All 16 of our policies are open for anyone to read. Search below or scroll to browse the full set.
Sets out how Welltrust receives, manages, investigates, resolves and learns from complaints in a manner that is open, timely, and focused on the needs of the individual. Meets Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Stage 1 — Local resolution: acknowledged in writing within 2 working days, investigated by the Registered Manager, written response within 10 working days.
Stage 2 — Formal review: if unsatisfied, senior management or independent reviewer, written final response within 20 working days.
Stage 3 — External escalation: LGSCO or other regulatory body. Welltrust cooperates fully.
Governs how consent is obtained, recorded, reviewed, and upheld across all care interactions. Meets Regulation 9 (Person-Centred Care), Regulation 10 (Dignity and Respect) and Regulation 11 (Need for Consent).
1. Presume capacity · 2. Support decision-making · 3. Respect unwise decisions · 4. Best interests · 5. Least restrictive option.
Decision-specific and time-specific. Two-stage test: (1) Is there an impairment of the mind or brain? (2) Does that impairment cause inability to make the specific decision at the time needed? Person cannot decide if they cannot understand, retain, weigh up, or communicate.
Any person with capacity has an absolute right to refuse care. Respect without pressure, document, escalate to the Registered Manager where refusal creates significant safety risk, alert GP where clinically appropriate.
Promotes equality, values diversity, and protects human rights of all individuals connected with our services. Full compliance with the Equality Act 2010 and the Human Rights Act 1998.
Age · Disability · Gender Reassignment · Marriage and Civil Partnership · Pregnancy and Maternity · Race · Religion or Belief · Sex · Sexual Orientation.
Right to life · Freedom from inhuman or degrading treatment · Right to private and family life · Right to liberty · Freedom of religion. All care plans reflect cultural preferences, religious observances, communication needs, gender preferences for personal care, and correct names and pronouns.
Governance framework for safe, effective, caring, and responsive services. Meets Regulation 17 (Good Governance).
PLAN — establish policies, standards, risk assessments, measurable objectives.
DO — deliver services in line with agreed standards; staff trained; care plans person-centred.
CHECK — structured audit programme, satisfaction surveys, incident trend analysis, supervision data.
ACT — implement corrective actions; update policies; share learning; verify improvement.
Care plans and record quality; medication administration and MAR accuracy; infection prevention and control; safer recruitment documentation; mandatory training compliance; health and safety; incident records. Each audit generates a written report with findings, action plan, named lead, and deadline. Unannounced spot checks assess staff competency and dignity during visits.
Safe and healthy working environment for all staff, service users, contractors, and visitors. Meets the Health and Safety at Work etc. Act 1974 and associated regulations applicable to domiciliary care.
Prevents, manages, and controls infections to protect service users, staff, visitors, and contractors. Meets Regulation 12 and the Health and Social Care Act 2008 Code of Practice on IPC.
Apply to all care interactions regardless of infection status:
Decontaminate hands before and after every direct contact, before medication, after PPE removal, after using the toilet. Soap and water when visibly soiled or after suspected C. difficile / norovirus. Alcohol hand sanitiser (min 60%) acceptable when hands not visibly soiled.
Do not attend work with diarrhoea/vomiting (48 hours symptom-free before return) or acute respiratory infection with fever (48 hours fever-free without antipyretics).
Clinical waste in yellow bags; sharps in rigid yellow containers — never recapped, never overfilled; domestic waste in black bags.
Protects the safety and wellbeing of staff who work alone in service users' homes and the community.
Safe, lawful, and person-centred management of medicines: prescribing liaison, ordering, receipt, storage, administration, recording, transportation, disposal, and incident management. Meets Regulation 12.
Right PERSON (two identifiers: name + DOB) · Right MEDICINE (name, form, expiry vs MAR) · Right DOSE · Right TIME · Right ROUTE · Right DOCUMENTATION (immediately after) · Right RESPONSE (monitor).
Completed immediately after each administration — never in advance. Include all prescribed, PRN, and covert medications with lawful authority. Record refusals, omissions, and deviations with reasons. Allergies prominently displayed on every chart.
Assess → Notify (Registered Manager + GP/pharmacist same day) → Record (incident report + MAR) → Monitor → Investigate (root cause within 5 working days) → Learn (staff retraining within 10 working days).
Applies the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) in all care and support activities. Supports Regulation 9 and Regulation 11.
(1) Is there an impairment of, or disturbance in, the functioning of the person's mind or brain? (2) Does that impairment cause the person to be unable to make the specific decision at the time it needs to be made? Cannot decide if unable to understand, retain, weigh up, or communicate.
A valid ADRT made by an adult with capacity must be respected. Where a person has a registered Health and Welfare LPA, the Attorney has authority for specified decisions — verified as registered with the Office of the Public Guardian.
Occurs where a person who lacks capacity is under continuous supervision and control and is not free to leave. Requires lawful authorisation. Suspected unlawful deprivation must be notified to the Registered Manager immediately, legal advice sought, and matter escalated to the local authority safeguarding team.
