Introduction
Policies form the cornerstone of safe, efficient and person centred care practice in health and social care sectors and they are more than just internal paperwork. The Health and Social Care Act 2008 (Regulated Activities) regulations 2014, the Fundamental Standards of Quality and Safety and legal compliance are all requirements of the Care Quality Commission (CQC). Creating policies that are in compliance guarantees that employees are aware of their duties, that service users are protected and that businesses can prove their accountability to authorities. How to write compliant policies in Health and Social Care in England is well detailed below.
Understanding the regulatory framework
CQC compliance is underpinned by specific legislation and standards. Policies must directly reflect:
- The Health and Social Care Act 2008 and associated regulations.
- CQC Fundamental Standards, such as person centred care, dignity, safeguarding and governance.
- The Equality Act 2010 to ensure fairness and inclusion.
- Working Together to Safeguard Children (2023) and Care Act 2014 guidance on safeguarding adults.
- Best practice frameworks, such as NICE guidance and Skills for Care standards.
The 2023 update to Working Together to Safeguard Children strengthened expectations around multi-agency collaboration and accountability, meaning policies must now evidence clear information sharing pathways and escalation routes.
Referencing these within policies shows the organisation is grounded in the legal and regulatory context expected by the CQC.
Establishing purpose and scope
Any policy should start with a clear purpose statement. For example, a policy on safeguarding adults should outline how it will protect those who are at risk of harm and abuse. The scope must include information about who the policy covers, including all employees, agency workers, contractors and volunteers. This ensures the uniformity that CQC inspectors will seek throughout the workforce.
Embedding person-centred care
Person centred care is a key component of the CQC. Policies must demonstrate how the organisation’s staff will treat people with respect and dignity and involve them in their own decisions. For instance, in addition to explaining safe administration, a drug policy should describe how people’s autonomy, consent and preferences are respected. A Personal Care Policy should also include details about how staff will record and respect individual preferences , such as bathing times, gender of carers and privacy choices are recorded and respected. This demonstrates Regulation 9 compliance by evidencing that care delivery aligns with each person’s wishes, dignity and independence.
Using clear and accessible language
Compliant policies must be understandable to staff at all levels. CQC inspectors often interview care workers to test their understanding of policies, so clarity is essential. Policies should use plain English, define any necessary technical terms and be free from jargon.
Policies must also use directive language such as “must” or “is required to” rather than vague suggestions. This makes responsibilities unambiguous and ensures staff accountability.
Examples of non-compliance and best practice
Showing contrast between weak and outstanding policy statements helps staff and managers understand expectations clearly.
Weak Policy Example: Staff should try to report incidents.
Outstanding Policy Example: All staff must report any incidents immediately to their line manager and complete an incident form within 24 hours.
The latter demonstrates clarity and accountability, a CQC expectation under the “Well-led” and “Safe” standards.
Including such contrasts within staff training or policy templates reinforces what “good” looks like and encourages consistent compliance across the organisation.
Roles and responsibilities
CQC expects clear accountability. Policies must outline the responsibilities of:
- Registered Manager – overall responsibility for compliance and safe delivery of care.
- Care staff – day-to-day implementation and reporting of concerns.
- Specialist roles (e.g., safeguarding leads, medication champions) – ensuring expertise in key areas.
- Governance boards or directors – strategic oversight and assurance.
The policy section must also show how staff escalate issues and who has ultimate accountability.
Procedures and implementation
Policies must include detailed procedures that demonstrate how compliance is achieved in practice. For example, a complaints policy should explain:
- How service users and families can raise concerns.
- Timescales for acknowledgement and resolution.
- Escalation to the Local Government Ombudsman or CQC if unresolved.
- Recording and auditing of complaints for governance purposes.
CQC inspectors will check whether staff follow these procedures consistently, so they must be practical and easy to implement. Embedding these standards in policies helps services demonstrate to inspectors that they comply with regulations.
Alignment with CQC fundamental standards
Each policy should reference and embed CQC’s Fundamental Standards, including:
- Safety – policies on risk assessments, medication and infection control.
- Effectiveness – policies ensuring staff are trained, competent and supervised.
- Caring – policies promoting dignity, respect and compassion.
- Responsiveness – policies ensuring individualised care planning.
- Well-led – governance and quality assurance policies to drive improvement.
Embedding these standards in policies helps services demonstrate compliance during inspections.
Embedding equality, diversity and inclusion (EDI) in policies
Outstanding providers do not treat EDI as a standalone policy, they embed inclusivity throughout every document. Each policy should explicitly reference how it supports equality of access, reasonable adjustments, and cultural sensitivity.
For example, recruitment policies should demonstrate fair treatment, while communication policies should highlight the use of accessible formats for people with sensory or language needs. Embedding EDI ensures compliance with the Equality Act 2010 and aligns with CQC expectations for compassionate, non-discriminatory care.
Review and update cycles
CQC expects providers to keep policies current. A compliant policy should state:
- Review frequency (at least annually, or sooner if legislation changes).
- Responsible person (usually the Registered Manager).
- A process for updating staff and ensuring they sign to confirm understanding.
Outdated policies are a common reason for CQC compliance failures, so timely reviews are crucial.
Staff training and awareness
The CQC examines whether staff understand and adhere to policies. Training delivery methods (e.g. induction, refresher courses, monitoring) should be covered in policies. During training, staff must sign a document attesting to their understanding of important policies, particularly those about grievances, medicines, and safeguarding.
Monitoring and governance
CQC compliance requires evidence that policies and procedures are not just written but monitored in practice.
A compliant policy should explain:
- How compliance will be audited (e.g., spot checks, care plan reviews).
- How the manager will use feedback from service users to test effectiveness
- How the Registered Manager will address breaches, including disciplinary measures where necessary.
This ties directly to Regulation 17: Good Governance, which requires providers to continually assess and improve the quality and safety of services.
Conclusion on how to write compliant policies in Health and Social Care in England
Compliant policy writing is not an administrative exercise, it is the foundation of safe, compassionate, and transparent care. Outstanding policies show how principles become actions, how evidence drives improvement, and how leadership ensures every staff member understands their role in delivering excellence.
When policies integrate CQC Fundamental Standards, embed person-centred and inclusive practice, and translate legal frameworks into day-to-day behaviour, they not only meet inspection requirements but also actively improve the lives of service users and the confidence of staff delivering care.
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By: Godfrey Mushandu /LinkedIn
