to be a responsible individual
and who is able to comply with the duties of a responsible individual.
Huw Irranca-Davies
Minister for Children and Social Care under authority of the Cabinet Secretary for Health and Social
Services, one of the Welsh Ministers
Date12 December 2017
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Annex B: Schedules to Regulations 35, 59, 60 and 84
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SCHEDULE 1 Regulation 35
PART 1
Information and documents to be available in respect of persons working in regulated services
1. Proof of identity including a recent photograph.
2.Where required for the purposes of an exempted question in accordance with section 113A(2)(b) of
the Police Act 1997(28), a copy of a valid(29) criminal record certificate issued under section 113A of
that Act together with, after the appointed day and where applicable, the information mentioned in
section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on
request).
3.Where required for the purposes of an exempted question asked for a prescribed purpose under
section 113B(2)(b) of the Police Act 1997, a copy of a valid( 30) enhanced criminal record certificate
issued under section 113B of that Act together with, where applicable, suitability information relating
to children (within the meaning of section 113BA(2) of that Act) or suitability information relating to
vulnerable adults (within the meaning of section 113BB(2) of that Act).
4.Two written references, including a reference from the last employer, if any.
5.Where a person has previously worked in a position whose duties involved work with children or
vulnerable adults, so far as reasonably practicable verification of the reason why the employment or
position ended.
6.Documentary evidence of any relevant qualification.
7.Where relevant, documentary evidence of registration with Social Care Wales.
8. A full employment history, together with a satisfactory written explanation of any gaps in
employment.
9.Evidence of satisfactory linguistic ability for the purposes of providing care and support to those
individuals for whom the worker is to provide care and support.
10.Details of registration with or membership of any professional body.
PART 2
Interpretation of Part 1
11.For the purposes of paragraphs 2 and 3 of Part 1 of this Schedule—
(a) if the person to whom the certificate relates is not registered with the DBS update service, a
certificate is only valid if—
i. it has been issued in response to an application by the service provider in accordance with
regulation 34(3) or (6), and
ii. no more than three years have elapsed since the certificate was issued;
(28) 1997 c. 50.
(29) For the meaning of “valid”, see Part 2 of this Schedule.
(30) For the meaning of “valid”, see Part 2 of this Schedule.
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(b) if the person to whom the certificate relates is registered with the DBS update service, the
certificate is valid regardless of when it was issued.
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SCHEDULE 2 Regulation 59
Records to be kept in respect of regulated services
PART 1
Records to be kept in respect of all regulated services
1. In respect of each individual, records of—
(a) all relevant assessments;
(b) personal plans;
(c) reviews of personal plans;
(d) care and support plans;
(e) reviews of care and support plans;
(f) care provided, including daily records or records of specific care interventions;
(g) correspondence, reports and records in relation to additional support provided by education,
health and other allied services.
2. A record of any charges by the service provider to individuals for the provision of care and support
and any additional services.
3. A record of all medicines kept in the service for each individual and the date and time on which
they were administered to the individual.
4. A record of all money or other valuables deposited by the individual for safekeeping or received on
the individual’s behalf, which must include a record of—
(a) the date on which the money or valuables were deposited or received;
(b) the date on which any money or valuables were—
i. returned to the individual, or
ii. used, at the request of the individual, on their behalf;
(c) where applicable, the purpose for which the money or valuables were used;
(d) the written acknowledgment of the return of the money or valuables.
5. A record of the following events that occur in the service—
(a) any serious accident , or injury which is significantly detrimental to the well -being of an
individual;
(b) the outbreak of infectious disease in the service;
(c) any theft or burglary;
(d) any safeguarding referral made in respect of an individual;
(e) falls and consequent treatment provided to an individual;
(f) incidence of pressure damage and of consequent treatment provided to an individual;
(g) date and circumstances of any measures of control, restraint or discipline used on an individual.
6. A record of every fire practice, drill or test of fire equipment (including fire alarm equipment)
conducted in the service and of any action taken to remedy defects in the fire equipment.
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7. A record of all complaints made by individuals or their representatives or by persons working at the
service about the operation of the service, and the action taken by the service provider in respect of any
such complaint.
8. A record of all persons working at the service, which must include the following matters—
(a) the person’s full name, address, date of birth, qualifications and experience;
(b) a copy of the person’s birth certificate and passport (if any);
(c) a copy of each reference obtained in respect of the person;
(d) the dates on which the person commences and ceases to be so employed;
(e) the position the person holds at the service, the work he or she performs and the number of hours
for which he or she is employed each week;
(f) records of disciplinary action and any other records in relation to the person’s employment;
(g) a record of the date of a DBS certificate and whether there was any action taken as a result of the
content of the certificate.
9. A copy of the duty roster of persons working at the service, and a record of whether the roster was
actually worked as intended.
PART 2
Additional records to be kept in respect of care home services, secure accommodation services and
residential family centre services
10. A record of any furniture brought by an individual into the room occupied by him or her.
11. A record of any of the following events that occur in the service—
(a) any fire;
(b) unexplained or unauthorised absence;
(c) death of an individual.
12. A record of all visitors to the service, including the names of visitors and the persons they are
visiting.
