Our Policy

CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT

Complaints and Compliments Policy and Procedure

Summary: This policy aims to: To deal with complaints in line with
CQC Regulation 17: Complaints to ensure that the service
users are sure that their comments and complaints are
listened to and acted on effectively, and know that they
will not be discriminated against for making a Complaint
CINOX HEALTHCARE LTD recognises that there will be
times when the service provided does not meet the
expectations of the service users or their
representatives. Therefore, there must be a robust and
consistent process for receiving and handling complaints
appropriately and for ensuring that the information
gained is used as an opportunity for organisational
learning and continuous improvement of services.
Scope: This policy provides a robust framework for all staff
employed, either directly or indirectly (including
non-executive directors, volunteers, governors) in the
investigation of concerns and complaints. The following
people may be affected by this policy: All staff. Whether
temporary or permanent, Local Authorities,
Commissioners. Families, NHS, and Service users.
Document Type Policy and Procedures
Verified By Chinwe Eucheria
Issued Date 06-07-2025
Review Date 06-07-2026
Complaint and Compliments Policy and Procedure
1. Introduction and Policy Statement
This policy sets out our intent and objectives for the complaints handling process, including offering a
clear and approachable system for stakeholders to complain, thoroughly investigating all complaints to
identify the cause, issues and corrective actions required, and implementing measures to prevent
reoccurrences where applicable. The policy aims to deal with complaints in line with CQC Regulation 17:
Complaints to ensure that service users are sure that their comments and complaints are listened to and
acted on effectively and know that they will not be discriminated against for making a Complaint.
1.1. CINOX HEALTHCARE LTD welcomes the views of service users, families, and other stakeholders
regarding the service we provide.
1.2. CINOX HEALTHCARE LTD recognises that there will be times when the service provided does not
meet the expectations of the service users or their representatives. Therefore, there must be a robust
and consistent process for receiving and handling complaints appropriately and for ensuring that the
information gained is used as an opportunity for organisational learning and continuous improvement of
services.
1.3. CINOX HEALTHCARE LTD is committed to delivering a fair, open and clear process for complaints
to ensure a satisfactory outcome for all stakeholders who raise a complaint.
EQUALITY AND HUMAN RIGHTS
CINOX HEALTHCARE LTD recognises that some sections of our society experience prejudice and
discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability,
gender, race, religion or belief, sexual orientation, and transgender.
The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and
marriage/civil partnership. CINOX HEALTHCARE LTD is committed to equality of opportunity and
anti-discriminatory practice both in the provision of services and in our role as an employer. CINOX
HEALTHCARE LTD believes that all people have the right to be treated with dignity and respect and is
committed to the elimination of unfair and unlawful discriminatory practices. CINOX HEALTHCARE LTD
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act
requires organisations to uphold and promote Human Rights in everything they do. It is unlawful for an
organisation to perform any act which contravenes the Human Rights Act. CINOX HEALTHCARE LTD is
committed to carrying out its functions and service delivery in line with the Human Rights based approach
and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy.
1.4. This policy sets out our intent and objectives for the complaints handling process, including offering a
clear and approachable system for stakeholders to complain, thoroughly investigating all complaints to
identify the cause, issues and corrective actions required, and implementing measures to prevent
reoccurrences where applicable.
1.5. Compliments received by CINOX HEALTHCARE LTD will be used as an opportunity to share good
practices and to encourage staff to continue to provide a good quality service.
1.6. This policy aims to ensure that:
• Staff recognise the importance of complaints and compliments in providing feedback about the
services provided
• All complaints are well managed and are investigated and resolved quickly, fairly and consistently
and in accordance with company policies and procedures
• Staff are empowered to deal with complaints as they arise in an open and non-defensive way
• Learning from complaints is identified and used for improvement and where action can be taken to
avoid reoccurrence, this is completed
• Faults are acknowledged, remedied and a clear and relevant explanation and apology offered
• The complaints service is accessible, well publicised, open and transparent and that staff know
how to escalate complaints
• The complaints procedure is supportive for those who find it difficult to complain
• There are clear standards of response an individual can expect when they make Complaint
• Good practice identified from compliments is shared across the organisation
1.7. CINOX HEALTHCARE LTD will ensure that all complaints are reviewed at the highest level of the
organisation to identify learning opportunities for those directly involved in the complaint and the
organisation as a whole.
1.8. CINOX HEALTHCARE LTD is committed to promoting equality and diversity. No client or any other
person involved in the investigation and resolution of a concern or complaint will receive unfair treatment
as a result of raising a complaint.
Who to contact internally if you have a complaint or concern?
CINOX HEALTHCARE LTD wherever possible, complaints are best dealt with on a local level between
the complainant and CINOX HEALTHCARE LTD. Point of call internally with our organisation for
complaints if the local process is not satisfactory is:
Registered Manager: Chinwe Eucheria whose details are:
39 Rush Green Road, Romford RM7 OPT
07854280352
Key Lines of Enquiries to meet Complaints Policy and Procedure
Caring C2: How does the service support people to express
their views and actively involved in making decisions
about their care, support and treatment as far as
possible?
Safe S6: Are lessons learned and improvements made when
things go wrong?
Responsive R2: How are people’s concerns and complaints
listened to and responded to and used to improve the
quality of care?
Safe S1: How do systems processes and practices keep
people safe and safeguarded from abuse?
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
Well-led W2: Does the governance framework ensure that
responsibilities are clear, and that quality performance,
risks and regulatory requirements are understood and
managed?
2. Openness, Transparency and Duty of Candour
2.1. Following the Francis Report (2013) it is a requirement for clinicians to be candid with clients about
avoidable harm and for safety concerns to be reported openly and truthfully. CINOX HEALTHCARE LTD
must be accurate, candid and must not provide misleading information to service users, their families,
regulators, and commissioners.
2.2Definitions of Openness, Transparency and Candour are as follow:
• Openness – enabling concerns and complaints to be raised freely without fear, with questions asked
being answered.
• Transparency – accurate information about performance and outcomes to be shared with staff, service
users, commissioners, and regulators
• Candour – any client harmed by a healthcare service is informed of the fact and an appropriate remedy
offered, regardless of whether a complaint has been made.
2.3. Being open involves:
• Acknowledging, apologising, and explaining when things go wrong.
• Conducting a thorough investigation into the incident, complaint, or claim.
• Reassuring clients and their families that lessons learnt will help prevent incidents occurring; and
• Providing support for those involved to cope with the physical and psychological consequences of what
happened.
2.4. CINOX HEALTHCARE LTD and everyone working for the organisation must be honest, open, and
truthful in all their dealings with service users and families, and organisational and personal interests must
never be allowed to outweigh the duty, to be honest, open and truthful.
2.5. CINOX HEALTHCARE LTD follows the Parliamentary Health Service Ombudsman (PHSO)
Principles of Good Complaints Handling as set out below:
• Getting it right – quickly acknowledging and putting right issues identified. Considering all the factors
when deciding the remedy with fairness for the complainant and where
appropriate others that have suffered
• Being customer-focused – apologising and explaining, managing expectations, dealing with people
professionally and sensitively and remedies that consider individual circumstances.
• Being open and accountable – clear about how decisions are made, proper accountability, delegation
and keeping clear records
• Acting fairly and proportionately – fair and proportionate remedies, without bias and discrimination
• Putting things right – consider all forms of remedy such as apology, explanation, remedial action or
financial offer
• Seeking continuous improvement – using lessons learned to avoid repeating poor service and recording
outcomes to improve services.
3. Scope
3.1. This policy applies to all, directly and indirectly, employed staff within CINOX HEALTHCARE LTD
and other persons working within the organisation.
3.2. This policy should be read in conjunction with:
• Safeguarding Adults Policies
• Information Governance Policies pertaining to record-keeping
• Duty of Candour Policy
4. Definitions
4.1. A complaint is “an expression of dissatisfaction made to an organisation, either written or spoken,
and whether justified or not, which requires a response. There is no difference between a ‘formal’
