Care Home Policies and Procedures: Every Policy CQC Expects You to Have

Every CQC inspection involves a policy review. Inspectors will not read every policy cover to cover, but they check that key policies exist, are current, reflect actual practice, and are known to staff. "Can you show me your policy on X?" is one of the most common questions a registered manager hears during an assessment visit.

This guide lists every policy CQC expects, mapped to key questions, with review frequencies and version control guidance.

How Policies Map to CQC Assessment

Under the single assessment framework, policies provide evidence across multiple key questions simultaneously. A safeguarding policy is primary evidence for Safe but also supports Well-Led (governance) and Responsive (protecting rights). For more on the framework, see our complete guide to CQC compliance for small care homes.

CQC looks for three things: the policy exists, it reflects current legislation, and staff know about it and follow it.

The Complete Care Home Policy List

Organised by primary CQC key question, with regulatory basis and secondary mappings noted. Regulation numbers refer to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 unless otherwise stated.

Safe

Policy	Regulatory Basis	Secondary KQ	Review
Safeguarding Adults	Regulation 13, Care Act 2014 s.42-46	Well-Led	Annual + legislative change
Safeguarding Children (if applicable)	Children Act 1989/2004	Well-Led	Annual
Medication Management	Regulation 12(2)(g)	Effective	Annual + NICE updates
Infection Prevention and Control	Regulation 12(2)(h), HSC Act 2008 Code of Practice	Effective	Annual + UKHSA updates
Health and Safety	Health and Safety at Work Act 1974	Well-Led	Annual
Fire Safety	Regulatory Reform (Fire Safety) Order 2005	—	Annual + post fire risk assessment
COSHH	COSHH Regulations 2002	—	Annual
Incident and Accident Reporting	Regulation 18 (CQC Registration Regs)	Well-Led	Annual
Risk Assessment	Regulation 12(2)(a)-(b)	Effective	Annual
Moving and Handling	Manual Handling Operations Regulations 1992	—	Annual
Lone Working	Health and Safety at Work Act 1974	—	Annual
Environmental Safety	Various (legionella, electrical, gas)	—	Annual
Falls Prevention	Regulation 12, NICE NG232	Effective	Annual + NICE updates
Missing/Absent Resident	Regulation 12	Responsive	Annual
Bedrails and Restrictive Practices	Regulation 13(4)-(5), MCA 2005	Caring	Annual

Effective

Policy	Regulatory Basis	Secondary KQ	Review
Consent and Mental Capacity	MCA 2005, Regulation 11	Caring	Annual
DoLS / Liberty Protection Safeguards	MCA 2005 Schedule A1 / LPS (when enacted)	Safe	Annual + LPS commencement
Nutrition and Hydration	Regulation 14	Caring	Annual
Care Planning	Regulation 9	Responsive	Annual
End of Life Care	Regulation 9, NICE NG142	Caring, Responsive	Annual
Staff Training and Development	Regulation 18(2)(a)	Well-Led	Annual
Staff Supervision and Appraisal	Regulation 18(2)(a)	Well-Led	Annual
Clinical Observations and Escalation	NICE CG50	Safe	Annual
Oral Health Care	NICE NG48	Caring	Annual

Caring

Policy	Regulatory Basis	Secondary KQ	Review
Dignity, Privacy, and Respect	Regulation 10	Responsive	Annual
Equality, Diversity, and Inclusion	Equality Act 2010, Regulation 10	Responsive	Annual
Communication	Regulation 9(3)(b)-(d), Accessible Information Standard	Responsive	Annual
Visitors and Relatives	Regulation 9	Responsive	Annual

Responsive

Policy	Regulatory Basis	Secondary KQ	Review
Complaints	Regulation 16	Well-Led	Annual
Admissions and Pre-Admission Assessment	Regulation 9	Safe, Effective	Annual
Activities and Social Engagement	Regulation 9(3)(b)	Caring	Annual
Discharge and Transfer	Regulation 9	Safe	Annual
Service User Records and Access	Regulation 17(2)(c)-(d), UK GDPR	Well-Led	Annual

Well-Led

Policy	Regulatory Basis	Secondary KQ	Review
Governance and Quality Assurance	Regulation 17	All	Annual
Duty of Candour	Regulation 20	Responsive	Annual
Whistleblowing (Freedom to Speak Up)	Public Interest Disclosure Act 1998	Safe	Annual
Recruitment (including DBS)	Regulation 19, Schedule 3	Safe	Annual
Disciplinary and Grievance	Employment Rights Act 1996	—	Annual
Business Continuity	Regulation 17(2)(f), Civil Contingencies Act 2004	Safe	Annual
Data Protection and Confidentiality	UK GDPR, Data Protection Act 2018	—	Annual + ICO changes
Notifications to CQC	Regulation 18 (CQC Registration Regs 2009)	—	Annual
Financial Procedures (if managing residents' money)	Regulation 13	Safe	Annual

For detail on complaints policy requirements, see our guide to care home complaints procedures.

Policies Often Missed

Duty of candour — Many small homes lack a standalone policy despite Regulation 20. CQC enforcement actions in 2023-2024 repeatedly cited this gap.
Deprivation of liberty — With Liberty Protection Safeguards still awaiting a commencement date as of early 2026, some homes have let DoLS policies lapse. The current framework under Schedule A1 of the MCA 2005 remains in force.
Business continuity — Plans for boiler failure, water loss, mass staff illness, or evacuation. CQC raised this across the sector during COVID-19.
Oral health — NICE NG48 requires care homes to support residents' oral health. A specific policy or clear section within personal care policy is expected.

Review Triggers Beyond the Annual Cycle

Review a policy immediately when:

Legislation changes — e.g., Building Safety Act 2022 changes affecting fire safety policy
Guidance updates — New NICE guidelines, UKHSA infection control guidance
After a serious incident revealing the policy was inadequate
After a CQC inspection identifying a gap (act within the stated timeframe, or 4 weeks if none given)
After a complaint revealing the policy did not cover the situation

For more on quality statements, see our guide to CQC quality statements explained.

Version Control

Every policy should include: policy title, version number, date of this version, next review date, author, approver, and a summary of changes from the previous version.

Maintain a policy register — a single spreadsheet listing every policy with current version and review dates. This is the first thing to hand an inspector. It demonstrates governance at a glance and prevents policies falling overdue. Set calendar reminders 4 weeks before each review date.

Making Policies Functional

A policy staff follow is evidence of compliance. A policy staff ignore is evidence of governance failure. To bridge the gap:

Keep policies concise — 8-10 pages, not 40
Use plain English — regulation references in metadata, not every paragraph
Add one-page quick-reference summaries — flowcharts or checklists staff can use in the moment
Test understanding in supervisions — "What would you do if a resident refused medication?" reveals more than "Have you read the medication policy?"
Record policy briefings — attendees, date, and key points when introducing updated policies

For guidance on how policies connect to staffing compliance, see our guide to safe staffing requirements.

Policy Audit Checklist

Use this quarterly:

Policy register up to date with current versions and review dates
No policies overdue for review
Updated policies have version control metadata completed
New or updated policies briefed to staff with attendance recorded
At least 3 staff can describe key steps in safeguarding, medication, and complaints procedures
CQC or Ombudsman recommendations on policies actioned
Policies reflect current legislation (check gov.uk and NICE)

A comprehensive, current, and genuinely used policy library is one of the most tangible things you can do to support a Good rating across all five key questions.