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Code of Practice for Inspection of Regulated Services for adults and children

Our approach to how we will inspect those services regulated under the Regulation and Inspection of Social Care (Wales) Act 2016

Published: 13 June 2023
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1. Introduction

About us

1.1 Care Inspectorate Wales (CIW) is the independent regulator of social care and childcare.  We register, inspect and take action to improve the quality and safety of services for the well-being of the people of Wales.

1.2 We aim to:

  • provide independent assurance about the quality and availability of social care in Wales;
  • safeguard adults and children, making sure that their rights are protected;
  • improve care by encouraging and promoting improvements in the safety and quality of social care services; and
  • inform policy, standards and provide independent professional advice to the people developing policy, the public and social care sector.

1.3 We achieve this by:

  • carrying out functions on behalf of Welsh Ministers;
  • deciding who can provide services;
  • inspecting and driving improvement of regulated services and local authority social services;
  • undertaking thematic reviews of social care services;
  • taking action to ensure services meet legislative and regulatory requirements; and
  • follow-up on concerns raised about regulated services.

1.4 We carry out our functions on behalf of Welsh Ministers under the following legislation:

Additional legislation includes:

1.5 The 2016 Act places service quality and improvement at the heart of regulation, strengthening protection for those who need it, and ensures that services deliver high-quality care and support. This supports the aims of the Social Services and Well-being (Wales) Act 2014 (External link) which enshrines the rights of people using care and support services in Wales into law.

How we regulate

1.6 Our primary concern is to ensure people using services are supported to achieve the best possible outcomes and are not placed at risk or do not experience harm. In order to achieve this we:

  • have a robust registration process, so that we only register service providers who have assured us they will comply with regulations;
  • undertake inspections; and
  • have a clear, progressive and proportionate securing improvement and enforcement pathway. 

2. The Code of Practice

The purpose of the Code of Practice

2.1 This Code of Practice (CoP) is a requirement under Section 33 of the 2016 Act. It describes our approach to how we will inspect those services regulated under the 2016 Act, including the frequency in which these services will be inspected. It also sets out the principles guiding our inspection work. Inspectors are required to have regard to the guidance in the CoP and be able to explain how they have taken it into account when undertaking an inspection.

2.2 The CoP informs everyone about how care and support services are inspected in Wales. This includes, people using services, their families, friends and carers, as well as providers of care and support services, commissioners of those services and members of the public.

Which services does the CoP apply to?

2.3 The CoP applies to the services we regulated as set out in 1.4. These are:

  • care homes (adults/children)
  • secure accommodation
  • residential family centre
  • domiciliary support
  • adoption*
  • fostering*
  • adult placement
  • advocacy
  • special school residential services 

CIW also inspects Boarding schools (operating for 295 days or less) and Further Education Colleges (for under 18s only). CIW does not have enforcement powers for these services.

*Local authority fostering and adoption services are inspected under our powers under section 149B(1) of the Social Services and Well-being (Wales) Act 2014 to review the way in which the local authorities’ social services functions are exercised, and section 161 of the same Act which permits CIW to inspect local authorities where it is necessary or expedient for the purposes of the review.

3. Rights-based approach to inspection

3.1 We ensure that respect, diversity, promoting equality and upholding people’s rights are embedded within our work. The Human Rights Act 1998 (External link), The Equality Act 2010 (External link) the United Nations Convention on the Rights of the Child (UNCR) (External link) the United Nations Convention on the Rights of Persons with Disabilities (External link) the United Nations Principles for Older Persons and the Welsh Government’s Action on Independent Living Framework are reflected in our frameworks for inspection. We consider how service providers promote peoples’ rights by considering how services ensure people:

  • have choice and control;
  • are safe;
  • are treated with respect;
  • have a voice; and
  • are helped to develop their full potential.

3.2 Further information on our commitment to promoting and upholding the rights of people who use care and support services is set out in our Human Rights guidance document (External link).

3.3 We take account of all relevant statutory frameworks and Wales Safeguarding Procedures when considering whether people using the service are safe. If during the inspection process, we see care practice which demonstrates people using the service are not safe or protected from harm, we will take enforcement action as well as make a safeguarding referral to the local authority. We will ensure measures are put in place to safeguard people using the service.