complaint and an ‘informal’ complaint. Both are expressions of dissatisfaction”, The Patient’s Association,
2013
4.2. It is, however, important to differentiate between concerns and complaints
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
4.3. A concern is an expression of dissatisfaction about an event or service which can usually be
remedied to the individual’s satisfaction within a short period of time if dealt with quickly, openly, and
honestly, through informal discussion with the staff team within the service. The complainant does not
expect a formal response.
. A complaint can also be an expression of dissatisfaction with a service that has personally affected an
individual and which requires a proportionate investigation and a formal response in order to promote
resolution between the parties concerned. It is usually historic (i.e., happened in the past) and cannot be
immediately remedied
4.5. A compliment is an expression of satisfaction made about the service provided by CINOX
HEALTHCARE LTD as a whole, or a staff team or an individual member of staff. Compliments received
by CINOX HEALTHCARE LTD will be used as a chance to share good practices across the organisation
and to encourage staff to continue to provide a good quality service.
5. Responsibilities as an employer:
Registered Manager:
The registered person should:
· be familiar with the purpose of a complaints procedure and the outcomes it has for their service
users
· create an atmosphere in which service users feel able to provide various forms of feedback on the
services they receive
· encourage staff to react positively to all forms of service user feedback
· establish procedures to meet the current regulatory requirements for reporting, dealing with and
using service users’ comments on services, including informal and formal complaints.
· promptly and thoroughly investigate any formal complaint made by a service user
· enable the person to have the support of a friend or advocate if needed
· make service users aware of their right to escalate their complaint if they are dissatisfied with the
outcome or the handling of their complaint by the care provider
· co-operate with any other agency appropriately investigating a complaint by a service user
· ensure that the information about service user satisfaction gained from all forms of feedback,
including complaints, is used in the service’s quality assurance system
· ensure that staff observe appropriate professional Codes of Practice in relation to complaints and
other feedback.
5.1. It is the responsibility of the Senior Management Team to ensure that ALL staff are aware of and use
this policy.
5.2. All staff have a responsibility to read this policy and understand its impact on their area of work. Staff
should be able to respond appropriately to a complainant and endeavour to achieve immediate resolution.
If this is not possible, all staff have the responsibility to escalate the concern/complaint in accordance with
this policy.
5.3. The Managing Director is responsible for ensuring that all concerns/complaints are fully investigated
and responded to within the agreed timeframe.
5.4. Responsibility for ensuring compliance with this policy rests with the Managing Director
Complaints against the Registered Manager / Nominated Individual
Where the Registered Manager is also the Nominated Indivudual, and there is a complaint against this
person, the organisation will appoint an independent consulting company that will act as a neutral entity to
deal with any complaints against the Registered Manager/ Nominated Individual. The organisation
appointed will usually be an advisor to our own service. The Current organisation that supports our
service in this area is : Ultra Healthcare Solutions, Unit 23 Basepoint Business Centre, Metcalf Way,
Crawley, RH11 7XX. Phone No: 02080640909. email address: info@ultrahealthcare.co.uk.
6. Procedure
Complaints can arise from a number of issues including:
• A failure to comply with policy, procedure, or standards of service delivery
• A decision which the complainant believes is not fair or clear to them
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
• The behaviour of CINOX HEALTHCARE LTD staff, volunteers, associates, or contractors
Complainants can also approach the Care Quality Commission (CQC) to raise their complaints.
Complaints received via the CQC will be treated in the same way as all other complaints. The CQC will be
asked to confirm whether complaint responses should be sent directly to complainants or sent to the CQC
to pass on. All complaints received via the CQC should be reported to the HR department for information
and monitoring.
6.1. Concerns can provide valuable lessons for services within the organisation. Concerns can usually be
resolved quickly and satisfactory by way of an apology, by providing the service required or by providing
an acceptable explanation. Staff who receive a concern should document the concern following this
procedure. If the concern is resolved locally,
this should be indicated.
6.2. Any concern or other comment not made in the form of a formal complaint, but which cause concern
about the quality or safety of services, should be escalated following this
procedure and subject to an investigation and response to the same standard as a formal complaint.
6.3. If the concern cannot be resolved to the satisfaction of the complainant, they should be asked
whether they would like the concern to be formally investigated and responded to. If this is the case, the
concern becomes a stage 1 complaint.
6.4. There are three stages of complaint review:
• Stage 1 (Local Resolution)
• Stage 2 (Complaint Review)
• Stage 3 (Ombudsman)
6.5. At any stage, the complaints handler or the Manager can make a judgement that the complaint
requires review and refer it to the Ombudsman if necessary.
Stage 1
All team members are involved in supporting service users, so they may be involved in handling informal
complaints. The Team members dealing with a complaint should work to the following simple formula:
1. Listen
2. Ask questions
3. AGREE on a solution – check satisfaction
4. Implement the solution – NOW
5. Follow up and check satisfaction
The aim should be to deal with less significant issues in an informal way at the point of service delivery to
ensure a speedy resolution.
6.6. Stage 1 complaints can be either written (including by e-mail) or verbal. Verbal complaints should not
be treated as any less serious than written complaints and should be handled in the same manner. Any
verbal complaint must be logged into the Complaint logbook. Complaints can be made to any member of
staff.
6.7. If a Stage 1 complaint is received, either in writing or verbally, the staff member who receives the
complaint should record it following the organisational procedure. If the complaint was verbal, the member
of staff recording the complaint should confirm with the complainant that the information recorded is
accurate. This can be face to face or over the telephone. The recorded complaint and the original
complaint, if in writing, should be forwarded to the Registered Manager. (Use Complaint Investigation
Form on the forms section below)
6.8. If a complainant was not satisfied with the outcome of their concern, and they would like their
complaint to be formally investigated and responded to, the Managing Director/Nominated Individual
should make sure this is done. The complainant should be informed that their complaint is being
escalated and it should be confirmed with the complainant that the information recorded is accurate.
6.9. Stage 1 complaints will be handled, ensuring the following take place:
• Acknowledgement of stage 1 complaints within 2 working days, informing complainants of the
investigation process and expected timescales for a response.
• Early resolution during a face-to-face meeting if appropriate.
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
• Thorough investigation of complaints that cannot be resolved by a face to face meeting, ensuring
investigation methods and findings are documented.
• Formal written response provided to the complainant within 28 days, describing the methods used in
the investigation, findings and any action taken as a result.
• Complainant kept informed of the reason for delay if a response is likely to take longer than 28 days,
with a contact at a minimum of every 28 days.
• A full apology is offered if the complaint is upheld.
• Information sent to the complainant informing them of how to escalate their complaint to stage 2 if they
are not satisfied with the response.
Stage 2
6.10. Not all conclusions will satisfy the complainant and they have the right to request a review of the
initial investigation into their complaint. This must be done within 6 months of the response to their
complaint at stage 1, and usually in writing following this procedure. If the complainant is unable to make
a request in writing, this may be done verbally.
6.11. A request to review the initial investigation into the complaint should be recorded and escalated
following this procedure.
6.12. Stage 2 complaints will be handled following this procedure, ensuring the following take place:
• Acknowledgement of stage 2 complaints within 2 working days informing complainants of the
investigation process and expected timescales for a response.
• Managing Director is informed of the escalation of the complaint and a senior manager not involved in
the initial investigation of the complaint is
assigned to review the investigation.
• Thorough review of the investigation of the initial complaint ensuring methods and findings are
documented.
• Formal written response provided to the complainant within 28 days, describing the methods used in the
investigation, findings and any action taken as a result.
• Complainant kept informed of the reason for delay if a response is likely to take longer than 28 days,
with a contact at a minimum of every 28 days.
• A full apology is offered if the complaint is upheld.