Safe management of all moving and handling activities. Prevents musculoskeletal injury to staff and harm to service users. Meets the Manual Handling Operations Regulations 1992.
No equipment used until the staff member has been trained in its safe use and competency has been assessed and documented.
Call emergency assistance if required. Do not move the person until assessed for injury. Follow the post-fall protocol in the care plan. Record incident same day. Notify GP. All falls reviewed at governance meetings.
Ensures all persons recruited are suitable, competent, safe, and aligned with the organisation's values. Establishes a safer recruitment framework with safeguarding at the centre. Meets Regulation 19 (Fit and Proper Persons Employed).
All new staff complete the full Care Certificate (15 standards) within 12 weeks. Probationary period is 6 months with formal reviews at 4 and 12 weeks. DBS checks renewed every 3 years or immediately where a concern arises.
Identifies, assesses, manages, and monitors risks to service users, staff, and the organisation. Meets Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance).
1. Identify hazards — anything that could cause harm.
2. Assess likelihood and severity — Low, Medium, or High.
3. Control — implement measures to reduce risk to an acceptable level.
4. Record — document assessment, controls, responsible person, include in care plan.
5. Review — following any incident, change, or at minimum every 12 weeks.
Individual — falls, skin integrity, nutrition, medication, moving and handling, mental health, self-neglect, safeguarding, environmental hazards, condition-specific risks. Environmental — the service user's home before first visit. Operational — organisational risk register updated monthly. Dynamic — during every care visit.
Unequivocal commitment to safeguarding the welfare, safety, dignity, and rights of all adults receiving care. Safeguarding is a legal responsibility shared by every member of staff. Zero tolerance for abuse, neglect, exploitation, and failure to report safeguarding concerns.
Empowerment · Prevention · Proportionality · Protection · Partnership · Accountability.
Step 1 — immediate safety (call 999 if in immediate danger). Step 2 — internal report to Registered Manager same shift, factual concern report without opinion. Step 3 — external referral to local authority Adult Safeguarding Team; police if crime; regulatory notifications. Step 4 — cooperate fully with Section 42 enquiries. Step 5 — review case at closure, identify lessons, update risk assessments.
Ensures all staff are appropriately trained, competent, and supported. Meets Regulation 18 (Staffing) and the Care Certificate Standards (Skills for Care).
Weeks 1-2: mandatory core training + organisational induction. Weeks 2-4: supervised shadow shifts with a competency-signed-off member of staff. Week 4+: gradual progression to supervised independent practice; formal competency assessment by a Level 3 Lead Practitioner. Weeks 4-12: complete all 15 Care Certificate standards. Probationary reviews at 4 weeks and 12 weeks.
Autism and PBS · Epilepsy and emergency buccal midazolam · Dementia care · End of Life · PEG and nasogastric feeding · Catheter care · Tracheostomy and ventilator care. No specialist care performed without documented competency sign-off by a qualified clinical assessor.
Care Worker → Senior Care Worker → Team Leader → Deputy Manager → Registered Manager → Specialist/Clinical Role. Welltrust actively supports access to funded qualifications through the Skills for Care Workforce Development Fund.
Enables and protects staff who raise genuine concerns about wrongdoing, malpractice, or unsafe practice. Reflects the organisation's commitment to an open and transparent culture. Meets the Public Interest Disclosure Act 1998 (PIDA), as amended by the Enterprise and Regulatory Reform Act 2013.
Whistleblowing is distinct from a personal grievance, which is dealt with through the grievance procedure.
Zero tolerance for any retaliation against an individual who raises a concern in good faith, including: dismissal or threat of dismissal · demotion or redundancy · bullying, harassment, or victimisation · exclusion or isolation. Any manager found to have subjected a whistleblower to detriment will face disciplinary action up to and including dismissal.
Step 1 — Internal: line manager or Registered Manager. Verbal or written. A reasonable belief that wrongdoing is occurring is sufficient — evidence not required. Step 2 — Responsible Persons: Emmanuel Odoh or Ujunwa Christabel Ezeama directly. Step 3 — External: relevant regulatory authority, HSE, or Police. Protection under PIDA applies for qualifying disclosures to prescribed persons.
Being open and honest with people when things go wrong is both a legal duty and fundamental to safe, compassionate care. Meets Regulation 20. Zero tolerance for concealment of incidents, delayed disclosure, or misrepresentation of facts.
Any unintended or unexpected incident occurring during regulated activity that results in, or could result in:
Where any doubt exists, candour obligations should be applied.
1. Immediate safety · 2. Internal escalation (same shift) · 3. Verbal notification to the person or representative — honest facts, no speculation · 4. Meaningful apology — timely, verbal + written; an apology is not an admission of legal liability · 5. Written notification within 14 working days: incident summary, known facts, actions taken, investigation process, follow-up contact · 6. Thorough investigation — root cause analysis proportionate to the incident · 7. Learning and improvement — lessons shared, policies updated, preventative actions implemented.
All near misses — events that could have caused harm but did not — must be recorded, reviewed, and used to trigger preventative action. Near miss data is a critical leading indicator of risk and is reviewed at monthly governance meetings.
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