3.4 Where people lack capacity, we will explore the extent to which providers of services adhere to the principles of the Mental Capacity Act 2005 (External link) and The Deprivation of Liberty Safeguards (DoLS) (External link).

3.5 The Welsh Language Standards (External link) further support us in implementing a rights-based approach. We use the principles of the Standards during our inspections, this helps us ensure people have a right to access a service in Welsh if they so wish. The Standards support people who are Welsh speaking to have services provided in Welsh, when they need it, without them having to ask for it.  The standards are supported by More Than Just Words.

Some examples might include:

  • Recognising the importance of promoting Welsh language and culture and taking action to do so
  • Welsh speaking staff supporting people who speak Welsh;
  • Welsh language signage to help orientate Welsh speakers; or
  • information about the service provided in Welsh for those who want it.

Alongside reviewing how services implement the Welsh Language Standards we have an active offer, which includes providing Welsh speaking inspectors for services where Welsh is the main language of choice.

4. The inspection process

Why do we inspect

4.1 Inspection is a core activity of CIW and helps ensure people accessing care and support services are safe, their well-being is promoted and their rights are upheld. It is how we drive continuous improvement in the social care sector and check providers of services are meeting their statutory duties.

The principles guiding our work  

4.2 Our work is guided by the following principles.

  • putting people first: the voice and well-being of people are at the heart of our work underpinned by a rights-based approach
  • being intelligence-led: our work is informed by data and intelligence
  • being risk based and responsive: we take a planned, risk based, proportionate and timely approach to our work
  • working collaboratively: we listen, share information and work collaboratively
  • supporting improvement and innovation: we use our knowledge and powers to support social care and childcare services to improve and encourage new ways of working
  • reflecting and learning: we take time to reflect and learn from all aspects of our work, and to adjust our approach where necessary

How we inspect

4.3 Inspections consist of four key stages including:

  • inspection planning/preparation;
  • the inspection visit;
  • feedback; and
  • reporting.

4.4 We hold a considerable amount of information on services through our registration and inspection processes as well as obtaining information from other sources. This helps us to determine the type and frequency of inspection required for a particular service. We use this information to plan and inform what we want to focus on when we visit the service and any specific measures we need to consider for engaging with the people using the service or staff. For example, where individuals have communication needs, the inspector can consider how they will engage with people.

4.5 During an inspection visit, inspectors will seek three broad types of evidence.

  • What is said - inspectors engage with and listen to people using services, along with their relatives, friends and carers, and talk to them about their experience of care. We also talk to providers, relevant professionals and staff working at the service. Where people are unable to communicate directly with us, we may use a specialist inspection tool (SOFI), where it is appropriate to do so, to observe and draw conclusions about how individuals are supported.
  • What is seen - inspectors observe interactions that take place between people giving and receiving care and support during the course of the visit. We also observe the physical environment in which care and support is provided, and assess the degree to which it is safe and suitable for the purpose intended.
  • What is read - inspectors consult written records, policy documents and other material, seeking to confirm they are comprehensive and up-to-date, and demonstrate suitable processes are put into practice.  

4.6 Inspectors make notes during the inspection, which inform our inspection reports. They may also ask for copies of documents, request information be sent to them or remove records where required. When we remove original copies of individual care records and the information is still required to inform staff how to support people, copies of the information will be provided to the service to ensure continuity and safety.

4.7 If the inspection visit is as a result of enforcement action and the inspector needs to seize information under 2016 Act, we will inform the service provider of this and what it means. Where an inspector seizes and removes evidence they will do so having regard to the Police and Criminal Evidence Act 1984 (PACE) (External link).