• Information sent to the complainant informing them of how to escalate their complaint to external bodies
for an independent review if they are not satisfied with
the response.
Stage 3
6.13. Should the complainant remain unhappy with the response provided to the complaint at
Stage 2, they are entitled to report the matter to the relevant body.
Compliments
6.14. A service may receive a compliment either in writing or verbally. The member of staff
who receives the compliment should ensure that compliments are forwarded to the Registered Manager
and allow them to be logged?
7. Complaints Investigation and Risk Management
7.1. The procedures for managing complaints, incidents and claims for negligence are dealt with under
separate policies. However, if during the course of investigating an incident, a
complaint is received, the incident procedure should take precedence in terms of investigation. If the
investigation of a complaint reveals the need to take action under the serious incident procedure or the
safeguarding procedures, the investigator should inform the Safeguarding Team or Managing Director
and again the incident procedure should take precedence in terms of investigation. In these
circumstances, the complainant should be informed of the investigation, kept updated on progress and
informed of the outcome.
7.2. If the investigation of a complaint reveals a possibility that there may have been negligence, the
Managing Director must be immediately notified. The existence of negligence does not prevent a full
explanation from being given and if appropriate, an apology. An apology is not an admission of liability.
8. Unreasonably Persistent Complainers
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distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
8.1. Complainants that could be described as unreasonably persistent through either the quantity or
unreasonableness of their complaints require a considered approach. At no time should a complaint be
excluded from consideration under this policy. In cases where the Manager considers that a complainant
is unreasonably persistent, they should consider putting in place a system for managing this that is
appropriate and proportional to the situation. This should be considered in isolation and may involve the
advocates or other relevant people.
If a complainant has made unreasonable complaints in the past, we will not assume that their next
complaint is unreasonable. Each case will be considered on its merits.
All relevant correspondence will be evaluated to consider the circumstances, including:
• whether a complainant has made persistent or unreasonable demands
• whether there is a strong likelihood that complaints are being made to intentionally cause
harassment, divert resources or disrupt the proper workings of CINOX HEALTHCARE LTD
• or threatening to staff or has produced excessive correspondence
• whether the complainant displays vexatious behaviour
8.2. Such systems may include any or all of the following:
• A letter to the complainant setting out responsibilities for the parties involved if CINOX HEALTHCARE
LTD is to continue processing the complaint. If terms are contravened, consideration will then be given to
implementing other actions as indicated below.
• Decline contact with the complaint, either in person, by telephone, by fax, by letter, by email or any
combination of these, provided that one form of contact is maintained.
This may also mean that only one CINOX HEALTHCARE LTD employee will be nominated to maintain
contact (and a named deputy in their absence). The complainant will be notified of this person.
• Notify the complainant, in writing, CINOX HEALTHCARE LTD has responded fully to the points raised
and has tried to resolve the complaint but there is nothing more to add and continuing contact on the
matter will serve no useful purpose. The complainant will also be notified that the correspondence is now
at an end.
Confidentiality
Under the Data Protection Act 2018 and the Human Rights Act 1998, all personal and sensitive
organisational information, however, received, is treated as confidential, including:
• anything of a personal nature that is not a matter of public record about a customer, member of
staff, or volunteer
• sensitive organisational information.
We will ensure that the members of staff managing the complaint only involve other agencies and share
information with the consent of the individual concerned, unless:
CINOX HEALTHCARE LTD is required to share information by law
• The information is necessary for the safeguarding of vulnerable adults or children
9. Complaints that cannot be dealt with under this policy
9.1. A complaint made by an employee about any matter relating to their employment.
9.2. A complaint, the subject of which has previously been investigated under this policy.
9.3. A complaint that is being or has been investigated by the Ombudsman.
9.4. A complaint arising out of an alleged failure to comply with a request for information under the
Freedom of Information Act 2000 or a subject access request under the Data Protection Act 2018.
9.5. A complaint which CINOX HEALTHCARE LTD has been notified that criminal proceedings have
been commenced in relation to the substance of the complaint where it will prejudice the proceedings.
10. Learning from Compliments and Complaints
10.1. CINOX HEALTHCARE LTD views feedback in the form of complaints and compliments to be a
valuable resource in continually monitoring and improving the quality of service provided.
10.2. All compliments received will be reviewed by the Quality and Governance Team to identify if any
good practices can be shared across the organisation.
10.3. Complaint trends, lessons learned, and any action taken as a result will be reviewed within the
quality and governance structures of CINOX HEALTHCARE LTD at all levels of the organisation.
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
If it is identified that the actions implemented are applicable to other services, the action will be added to
the action plans of those services. The implementation of actions will be monitored.
11. Records and Retention
11.1. A comprehensive record of all documentation related to a complaint will be retained following this
procedure, including all internal correspondence, such as emails and file notes, investigation records and
statements from staff which should be timed and dated where possible.
11.2. Copies of concern or complaint correspondence must not be kept in the service user’s medical
records, subject to the need to record any information which is strictly relevant to their health. Concern or
complaint correspondence must be kept and stored separately whether in paper or electronic format, with
access only given were strictly required according to the job role.
11.3. In line with the Data Protection Act 2018, complaints documentation is classified as personal data.
Clients are able to request copies of complaints files in the same way as they do for their health records.
12. Training Requirements
12.1. All staff required to complete a complaints form will be shown how to do this as part of their
induction training program. Further training will be provided for staff in specialised roles where relevant.
13. Policy Review Statement
13.1. This document may be reviewed at any time at the request of either staff or management but will
automatically be reviewed every year from initial approval and thereafter on an annual basis unless
organisational changes, legislation, guidance, or non-compliance prompt an earlier review.
Contacting External Organisations:
Complainants have the right to refer their complaint to the Local Government Ombudsman (LGO) if they
are unhappy with the outcome of the investigation. Once a complaint has been fully dealt with by CINOX
HEALTHCARE LTD and the Complainant remains unsatisfied with the outcome, they can complain to the
Local Government Ombudsman (LGO).
The LGO provides a free, independent service.
Complainants can contact the LGO Advice Team for information and advice, or register one’s complaint:
Telephone: 0300 061 0614
Email: advice@lgo.org.uk
Website: www.lgo.org.uk
The LGO will not usually investigate a complaint until the provider has had an opportunity to respond and
resolve matters.
Care Quality Commission (CQC)
National Correspondence
Citygate,
Gallowgate
Newcastle upon Tyne
NE1 4PA
Tel: 03000 616161 Fax: 03000 616171
https://www.cqc.org.uk
14. Associated Documents and References
• Consent to Care
• Consent to Share
• Data Protection Act 2018
• Freedom of Information Act 2000
• Freedom of Information Act the Social Care and Social Work Improvement Scotland
• Health and Social Care Act 2008 (regulated activities) Regulations 2014
• Human Rights Act 1998
• Mental Capacity Act 2005
• National Care Standards at Home 2005
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20- Duty of
Candour
• Risk Management
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
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CINOX HEALTHCARE LTD
39 Rush Green Road, Romford RM7 OPT
• Safeguarding Policies
• Serious Incidents Requiring Investigation
• The Care Act 2014
• Local Authority Social Services and National Health Service Complaints (England) Regulations
2009. Online Accessed on 26/10/2022
Getting Help
If you require any help with any matters relating to this policy and procedure, please speak to
your line manager or senior manager.
It is the responsibility of every member of staff to ensure that they are working within this policy
and keep up to date with changes in policy that may affect their practise at work.
Forms associated with this policy:
1) Complaint investigation form
2)Complaint acknowledgement letter
©2023 Ultra Health Care. Only CINOX HEALTHCARE LTD can access this policy. Sharing, copying or
distribution to unregistered entities constitutes a breach of contract. This document cannot be shared or
copied without the prior written approval of Ultra Health Care. Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
Page 9 of 9