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SCHEDULE 3 Regulation 60
Notifications by the service provider
PART 1
Notifications to the service regulator in respect of all services
1. Any revision to the statement of purpose, 28 days prior to the revised statement of purpose coming
into effect.
2. Service provider (individual or organisation) changes their name.
3. Where, on or after 1 April 2020, the service provider is a body corporate, any change in the — (a)
directors, (b) trustees, or (c) members of the managing committee, of the body corporate.
3A. Where, on or after 1 April 2020, the service provider is an unincorporated body, any change in the
persons who are concerned in the management and control of the body.
4. Where the service provider is an individual, the appointment of a trustee in bankruptcy in relation
to that individual.
5. Where the service provider is a body corporate or partnership, the appointment of a receiver,
manager, liquidator or provisional liquidator in relation to that body corporate or partnership.
6. Where the service provider is a partnership, death of one of the partners.
7. Where the service provider is a partnership, any change in the partners.
8. Expected absence of the responsible individual for 28 days or more, 7 days prior to commencement
of the absence.
9. The unexpected absence of the responsible individual, no later than 7 days after the commencement
of the absence.
10. Unexpected absence of the responsible individual for 28 days or more, where no prior notification
has been given, immediately on the expiry of 28 days following the commencement of the absence.
11. Return from absence of the responsible individual.
12. The responsible individual ceases, or proposes to cease, being the responsible individual for the
service.
13. Any abuse or allegation of abuse in relation to an individual that involves the service pr ovider
and/or a member of staff and/or volunteer;
14. Service provider, responsible individual or appointed manager convicted of a criminal offence.
15. Any allegation of misconduct by a member of staff.
16. Any occurrence of a category 3 or 4 pressure damage or unstageable pressure damage;
17. Serious accident or injury to an individual.
18. The outbreak of any infectious disease.
19. Any incident reported to the police.
20. Any events which prevent, or could prevent, the provider from continuing to provide the service
safely.
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21. Where accommodation is provided, the death of an individual and the circumstances.
22. Any request to a supervisory body in relation to the application of the deprivation of liberty
safeguards (DOLS).
23. The premises are, or are proposed to be, significantly altered or extended.
24. Additional premises are, or are proposed to be acquired.
25. Any proposal to change the address of the principal office, 28 days prior to the change taking
place.
PART 2
Additional notifications to the service regulator where care and support is provided to children
26. Any referral to the DBS pursuant to the Safeguarding Vulnerable Groups Act 2006.
27. Where the service provider, responsible individual or appointed manager is charged with any
offence specified in the Schedule to the Safeguarding Vulnerable Groups Act 2006 (Prescribed Criteria
and Miscellaneous Provisions) Regulations 2009( 31), notice of the offence charged and the place of
charge.
28. Instigation and subsequent outcome of any child protection enquiry involving a child
accommodated by the service.
29. Any allegation that a child accommodated by the service has committed a serious offence.
30. Any incident of child sexual or criminal exploitation or suspected child sexual or criminal
exploitation.
31. Any incident where an accommodated child goes missing or has an unexplained absence.
PART 3
Notifications to the placing authority where a care home service is provided to children
32. Any abuse or allegation of abuse in relation to a child accommodated by the service that involves
the provider or a member of staff.
33. Serious accident or injury to a child accommodated by the service.
34. Any occurrence of a category 3 or 4 pressure damage or unstageable pressure damage.
35. The outbreak of any infectious disease.
36. Any incident reported to the police.
37. The death of a child accommodated by the service and the circumstances.
38. Any referral to the DBS pursuant to the Safeguarding Vulnerable Groups Act 2006.
39. An allegation that a child accommodated by the service has committed a serious offence.
40. Any incident where an accommodated child goes missing or has an unexplained absence.
(31) S.I. 2009/37.
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41. Instigation and subsequent outcome of any child protection enquiry involving a child
accommodated by the service.
42. Any incident of child sexual or criminal exploitation or suspected child sexual or criminal
exploitation.
PART 4
Notifications to the local authority in whose area the home is situated where a care home
service is provided to children
43. Death of a child and the circumstances.
44. Any incident of child sexual or criminal exploitation or suspected child sexual or criminal
exploitation.
45. Any incident where an accommodated child goes missing or has an unexplained absence.
PART 5
Notifications to the appropriate police officer where a care home service is provided to children
46. Any incident of child sexual or criminal exploitation or suspected child sexual or criminal
exploitation.
PART 6
Notifications to the health board in whose area the home is situated where a care home service
is provided to children
47. The outbreak of any infectious disease.
48. The death of a child and the circumstances.
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SCHEDULE 4 Regulation 84
Notifications by the responsible individual
1. The appointment of a manager (see regulation 7(1)).
2. The expected absence of the appointed manager for 28 days or more, 7 days prior to the
commencement of the absence.
3. The unexpected absence of the appointed manager, no later than 7 days after the commencement of
the absence.
4. The unexpected absence of appointed manager for 28 days or more where no prior notification has
been given, immediately on the expiry of 28 days following the commencement of the absence.
5. Return from absence of appointed manager.
6. Interim arrangements where the manager is absent for longer than 28 days.
7. Someone other than the appointed manager is proposing to manage or is managing the service.
8. The appointed manager ceases, or proposes to cease, managing the service.