How information is considered throughout the inspection process

4.10 The following demonstrates what information is used throughout the inspection process and what we do with it:  

  1. Information used by CIW throughout the inspection process.
  • Service provider information
    • Information submitted through registration
    • Statement of purpose
    • Annual return
    • Annual quality of care report
    • Notifications that inform CIW about the service e.g. hospital admissions, deaths, mediation errors, falls, absence of the manager etc.
  • Other information held by CIW
    • Registration reports
    • Previous inspection reports
    • Information we hold under our enforcement process
    • Information we have about other services the provider operates
    • Concerns, notifications and safeguarding referrals
  • Information provided by others
    • Concerns or information from, People using the service, relatives/friends, staff, other regulators or members of public
    • Safeguarding referrals from the Local Authority
    1. Where information is received, relating to matters that are outside the scope of CIW’s functions, it is referred on to a more suitable body.
  1. Inspection preparation and planning
    Information is collated and consider determining the type and frequency of inspection; and identify the themes to focus on
  2. Inspection visit
    • Record what we saw, what we were told and what we read.
    • Feedback is provided to the service provider.
  • Safeguarding
    If we see or are informed about safeguarding concerns during out inspection we will feed this back to the provider at the earliest opportunity so that they can take action. We may also need to make referrals to other agencies as part of our statutory duty to safeguard people.
  • Where shortfalls are identified, this could lead to:
    • Recommendations for improvement
    • Issue of non-compliance notice
    • Other enforcement actions such as improvement and penalty notices
  1. Follow up/inspection to take place.
  2. Inspection report
    Findings from the inspection will be published.
  3. Follow up/inspection to take place.

When will services be inspected?

4.11 Our powers allow us to inspect regulated services at any time and on any day. The frequency of inspection for different service types is set out in section 6.

4.12 Our inspections will usually be unannounced, however for some service types e.g. domiciliary support services, fostering services, adoption services, boarding schools, special residential schools and advocacy services we may give the provider a short period of notice where it is appropriate to do so. This is because the views of people using the service are critical to our inspections and for these service types, we need to plan visits in advance.

Focus of inspection

4.13 To understand people’s experiences of care, the focus of our inspections is on the quality and safety of services and the outcomes for the people using services. Therefore we consider the following themes during inspections:-  

Well-being: the well-being of individuals receiving care and support. 

  • Inspectors evaluate the extent to which outcomes are being achieved. 

Care and support: the quality of care and support staff provide.

  • Inspectors evaluate the degree to which people receive a high-quality service which reflects best practice, is provided by staff who have the appropriate knowledge and skills and supports people to achieve the best possible outcomes. 

Environment: the physical setting in which care and support is provided. This theme does not apply to regulated service types that do not provide accommodation. 

  • Inspectors evaluate the degree to which outcomes for people are supported by surroundings that are safe, clean, accessible, comfortable, welcoming, well-maintained, stimulating, and suitably equipped and furnished. 

Leadership and management: organisational arrangements for the provision of care and support. 

  • Inspectors evaluate the degree to which organisational arrangements provide assurance for the delivery of high quality services, by motivated staff in a well led and managed service. 

4.14 The number of themes considered will depend on the type of inspection undertaken, as described in section 5. To support a consistent approach to the inspection process, we have developed practice guidance for specific types of regulated services focused on outcomes.

4.15   These inspection frameworks are accessible on the providing a care service area of our website.

Ratings 

4.16    Under section 37 of the 2016 Act, the Welsh Ministers can make regulations for ratings that may be given in relation to the quality of care and support provided by a service provider following an inspection. The Regulated Services (Inspection Ratings) (Wales) Regulations 2025 came into force on 31 March 2025. 

4.17    CIW will award a rating to all care home and domiciliary support services in relation to each of the relevant themes identified in 4.13. We do not award an overall rating for the provider but we do award ratings against each of the four inspection themes using a four-point rating scale.

  • Excellent
  • Good
  • Requires improvement
  • Requires significant improvement

More detail is set out in our Framework for Inspection.

5. Types of inspection

5.1 All providers regulated under the 2016 Act must register any service(s) they deliver in Wales as part of a single registration. Under usual circumstances we will inspect  individual service(s) but we are also able to inspect a number of services registered under a single registration as part of the same inspection or inspect the service provider as a whole. 

Service inspection

5.2 Inspections involve in-depth consideration of all four themes. In the case of services that do not provide accommodation, environment is not considered.

5.3 The timing of the first inspection is determined at registration.

5.4 It is an opportunity for inspectors to ensure providers are supporting people to achieve their well-being outcomes underpinned by standards of service provision as set out in the regulations and are meeting the conditions of their registration. After the first inspection, services will receive further inspections in line with the frequency set out in section 6.