Safeguarding Policy for Adults and Children

Cinox Healthcare Service

39 Rush Green Road, Romford, RM7 0PT

Telephone: (01708) 982612

Email: info@cinoxcare.co.uk

Safeguarding Policy for Adults and Children

(Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment)

Document Control and Authorisation
Field Detail
Version
1.0
Date Created 05 January 2026
Next Review Date 05 January 2027
Approved by Chinwe Eucheria Mbah-Uzobude –
Registered Manager / Nominated
Individual
Distribution All staff, volunteers, contractors, and
available to all service users and
stakeholders upon request.
1. Purpose, Scope, and Guiding Principles of Safeguarding

1.1. Core Commitment and Legislative Foundation

Cinox Healthcare Service holds an absolute and unwavering commitment to safeguarding
the welfare, rights, and safety of every child, young person, and adult at risk who utilises its
services. This commitment is deeply embedded in the service’s operations and is mandated
by key statutory frameworks, including:
● The Care Act 2014, which sets out the legal duties for adult safeguarding.
● The Children Act 1989 and 2004, establishing the paramountcy of child welfare.
● Working Together to Safeguard Children 2023, defining multi-agency child
protection arrangements.
● The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014,
specifically Regulation 13 on freedom from abuse and improper treatment.
1.2. Applicability and Scope of the Policy
This comprehensive policy is mandatory and applies universally across the entire service,
encompassing:
● Personnel: All individuals working for Cinox Healthcare Service, including
permanent employees, bank staff, volunteers, agency workers, external contractors,
and students on placement.
● Service Users: All individuals receiving regulated activities, specifically personal
care or the treatment of disease, disorder, or injury (TDDI), within their own homes or
community settings, covering all age groups (0–65 and 65+).
● Specialisms: The policy is tailored to address specific safeguarding vulnerabilities
across all specialisms provided by the service, including autism and learning
disabilities, dementia, physical disabilities, sensory impairment, and mental health
needs.
1.3. Fundamental Safeguarding Principles
Safeguarding practice within Cinox is underpinned by established national principles:
● Adult Safeguarding Principles (Care Act 2014):
○ Empowerment: Supporting people to make their own decisions and informed
consent.
○ Prevention: Taking action before harm occurs.
○ Proportionality: The least intrusive response appropriate to the risk
presented.
○ Protection: Providing support and representation for those in greatest need.
○ Partnership: Working with local communities and professionals for joined-up
solutions.
○ Accountability: Clear roles and responsibilities and transparent processes.
● Child Safeguarding Principle: The “paramountcy of welfare” principle, meaning
the child’s welfare must be the primary consideration in all decisions and actions
taken in relation to their safety.
2. Legal and Regulatory Framework
Cinox Healthcare Service operates in full compliance with the following statutory and
regulatory landscape:
● Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
○ Regulation 13: Ensuring service users are safeguarded from abuse and
improper treatment.
○ Regulation 17: Maintaining good governance, including effective systems for
managing risks and quality.
○ Regulation 18: Ensuring sufficient and appropriately skilled staffing to
provide safe care.
● Care Act 2014 and Statutory Guidance: Establishing the duties of local authorities
and partners in adult safeguarding.
● Children Act 1989 and 2004, and Working Together to Safeguard Children 2023:
Mandating multi-agency working for child protection.
● Mental Capacity Act 2005 and Code of Practice: Governing decisions made on
behalf of individuals who lack capacity.
● Human Rights Act 1998 and Equality Act 2010: Ensuring all safeguarding
responses respect the human rights and protect against discrimination of service
users.
This policy is integral to demonstrating compliance with the Care Quality Commission (CQC)
fundamental standards, ensuring the service is judged to be Safe, Effective, Caring,
Responsive, and Well-led.3. Key Definitions in Safeguarding
3.1. Abuse and Neglect
Abuse and neglect are broad concepts and are not limited to:
● Physical Abuse: Including hitting, slapping, pushing, misuse of restraint, or
inappropriate sanctions.
● Emotional/Psychological Abuse: Including threats, intimidation, humiliation,
isolation, or harassment.
● Sexual Abuse: Including sexual assault, sexual exploitation, or non-consensual
sexual acts.
● Financial or Material Abuse: Including theft, fraud, pressure in connection with
wills, property or inheritance, or misuse of property, possessions, or benefits.
● Discriminatory Abuse: Including racist, sexist, homophobic, transphobic, or ageist
abuse, or abuse based on a person’s disability, faith, or background.
● Organisational/Institutional Abuse: Including neglect and poor practice within an
institution or specific care setting, such as repeated instances of poor care, rigid
routines, or lack of choice.
● Domestic Abuse: Any incident or pattern of incidents of controlling, coercive,
threatening behaviour, violence or abuse between those aged 16 or over who are, or
have been, intimate partners or family members.
● Modern Slavery: Including human trafficking, forced labour, and domestic servitude.
● Self-Neglect: Where a person neglects their personal hygiene, health, or
environment and refuses necessary care, which may place them at risk of harm.
● Neglect or Acts of Omission: Including failing to provide basic needs such as
medication, food, heating, or medical care.
3.2. Terminology
● Child: Anyone under the age of 18 years.
● Adult at Risk: A person aged 18 or over who:
1. Has needs for care and support (whether or not the local authority is meeting
any of those needs).
2. Is experiencing, or is at risk of, abuse or neglect.
3. As a result of those care and support needs, is unable to protect themselves
from either the risk of, or the actual experience of, abuse or neglect.
3.3. Specific Risks for Children and Young People
The service specifically recognises and trains staff to be aware of elevated risks for children
and young people, including: domestic abuse, criminal and sexual exploitation (including
county lines), grooming, online abuse, forced marriage, and female genital mutilation (FGM).
4. Service User Groups and Vulnerabilities
Cinox acknowledges that the diverse needs of its service users create varying levels of
vulnerability to abuse or neglect. Staff must be highly attuned to these risk factors:
Service User Group
Autism and Learning
Disabilities
Key Vulnerabilities and
Increased Risks
Mitigating Actions for
Staff
Communication
differences, reliance on
others for
decision-making and
personal care, difficulties
in understanding risk or
complex consent,
isolation, and
susceptibility to
Use accessible
information, establish
clear boundaries, use
preferred communication
methods (e.g., visual
aids, Makaton), and
work with independent
advocates.

