Care Quality Commission (Registration) Regulations 2009 (Part 4)

The intention of this regulation is to make sure that providers have produced and sent to CQC a clear statement of all the information listed under Schedule 3.

Providers must notify CQC of any changes to their statement of purpose and ensure it is kept under review, and notify CQC when there are any changes to the information listed in Schedule 3.

Schedule 3

Schedule 3 sets out the information that must be included in the Statement of Purpose:

1. The aims and objectives of the service provider in carrying on the regulated activity;
2. The kinds of services provided for the purposes of the carrying on of the regulated activity and the range of service users’ needs which those services are intended to meet;
3. The full name of the service provider and of any registered manager, together with their business address, telephone number and, where available, electronic mail addresses;
4. The legal status of the service provider;
5. Details of the locations at which the services provided for the purposes of the regulated activity are carried on.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

Whether or not a provider can comply with this regulation is assessed as part of the registration process, as part of any service inspection and whenever the CQC receives information that suggests it is not being met.

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 12: Statement of purpose.

Statement of Purpose

The intention of this regulation is to require providers to make sure that they take all reasonable steps to meet the financial demands of providing safe and appropriate services.

To meet this regulation, providers must have the financial resources needed to provide and continue to provide the services as described in the statement of purpose to the required standards.

The CQC cannot prosecute for a breach of this regulation but can take regulatory action.

Whether or not a provider can comply with this regulation is assessed as part of the registration process, as part of any service inspection and whenever the CQC receives information that suggests it is not being met.

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 13: Financial position.

The intention of this regulation is that CQC can be assured that the service will continue to be properly managed if the person in charge of their service is absent.

To meet the requirements of this regulation, the provider must inform CQC about any planned or unplanned absences from the service that are for a continuous period of 28 days or more, how the service will be run while they are away and when they return from a significant absence.

Providers must use forms provided by CQC to make notifications under this regulation.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 14: Notice of absence.

All notification forms can be accessed at CQC: Notifications.

The intention of this regulation is to ensure that CQC is notified of specific changes in the running of the service, so that CQC can be assured that the provider has taken appropriate action.

The provider must inform CQC when:

• The person who manages or carries on the service changes;
• There is a change to the registered details of the service and any individual, partnership or organisation who manage or carry it on;
• The registered person becomes financially insolvent
• The service closes.

Providers must use forms provided by CQC to make notifications under this regulation.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 15: Notice of changes.

All notification forms can be accessed at CQC: Notifications. 

The intention of this regulation is to ensure that CQC is notified of the deaths of people who use services so that where needed, CQC can take follow-up action.

Notifications include those deaths that:

• Occurred while services were being provided in the carrying on of a regulated activity; or
• Have, or may have, resulted from the carrying on of a regulated activity.

Notifications about deaths must be sent to CQC without delay.

Providers must use forms provided by CQC to make notifications under this regulation.

Note: If the person that has died is detained or liable to be detained under the Mental Health Act 1983, the notification should be made under Regulation 17.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 16: Notification of death of a service user.

All notification forms can be accessed at CQC: Notifications.

Accidents, Injury and Incidents

Duty of Candour

The intention of this regulation is to ensure that CQC is notified of the death or unauthorised absence of a person in any location who is liable to be detained under the Mental Health Act 1983 so that where needed, CQC can take follow-up action.

Notifications about deaths must be sent to CQC without delay.

Providers must use forms provided by CQC to make notifications under this regulation.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 17: Notification of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983.

All notification forms can be accessed at CQC: Notifications.

The intention of this regulation is to specify a range of events or occurrences that must be notified to CQC so that where needed, CQC can take follow-up action.

Providers must notify CQC of all incidents that affect the health, safety and welfare of people who use services.

Providers must use forms provided by CQC to make notifications under this regulation.

Injuries

Injuries to people using the service that result in any of the following must be reported:

1. Impairment of the sensory, motor or intellectual functions which are not likely to be temporary;
2. Changes to the structure of the body;
3. Prolonged pain or prolonged psychological harm;
4. A shortening of life expectancy.

Injuries that require medical treatment to prevent any of the above must also be reported.

In addition, injuries that medical treatment to prevent death must also be reported.

Abuse

Any abuse or neglect (and any allegation of abuse or neglect) must be reported.

Police incidents or investigations

Any incident that is reported to or investigated by the police must be reported.

Staffing issues

A report should be made if there are an insufficient number of suitably qualified, skilled and experienced staff employed to deliver regulated activity safely.

Premises owned or used by the provider for the purposes of carrying on regulated activity

The following must all be reported:

1. Interruptions to electricity, gas, water or sewerage for longer than 24 continuous hours;
2. Physical damage to premises which has, or is likely to have a detrimental effect on service users;
3. Failure or malfunctioning of fire alarms or other safety devices for longer than 24 continuous hours.

Other events that prevent (or threaten to prevent) safe service provision

Any event that prevents (or threatens to prevent) a provider's ability to meet required regulations and provide a safe service must be reported.

Deprivation of liberty

All Deprivation of Liberty Safeguards (DoLS) applications must be reported.

All applications made to the Court of Protection for deprivations in settings that do not come under the DoLS Framework must be reported.

The outcome of the applications, any changes to an authorisation and any withdrawal of an authorisation must also be reported.

Mental health admissions (under 18 years only)

Any placement of an under 18 year old in an adult psychiatric unit lasting longer than 48 continuous hours must be reported.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 18: Notification of other incidents.

All notification forms can be accessed at CQC: Notifications.

Accidents, Injury and Incidents

Duty of Candour

Disclosure and Raising a Concern

Emergencies and Unplanned Events

The intention of this regulation is to make sure that providers give timely and accurate information about the cost of their care and treatment to people who use services.

To meet this regulation, providers must make written information available about any fees, contracts and terms and conditions, where people are paying either in full or in part for the cost of their care, treatment and support.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 19: Fees.

This regulation applies only to registered persons who carry on or manage the regulated activity of termination of pregnancies and are not an English NHS body.

To meet this regulation the provider must follow the requirements of the regulation and the procedures and guidance issued by the Department of Health in May 2014 which are:

• Procedures for the Approval of Independent Sector Places for the Termination of Pregnancy (Abortion);
• Guidance in Relation to Requirements of the Abortion Act 1967.

The Department of Health’s guidance takes account of legal requirements and best practice in relation to termination of pregnancy.

The CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, they can also take additional regulatory action.  

At any point, if a provider does not comply with this regulation the CQC must legally refuse or withdraw registration.

For guidance on meeting this regulation see Regulation 20: Requirements relating to termination of pregnancies.

Notifications made pursuant to regulations 14 to 18 and 21 and 22 must be made using the forms provided by the Commission for this purpose.

To meet this regulation, all notifications made under regulation 14, 15, 16, 17 and 18 above must be made using forms provided by the CQC.   

All notification forms can be accessed at CQC: Notifications.