Focused inspection

5.5 Focused inspections are usually carried out in response to a specific concern, or to follow-up on regulatory breaches or other issues identified at a previous inspection. Focused inspections are generally shorter than inspections, and will not necessarily cover all four themes. However, a focused inspection will always cover the theme of ‘well-being’.

5.6 Where the follow-up inspection is in regards to a previously identified regulatory breach, the follow-up inspection will usually take place within 6 months of that previous inspection. However, the timing of that inspection will be based on the judgement of the inspector in considering the severity of the regulatory breach and the time required by the provider to address the issue(s).

Provider inspection

5.7 Provider inspections will look specifically at the corporate governance and management arrangements of the service provider. Depending on the circumstances this may also include an inspection of all the services within the provider’s portfolio, focusing on specific areas of concern. These inspections of the individual services will normally be focused inspections, but could be full inspections depending on the circumstances.

5.8 To ensure the regulator has sufficient oversight of larger service providers (those with five or more registered services within its portfolio), we will nominate a senior manager who has responsibility for engaging with the provider and overseeing the performance of all their services. This may include regular meetings with the provider to discuss performance, provider development, improvement work etc. 

Thematic inspections

5.9 Thematic inspections focus on certain areas of practice across the social care sector. For example, this could include reviewing care practice in learning disability residential homes, medication practice in care homes or dementia care. This enables us to have an understanding of, report on and make recommendations in relations to specific care practices across Wales. Length of inspections

5.10 The size or complexity of the service will determine how long the inspection should be and the number of inspectors present. A small service where there are no concerns will normally be inspected by one inspector over the course of one day. A service that is large and/ or has complex issues could result in more than one inspector being present and/or could take longer than one day. As part of the inspection we have discussions with people using the service, their representatives and staff. We may do this separately to the site visit for example when we visit people receiving domiciliary support services.

6. Scheduling of inspections

6.1 Services will be monitored through a rolling programme of scheduled inspections. Information received between scheduled inspections is monitored to inform us how the service(s) is performing and when a subsequent inspection should be scheduled.

6.2 We use an evidence-based approach to make decisions about how we regulate services. Our approach to scheduling an inspection is based on the type of service and our knowledge of how the service is operating 

6.3 There are a range of factors that will be considered to inform our scheduling that include but are not limited to:

  • if the service is a newly registered service - some newly established services can be of greater risk during the initial set up period
  • if we have identified areas for improvement or issued a priority action notice
  • if there is an absent Responsible Individual for more than six  months as this may impact on the safe operation of the service
  • if the service has recently been on CIW’s enforcement pathway

6.4 In order to determine the frequency of inspection we have developed a scheduling model that captures and weighs the factors listed above. We use the available information to identify whether a service requires a routine, early or priority inspection. This model is used for the specific purpose of scheduling an inspection with the quality of the service being determined at inspection.

6.5 The list below sets out the scheduling of inspections for different types of services and the intervals that could be expected if a service is identified as requiring a routine, early or priority inspection. 

Inspection intervals by service type

  • Care homes including care homes for children and care homes providing nursing care and secure accommodation
    Maximum interval between inspections
    • Routine: 18 months
    • Early: 12 months
    • Priority: 6 months
  • Domiciliary support 
    Maximum interval between inspections
    • Routine: 18 months
    • Early: 12 months
    • Priority: 6 months
  • Adult placement 
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months
  • Residential family centres 
    Maximum interval between inspections
    • Routine: 18 months
    • Early: 12 months
    • Priority: 6 months
  • Advocacy 
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months
  • Adoption
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months
  • Fostering
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months
  • Special school residential services
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months
  • Boarding schools and further education colleges
    Maximum interval between inspections
    • Routine: 48 months
    • Early: 12 months
    • Priority: 6 months

6.6 The first inspection of a newly registered service will be determined by the Registration team.

6.7 It is important to note we may undertake an inspection at any time in response to incoming concerns, notifications and safeguarding referrals.

7. Conduct during inspection

Inspectors

7.1      We will be polite and courteous in our dealings with you.  Inspectors employed by CIW have come from a variety of professional backgrounds within health and social care; many have previously worked as nurses, social workers, teachers or as registered managers of care services. However all inspectors are civil servants and must meet the professional standards set out in The Civil Service Code (External link). 