exploitation.
Dementia Impaired memory,
orientation, and
judgement, increased
dependency on
caregivers, potential for
misinterpreting care
interventions as assault,
and vulnerability to
financial abuse.
Provide person-centred
care, ensure clear
identification of staff,
manage transitions
carefully, and involve
family/advocates in
financial management.
Physical Disabilities Significant need for
personal care and
intimate assistance,
dependence on
equipment, barriers to
mobility, reduced ability
to communicate
concerns quickly, and
isolation.
Ensure all equipment is
safe, maintain dignity
during personal care,
facilitate independent
communication (e.g.,
communication boards),
and respect privacy.
Sensory Impairments Reduced ability to see,
hear, or interpret
environmental cues or
warning signs of danger,
increased isolation, and
difficulty accessing
crucial safety
information.
Ensure staff are trained
in sensory-specific
communication, use
clear verbal and
non-verbal cues, and
make sure
documentation is
available in accessible
formats.
Mental Health Needs Stigma, potential for
coercion or
manipulation,
dependency on services,
impaired perception of
risk due to symptoms,
and possible exploitation
Promote empowerment
and recovery, ensure
transparent information
sharing, respect
confidentiality, and
conduct thorough,
decision-specific
due to instability or
homelessness.
capacity assessments.
Staff Obligation: Staff must proactively adapt their communication styles, ensure all
information is accessible, and work closely and collaboratively with families, advocates,
and multi-disciplinary professionals to actively mitigate these inherent risks.
5. Roles and Responsibilities in Safeguarding
Safeguarding is the responsibility of every individual associated with Cinox Healthcare
Service, but specific roles carry mandated duties:
5.1. Registered Manager / Nominated Individual / Director / Clinical & Safeguarding
Lead (Chinwe Eucheria Mbah-Uzobude)
This role holds the highest level of accountability and is responsible for:
● Overall Leadership: Providing effective leadership for safeguarding children and
adults, fostering a culture of safety, and ensuring governance systems are robust.
● Policy Compliance: Ensuring all staff are aware of, trained on, and consistently
adhere to this policy, and that all concerns are acted upon with due diligence,
promptness, and appropriateness.
● Culture: Promoting an open, transparent, and learning culture where abuse is not
tolerated and staff can raise concerns, including whistleblowing, without fear of
reprisal.
● External Cooperation: Ensuring full and active cooperation with statutory partners,
including the Local Safeguarding Adults Board (LSAB) and Local Safeguarding
Children Partnership (LSCP), and participating in all relevant safeguarding reviews
(SARs/SCRs).
● Systemic Safeguards: Establishing and maintaining robust systems for safer
recruitment, mandatory safeguarding training, effective supervision, and critical
incident analysis.
5.2. Deputy Manager
The Deputy Manager provides essential support and cover, with responsibility for:
● Safeguarding Deputy: Acting as the primary Safeguarding Deputy in the absence of
the Registered Manager, including making necessary decisions regarding external
referrals to the local authority and other agencies.
● Staff Supervision: Providing hands-on, day-to-day supervision of care staff,
verifying their understanding of, and adherence to, safeguarding procedures.
● Immediate Action: Ensuring immediate safety actions are correctly implemented
when a concern arises during their shift.
● Investigating any Safeguarding concerns raised against the manager
5.3. Care Coordinator
The Care Coordinator is crucial for the effective, practical management of safeguarding
risks at the point of care delivery:
● Documentation: Ensuring all relevant safeguarding information, risk assessments,
and vulnerability details are clearly and accurately recorded within service user care
plans.
● Monitoring and Flagging: Systematically monitoring patterns of incidents, missed
visits, or unusual observations across service user care packages and immediately
flagging potential concerns to the Registered Manager or Deputy.
● Information Sharing: Ensuring information sharing with other professionals and
agencies is timely, accurate, lawful, and proportionate to the concern.
5.4. All Staff, Volunteers, and Contractors
All individuals working for Cinox are required to:
● Personal Duty: Treat safeguarding as everyone’s personal responsibility and
actively intervene or report to protect service users from harm, abuse, or neglect.
● Recognise, Respond, Record, Report (4Rs):
○ Recognise the signs and indicators of abuse.
○ Respond appropriately and immediately ensure safety.
○ Record all concerns accurately, factually, and contemporaneously.
○ Report the concern immediately to the Registered Manager/Deputy or
directly to external agencies if the concern is urgent or the Registered
Manager is implicated.
● Training Compliance: Attend and fully participate in mandatory safeguarding
training and ensure their professional knowledge remains current and up-to-date.
Non-Compliance: Failure to adhere to the duties outlined in this policy will be addressed
seriously through the service’s performance management or disciplinary procedures. Severe
breaches may result in referral to professional regulators (e.g., NMC, Social Work England)
or the Disclosure and Barring Service (DBS) where criteria are met.
6. Safeguarding Procedures – Adults and Children
6.1. Recognising Abuse and Neglect: Indicators
Staff must be trained to recognise potential indicators of abuse and neglect, which may
manifest as:
● Physical: Unexplained injuries (bruises, cuts, burns), frequent falls, or reluctance to
discuss injuries.
● Behavioural/Emotional: Sudden, significant changes in behaviour or mood, unusual
fearfulness, avoidance of certain people, withdrawal, or low self-esteem.
● Neglect/Self-Neglect: Poor personal hygiene, malnutrition, dehydration, untreated or
recurring medical problems, or unsuitable/hazardous living conditions.
● Financial: Unexplained loss of money or possessions, inability to account for
finances, or sudden changes in financial arrangements (e.g., changes to wills).
For children and young people, staff must also be acutely aware of specific indicators
relating to exploitation, radicalisation, online abuse, and the impact of domestic abuse within
the home.
6.2. Immediate Response to Safeguarding Concerns (The First 5 Steps)
If a staff member becomes aware of, or suspects, abuse or neglect involving a child,
young person, or adult:
1. Ensure Immediate Safety: The absolute priority is the safety of the person at risk.
Call emergency services (999 or 111) immediately if the person is in immediate
danger, requires urgent medical attention, or a crime is in progress.
2. No Promise of Confidentiality: Explain clearly to the person that you cannot
promise confidentiality, as the information must be shared with people and agencies
who have the authority and duty to help keep them safe.
3. Listen and Avoid Leading: Listen carefully, calmly, and non-judgementally. Do not
interrogate the person. Avoid asking leading questions (e.g., “Did [name] hurt you?”).
Use open questions (e.g., “Tell me what happened next”).
4. Record Factual Detail: Document the concern as soon as physically possible. The
record must be factual, include the person’s exact words where possible, and clearly
note the date, time, place, people present, and the staff member’s factual
observations.
5. Report Internally Immediately: Report the concern immediately to the Registered
Manager or, if they are absent, the Deputy Manager.
External Escalation: If a staff member believes that reporting internally would delay the
necessary protective action, or would put the person at further risk (e.g., if the manager is
implicated), they must bypass the internal route and contact the local authority, police, or
other relevant agency directly.
6.3. Reporting to External Statutory Agencies
The Registered Manager/Deputy is responsible for submitting formal statutory referrals:
● For Adults: The concern must be reported to the Local Authority Adult
Safeguarding Team in the area where the adult usually resides, strictly following
local Safeguarding Adults Board (LSAB) procedures.
● For Children and Young People: The concern must be reported to Children’s
Social Care or the Multi-Agency Safeguarding Hub (MASH), in line with Local
Safeguarding Children Partnership (LSCP) procedures.
● Police Involvement: Where a crime is suspected, or there is an immediate risk of
serious harm, the Police must be contacted immediately via 999 or 101.
● CQC Notification: The Registered Manager/Deputy must also consider notifying the
Care Quality Commission (CQC) of safeguarding incidents under statutory
notification requirements (Regulation 18 and associated guidance).
6.4. Multi-Agency Working and Review
Cinox is committed to robust multi-agency collaboration by:
● Participation: Actively participating in strategy meetings, case conferences, core
groups, and review meetings as requested by statutory partners.
● Information Sharing: Sharing relevant information lawfully, proportionately, and in a
timely manner with social care, health services, police, and other mandated partners.
● Learning and Implementation: Contributing to Safeguarding Adults Reviews
(SARs) and Child Safeguarding Practice Reviews (CSPR) where required, and
diligently implementing all mandated learning points from these reviews into service
practice.
7. Allegations and Concerns about Staff
Any allegation or serious concern regarding the conduct or competence of a member of