As with social care workers, inspectors also act in accordance with the Code of Professional Practice for Social Care (External link). This brings the expectation that inspectors will:

  • carry out their work with care, integrity, courtesy, sensitivity and professionalism
  • evaluate the provision of services objectively ensuring evidence is both triangulated and weighted appropriately
  • report on the inspection honestly, fairly and impartially
  • communicate clearly and openly to promote the health, safety and well­being of people who use care services
  • act in the best interests of people using services
  • respect confidentiality of information
  • be accountable and take responsibility for the quality of their work
  • promote, uphold and respect the privacy, dignity, rights, health and well­being of people who both use or are employed by care services

How service providers and staff can support the inspection process

7.2 We will always seek to minimise the impact  an inspection visit can have on the service, its staff and the people using the service. To help inspectors achieve that aim, service providers and their staff can assist the inspection in the following ways:

  • talk to the inspector
  • tell the inspector about any possible risks
  • tell the inspector if their presence will upset people
  • do what you would normally do (we want to see what it is normally like for people)
  • allow the inspector to walk around communal areas, as long as it is safe to do so
  • allow inspectors a private area to talk to people using the service, staff and visitors
  • if during feedback you disagree with anything the inspector tells you, please tell them and be clear about the reasons why
  • if you have any concerns about how the inspection is being conducted raise this immediately with the inspector or their manager

7.3 We expect you to be polite and courteous in your dealings with us. However, we will not tolerate unreasonable, aggressive or abusive behaviour, unreasonable demands or unreasonable persistence. We regard any incident of this nature as serious and we will take action in accordance with Welsh Government policy to protect our staff where necessary.

8. Feedback at and reporting of inspection

Feedback

8.1 Initial feedback will be provided throughout the inspection visit and summarised at the end of the visit to those in charge of the service on the day. This will be an overview of findings as further analysis may be required before firm conclusions can be drawn. This provides an opportunity for the manager and/or RI to correct any inaccurate information and provide any evidence they think may have been overlooked. 

8.2 Where an inspector considers outcomes for people are poor and significant improvement is required and is thinking of or intending to issue a priority action notice or take other enforcement action, the provider will be clearly informed. 

8.3 The inspector will provide detailed feedback to the Responsible Individual as soon as is mutually convenient after the last inspection activity has been completed.  . Feedback will be structured around the assessment themes and should focus on strengths and areas where improvement is required. 

Inspection report

8.4 People’s experiences of services are at the heart of our reports including the impact of those services on their well-being. Whilst providers and professionals read our reports, they are written for the general public. This enables people who use and choose services and their relatives to understand the quality of care provided.

8.5 Inspectors base their reports on the evidence they gather prior to, during and following the inspection visit. The inspector considers a variety of evidence to support their findings in their report. This will be a consideration of what is said, what is seen and what is read to inform our findings and our overall judgements.

When will the inspection report be published?

8.6 Our approach to drafting, finalising and publishing publish inspection reports is set out  in our policy on Publishing Inspection reports. 

8.7 In the interests of fairness and transparency, we accept the right of Registered Persons, Responsible Individuals or relevant persons to question our reports where they believe them to be inaccurate or missing consideration of important evidence. This gives us the opportunity to correct any errors and consider additional information before an inspection report becomes publicly available. Further information about this process is available in our Requesting a review of evidence and findings of inspection reports (including ratings).

9. Improving the quality of services

9.1 We want all services to strive to continuously improve. Securing improvement and taking enforcement action is a core part of our work. This is set out in detail in our Securing Improvement and Enforcement Policy. Where we identify issues which impact on people’s outcomes or place them at risk because service standards as set out in regulations are not being met we will take proportionate and graduated action. 

9.2 The types of actions we take include:

Where we identify potential to improve outcomes for people but there is negligible impact on people’s well-being  we will discuss this with the provider during inspection feedback. We may follow this up at the next scheduled inspection. 

  • Where we identify areas for improvement we will inform the provider and expect them to take action to address the issues identified. This is recorded in the inspection report and we will be follow at the next early inspection.
  • Where outcomes for people require significant improvement, we will issue a priority action notice which is the first step in our enforcement process. In these cases, we will undertake a priority follow-up inspection to test whether the provider has made the required improvements
  • In certain circumstances, where we determine the risk to people is so significant; we may take urgent action to place restrictions on or cancel the provider’s registration. This could include for example issuing an Improvement Notice, preventing further admissions or closing the service.

9.3 For those services not registered by CIW, we do not have enforcement powers but will highlight areas for improvement or priority action with the provider and follow this up at inspection, working with relevant partners such as commissioners or other inspectorates. 

Raising a complaint about an inspection

9.4 We take complaints very seriously and are committed to reflecting and learning on issues arising from these. 

9.5 If the service provider, a person using the service or a member of the public has a complaint about the conduct, attitude or behaviour of an inspector, or any CIW staff member, we have a Complaints Policy that should be followed.

9.6 The complaints policy is separate to the responding to inspection report process described in paragraphs 8.7 to 8.8. A complaint made against the conduct of an inspector will not normally delay the publication of an inspection report.
 

10. Information

10.1 The knowledge and information we hold is one of our most important assets. It ensures the decisions we make and the advice we give is underpinned by a robust evidence base.

10.2 Through our registration and inspection processes we gather and hold information on providers, including information obtained from other intelligence sources. This valuable information helps us assess whether a registered provider and/or designated responsible individuals (depending on the legislation) is providing a high quality and safe service.

10.3 On occasion we may receive a request to release information relating to an individual case or service. Any individual has the right to request recorded information we hold, and subject to the statutory requirements of legislation around information handling, to be given a copy of this information.

10.4 To ensure the right information is available at the right time, and we uphold the statutory requirements required of us, we:

  • Safeguard the information we hold, in line with Welsh Government procedures, to ensure high standards of information security and data protection.
  • Store our information in the correct way, adhering to the Welsh Government’s information management (External link) principles.
  • Respond to requests for information within the established processes and timeframes required by law. (There are four laws governing our handling of requests for information, these are the Data Protection Act (DPA) 2018, UK General Data Protection Regulation (UK GDPR), Freedom of Information Act (FOIA) 2000 and Environmental Information Regulations (EIR) 2004)
  • Share information appropriately and lawfully, to enhance and re-use our knowledge, work collaboratively and reduce duplication.

10.5 Our Privacy Notice summarises how we handle all the types of personal information we collect. This includes the legal basis for collecting the information, how the information is processed, how long it is kept for, who it might be shared with, what your rights are in relation to it and the relevant contacts that you might need.

10.6 In certain cases CIW may participate in or undertake an inspection jointly with other regulatory bodies or agencies, such as the Police, Health and Safety Executive or Estyn, where relevant. Sharing information with these regulatory bodies or agencies is crucial in ensuring an effective use of information and resource. In these situations we share information in line with the statutory requirements placed upon us.

11. Terminology used in this Code

Care and support - Care addresses the physical and mental tasks and needs of the person cared for, while support refers to counselling, advice or other help provided as part of a plan prepared for the person receiving support.

Care Inspectorate Wales (CIW) - The independent regulator of social care and childcare. We register, inspect and take action to improve the quality and safety of services for the well-being of the people of Wales.

Code of Practice for Inspection. High-level description of the manner in which the inspection of adult and children services is to be carried out, in accordance with the requirements of the Act and associated regulations.

Concerns - An issue which has been reported to CIW that relates to the safety, wellbeing or rights of people using the service.

Inspection framework - A structured approach to support how CIW focuses its inspection activity throughout the inspection process.

Regulator - Organisation established by government to supervise, by means of rules and regulations, an area of commercial or social activity.

Safeguarding - General term for actions taken to promote the welfare of children and vulnerable adults and protect them from neglect, abuse and exploitation.

Service(s) - This refers to an individual service within a provider’s portfolio. For care homes this would be a care home, carried out at a specific location. For domiciliary support services this would be an individual service, carried out in a specific area.

Well-being - Broadly refers to the state of a person being healthy, happy, safe and comfortable with their life. 

12. References

Concerns about care? Please let us know if you have any concerns about us, a service, or a member of care staff. Raise a concern