staff, volunteer, contractor, or anyone working on behalf of Cinox must be treated as a
priority safeguarding concern. This applies if the person has:
● Behaved in a way that has harmed, or may have harmed, a child or adult at risk.
● Possibly committed a criminal offence against, or related to, a child or adult at risk.
● Behaved in a way that indicates they may pose a risk of harm to children or adults at
risk.
Management of Allegations:
The Registered Manager/Deputy will:
● Immediate Risk Management: Ensure the person against whom the allegation has
been made is immediately removed from direct contact with service users while
inquiries are ongoing (suspension, redeployment, or change of duties), where
necessary.
● Statutory Referral: Report the matter to the local authority safeguarding team
(Dorset Council 01305 221016and Out of Hours on 01305 221000). For concerns
about a child, the matter must also be reported to the Local Authority Designated
Officer (LADO) as required by local LSCP procedures.S
● Referral to Barring Service: Consider and, where criteria are met, make referrals to
the Disclosure and Barring Service (DBS) and relevant professional regulators
(e.g., NMC).
8. Raising Safeguarding Concerns about the Registered Manager
Cinox recognises that the multiple roles held by the Registered Manager (Nominated
Individual, Director/Owner, Clinical Lead, and Safeguarding Lead) create a potential conflict
of interest if an allegation or serious concern involves this role holder.
To ensure transparency, independence, and the absolute safety of service users, all
stakeholders are encouraged to escalate concerns through the following designated routes
without fear of victimisation:
Route
Internal Route
Description and Procedure
Report directly to the Deputy
Manager, who is formally designated to
act as the internal safeguarding lead for
all concerns involving the Registered
Manager. This must be the first internal
step.
External Statutory Routes
Local Authority: Contact the Dorset
Adult Safeguarding Team (for adults)
on 01305 221016: Out of Hours on
01305 221000 or Children’s Social
Care/MASH and LADO (for children/
allegations against staff). CQC:
Contact the Care Quality Commission,
referencing Regulation 13 and
Regulation 17 failures. Police: Contact
999/101 where a crime is suspected.
Whistleblowing Routes
Stakeholders may use recognised
whistleblowing channels where they
consider there is a wider public interest
in the concern, including prescribed
bodies set out in Public Interest
Disclosure Act guidance (PIDA 1998).
Cinox Guarantee: No person raising a safeguarding concern or making a whistleblowing
disclosure in good faith about the Registered Manager will be victimised, treated unfairly, or
obstructed. All concerns will be fully documented, investigated by appropriate external
bodies, and Cinox will provide full cooperation.
9. Whistleblowing Policy Summary
Cinox maintains a separate, comprehensive Whistleblowing Policy, aligned with the Public
Interest Disclosure Act 1998 (PIDA) and CQC expectations for raising concerns about
malpractice, risk, or wrongdoing.
● Staff Duty: All staff have the fundamental right and professional duty to raise
concerns about any wrongdoing, risk, or malpractice that affects service users, staff,
or the organisation.
● Reporting Channels: Concerns can be raised internally (Registered Manager or
Deputy Manager) or externally with the CQC, local authority, or other prescribed
bodies if internal reporting is deemed inappropriate or ineffective.
● Protection: Whistleblowers who act in good faith are protected by law from
dismissal, detriment, or victimisation.
10. Information Sharing, Confidentiality, and Record-Keeping
10.1. Information Sharing
Information will be shared:
● Lawfully: In line with data protection legislation (GDPR) and the principles of
confidentiality.
● Principle: On a strict ‘need-to-know’ basis.
● Caldicott Principles: Guided by the Caldicott principles, ensuring information is only
used when necessary, with minimum identifiable information, and shared only with
authorised individuals.
● Overriding Duty: Where there is a safeguarding concern, the duty to safeguard and
promote welfare overrides the duty of confidentiality. However, information sharing
will always remain proportionate and lawful.
10.2. Record-Keeping
Records of safeguarding concerns will:
● Be factual, clear, complete, contemporaneous, and signed/dated by the person
making the record.
● Include what was said or observed, all immediate actions taken, who was
informed, and any decisions made.
● Be stored securely and retained in accordance with Cinox’s records management
and GDPR policies.
11. Mental Capacity, Consent, and Safeguarding
Staff must apply the principles of the Mental Capacity Act 2005 (MCA) diligently:
● Assumption of Capacity: Capacity must always be assumed unless it is proven
otherwise on a decision-specific and time-specific basis.
● Support: Individuals must be supported to make their own decisions wherever
possible.
● Best Interests: Where an adult lacks capacity for a specific decision, a best interests
decision must be made, involving the individual, family, advocates, and professionals
as appropriate.
● Abuse and MCA: A lack of capacity must never be used as a justification for abuse,
neglect, or poor-quality care.
Refusal of Consent: Where a person with capacity refuses consent to share information,
Cinox will respect this, unless there is an identified risk of serious harm to them or others, or
a wider public interest that justifies sharing without their consent.12. Safer Recruitment and
Staff Checks
Cinox operates a robust safer recruitment process to prevent unsuitable people from working
with children or adults at risk, including:
● Vetting: Comprehensive verification of identity, references, full employment history,
and right to work.
● DBS Checks: Mandatory Enhanced DBS checks (including barred list checks
relevant to the role) before any unsupervised work with children or adults at risk
commences.
● Assessment: Thorough assessment of character, values, professional boundaries,
and understanding of safeguarding during the interview process and probation
period.
DBS Referral: Any staff member who is dismissed or removed from regulated activity
because they have harmed, or posed a risk of harm, to a child or adult at risk will be
referred to the DBS.13. Training, Supervision, and Safeguarding Culture13.1. Training
and Supervision
● Mandatory Training: All staff must receive safeguarding adults and children
induction training before unsupervised practice, with refreshers mandated at least
every 2 years, or sooner if required by policy changes or identified learning needs.
● Role-Specific Training: Additional, specialised training is provided for the
Registered Manager, Deputy Manager, and staff with specific lead responsibilities,
aligned with LSAB/LSCP requirements and NHS safeguarding frameworks.
● Supervision: Staff receive regular professional supervision and annual appraisals.
These forums must include mandatory discussion of safeguarding concerns,
professional boundaries, and reflective learning from incidents.
13.2. Promoting a Safety-First Culture
Cinox is dedicated to fostering a safety-first culture by:
● Empowerment: Actively encouraging staff to challenge poor practice, speak up, and
report concerns without fear of reprisal.
● Learning and Review: Systematically reviewing all safeguarding incidents,
complaints, and feedback to identify underlying patterns, implement corrective
actions, and share learning across the organisation.
● External Learning: Sharing learning from local and national safeguarding reviews
(SARs, CSPRs) within team meetings and training sessions to continuously improve
practice.
14. Audit, Monitoring, and Review
The Registered Manager/Deputy is responsible for the continuous quality assurance of
safeguarding practices:
● Safeguarding Log: Maintaining a detailed and accurate safeguarding log that
records all concerns, referrals, outcomes, and identified learning points.
● Annual Audit: Auditing safeguarding records at least annually to verify the
timeliness and quality of documentation, effectiveness of risk management plans,
and completion of follow-up actions.
● Governance Reporting: Reporting safeguarding themes, trends, and remedial
actions to internal governance meetings and responding transparently to external
scrutiny from the CQC and local safeguarding partners.
Policy Review: This policy will be reviewed at a minimum annually, or sooner if:
● Significant changes occur in legislation, statutory guidance (e.g., Working Together to
Safeguard Children).
● Learning from serious incidents, SARs, CSPRs, or CQC inspections indicates a need
for immediate changes in policy or procedure.
15. Policy Access and Implementation
● Accessibility: This policy will be made available to all staff, service users, and
stakeholders upon request and will be a mandatory component of all staff induction
packs.
● Supporting Materials: The policy is supported by detailed procedures, flowcharts,
and forms that outline the precise practical steps staff must follow when a concern
arises.
● Service User Information: The policy and procedures will be explained to service
users and their families in accessible formats, ensuring that language, literacy levels,
communication needs, and mental capacity are appropriately considered.
Implementation of and adherence to this policy are mandatory for everyone working for or
on behalf of Cinox Healthcare Service. Any failure to adhere to this policy may be treated as
misconduct and may also be reported to external regulatory bodies where required.

POLICY &
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Accessible Information Standards Policy and Procedure
Summary Cinox Healthcare Ltd recognises the importance of effective
communication with service users, their relatives and carers, and
the importance of providing information that enables them to receive
appropriate person-centred care and support. It also recognises that
people must receive safe care and are not put at risk of harm
because of lack of or ineffective communication with their service
provider.
Scope The following people may be affected by this policy: All staff.
Whether temporary or permanent, Local Authorities,
Commissioners. Families, NHS, and Service users.
Docume
nt Type
Policy & Procedure
Verified By Chinwe Eucheria
Issued
Date
01-03-2023
Last
Review
06-07-2025 to be reviewed on 06-07-2026

Accessible Information Policy
The document sets out the values, principles and policies underpinning Cinox
Healthcare Ltd’s approach to providing accessible information for services users, their
©2024 Care Quality
Support. Only Cinox
Healthcare Ltd can access
this policy. Sharing, copying or distribution to
unregistered entities constitutes a breach of
contract. This policy cannot be shared or
copied without the prior written approval of
Care Quality Support. Breach of contract
subject to prosecution. Prohibited from
unauthorised distribution.
PAGE 1 of 6
V.1001
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39 Rush Green Road, Romford RM7 OPT
relatives, and carers. It should be used in relation to the Service Users with
Communication Difficulties Policy.
Policy Statement
Cinox Healthcare Ltd recognises the importance of effective communication with
service users, their relatives and carers, and the importance of providing information that
enables them to receive appropriate person-centred care and support. It also recognises
that people must receive safe care and are not put at risk of harm because of lack of or
ineffective communication with their service provider.
Cinox Healthcare Ltd understands that communication and the provision of information
is a fundamental part of treating people with dignity and respect and in providing good,
compassionate care. Furthermore, the service recognises that effective communication
can be affected by conditions such as dementia, stroke, hearing conditions, sight loss or
cases where the service user lacks capacity to make decisions.
Cinox Healthcare Ltd recognises its legal and ethical duties relating to effective
communication and the provision of information which includes the following.
1. A duty under s.250 of the Health and Social Care Act 2012 which requires all
organisations that provide NHS services or publicly funded adult social care to
follow the Accessible Information Standard.
2. A duty under the Equality Act 2010 to eliminate discrimination and make
reasonable adjustments for disabled people, such as those with hearing or visual
impairments, including taking steps to put information into accessible formats if a
disabled person is at a substantial disadvantage if this is not done.
3. Requirements under the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014, particularly Regulation 9: Person-centred Care, which states that
the care and treatment of service users must be appropriate, meet their needs and
reflect their preferences.
4. Regulation 10: Dignity and Respect, Regulation 11: Need for Consent, Regulation
12: Safe Care and Treatment, and Regulation 13: Safeguarding Service Users from
Abuse and Improper Treatment all require effective communication between
Healthcare Ltd can access this policy. Sharing,
copying or distribution to unregistered entities
constitutes a breach of contract. This policy
cannot be shared or copied without the prior
written approval of Care Quality Support.
Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
©2024 Care Quality
Support. Only Cinox
PAGE 2 of 6
V.1001
POLICY &
PROCEDURE service provider and user.
Key lines of enquiry
CONTACT INFORMATION 07854280352
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39 Rush Green Road, Romford RM7 OPT

Caring C2: How does the service support people express their views and
be actively involved in making decisions about their care, support,
and treatment as far as possible?
Effective E4: How well do staff, teams, and services within and across
organisations work together to deliver effective care, support,
and treatment?
Responsive R1: How do people receive personalised care that is responsive
to their needs?
Safe S1: How do systems, processes and practices safeguard people
from abuse?
Well-Led W4: How does the service continuously learn to improve, learn
and ensure sustainability

Policy
To comply with the above requirements, the care service has adopted the following
policy.
©2024 Care Quality Support. Only Cinox
Healthcare Ltd can access this policy. Sharing,
copying or distribution to unregistered entities
constitutes a breach of contract. This policy
cannot be shared or copied without the prior
written approval of Care Quality Support.
Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
PAGE 3 of 6
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1. The service will implement the NHS Accessible Information Standard to achieve
excellent levels of support for service users with defined communication needs, and
to help their relatives and carers to address communication issues.
2. Service users have the right to be communicated with and receive sufficient
information about their care and treatment so that they make a balanced judgment
whether or not to give their consent.
3. The information and communication needs of service users will be identified as part
of their initial needs assessment and kept under review — this should include any
sensory problems affecting a person’s hearing or sight.
4. It is likely that prospective service communication needs will already have been
identified by other health and care agencies involved but we will always check that
these needs have been accurately assessed and addressed so that we can
communicate effectively with the person about their care needs and deliver the
appropriate care. (See step 1 of the Accessible Information Standard.)
5. We will clearly record the relevant information in the service users’ records in line
with step 2 of the Accessible Information Standard so that everyone involved in the
person’s care and support will know how to communicate effectively with that
person.
6. Cinox Healthcare Ltd will discuss with the service user as part of the care
planning process (and, if necessary, in consultation with other professionals and
agencies) what adjustments and interventions are needed to improve
communication with that person.
7. Agreed methods of communication and interventions will be recorded in the
person’s care plan in a prominent and consistent way so that all care staff know
exactly what has been agreed to meet the needs of service users, their relatives
and carers. (See step 3 of the Accessible Information Standard.)
8. Where a service user is transferred to another service, or receives care from
another service, we will, with the service users’ permission, share information that
we are requested to provide about their communication and information needs
(along with other information sharing) with the receiving service. (See step 4 of the
Accessible Information Standard.)
9. Where it is suspected that a service user does not have the mental capacity to
communicate, or in any other way has no ability to communicate, then the
provisions of the Mental Capacity Act 2005 will be implemented and best interests’
©2024 Care Quality
Support. Only Cinox
Healthcare Ltd can access
this policy. Sharing, copying or distribution to
unregistered entities constitutes a breach of
contract. This policy cannot be shared or
copied without the prior written approval of
Care Quality Support. Breach of contract
subject to prosecution. Prohibited from
unauthorised distribution.
PAGE 4 of 6
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CONTACT INFORMATION
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39 Rush Green Road, Romford RM7 OPT
decisions made, with the involvement of people close to the service user, such as
relatives, carers or advocates.
10. All reasonable adjustments will be made to meet the communication needs of
people with sensory difficulties, including people with visual and hearing difficulties. 11.
Where required and appropriate to the role of the care service, we will provide or
facilitate the sourcing and provision of resources and assistive technology such as
braille books and magazines, large print/easy read copies of literature, British Sign
Language interpreters for deaf people, braille or talking telephones and mobile phones,
hearing aids, text phones, loop hearing systems, etc.
12. For any service user, family member or carer who might require it, advocacy will be
provided or sought to help meet their communication and information needs. 13. All
staff are responsible for helping to deliver this policy by communicating in a way that is
accessible to every user of this service. (Points 9–13 all reflect step 5 of the Accessible
Information Standard.)
Training
At induction new care staff will receive training in line with the Care Certificate Standards
Framework with an emphasis in this policy context on Standard 6: Communication.
All care staff will receive training as relevant to their roles and responsibilities in the care
of people with hearing and sight problems and disabilities, which will include learning
about communication techniques and providing accessible information.
Review
This policy will be reviewed annually or more frequently in line with changes to the
national guidance and strategies on the provision of accessible information.
Associated Documents and References
Service Users with Communication Difficulties Policy.
Getting Help
©2024 Care Quality
Support. Only Cinox Healthcare Ltd can access
this policy. Sharing, copying or distribution to
unregistered entities constitutes a breach of
contract. This policy cannot be shared or
copied without the prior written approval of
Care Quality Support. Breach of contract
subject to prosecution. Prohibited from
unauthorised distribution.
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POLICY &
PROCEDURE
CONTACT INFORMATION
07854280352
asabuku06@gmail.com
39 Rush Green Road, Romford RM7 OPT
If you require any help with any matters relating to this policy and procedure,
please speak to your line manager or Senior manager.
It is the responsibility of every member of staff to ensure that they are working
within this policy and keep up to date with changes in policy that may affect their
practice at work.
©2024 Care Quality Support. Only Cinox
Healthcare Ltd can access this policy. Sharing,
copying or distribution to unregistered entities
constitutes a breach of contract. This policy
cannot be shared or copied without the prior
written approval of Care Quality Support.
Breach of contract subject to prosecution.
Prohibited from unauthorised distribution.
PAGE 6 of 6
V.1001