How can I tell if our care policies were written for someone else?

What does CQC actually say about policies?

There is no regulation called policies. They sit inside the wider duty to run the service well. CQC's guidance on Regulation 17, good governance, says records relating to the management of regulated activities means anything relevant to the planning and delivery of care and treatment. It names policies and procedures among them, alongside audits, reviews and action plans. So your policies are governance records, and the same standard applies to them as to your audits.

The regulation itself sets that standard in one line: systems or processes must be established and operated effectively. A policy filed in a binder is established. A policy your team follows on a wet Sunday night is operated effectively.

The guidance on Regulation 12, safe care and treatment, is more direct still. On policies for raising concerns about care, it says they must be in line with current legislation and guidance, and staff must follow them. On medicines, it says staff must follow policies and procedures about managing medicines, and that those policies should cover supply and ordering, storage, dispensing and preparation, administration, disposal and recording.

Two words carry the weight there: current, and follow. A bought template can fail on both.

Why do bought templates go wrong?

A template is not the problem in itself. Starting from a well written template can save a new service weeks of work. The trouble starts when the template is treated as the finished article.

The first reason is that it describes a different service. A template has to fit many providers at once, so it describes none of them exactly. It may mention a nurse on duty in a home with no nursing, a call monitoring system you do not use, or a team structure you have never had. Staff read it, see it is not about them, and stop reading.

The second is that nobody owns it after it arrives. The policy is downloaded, your service name goes in the header, and it is filed. When guidance changes, a supplier may send a new version, but nobody checks what changed or tells the team.

The third is that it is written for an inspector rather than a carer. Long paragraphs of legal wording, no clear steps, and the one thing a senior carer needs in the middle of the night buried near the end.

The cost shows up when the paper and the practice disagree. CQC's page on the processes evidence category says its assessments focus on how effective processes are, and that it looks at information that measures how well processes work. In my view, a policy that says one thing while staff do another is not a neutral gap. It tells an inspector that your own governance did not notice.

What are the signs a policy was written for someone else?

Most of these can be spotted in an afternoon with the policy file open and a cup of tea.

Sign	What it usually means	What to do
It mentions roles, equipment or services you do not have	It was adopted without being read against your service	Rewrite those sections around how you actually work
Staff cannot tell you what it says	It is not being used on shift	Ask two carers to explain it, then rewrite the parts they could not
Every policy carries the same review date	They were signed off as a batch, not reviewed	Give each policy its own date and its own reason to review early
It refers to guidance that has been withdrawn or replaced	Nobody has checked it against current sources	Check every reference against the source it names
There is no named owner	Nobody will notice when it drifts	Put one name against each policy
It reads the same as the policy at the service down the road	It describes a generic service, not yours	Add the detail only your service would know: your routines, your people, your contacts

If several rows apply to the same policy, rewrite it from scratch rather than patching it. A patched template still reads like a template.

How do I link policies to the fundamental standards?

CQC describes the fundamental standards as the standards below which your care must never fall. They are a far better starting point for your policy list than a supplier's index.

The Regulation 17 guidance says providers must operate effective systems to assess and monitor their service against Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. That gives you a simple test for your whole policy set. Work from the regulations, not from the folder. For each regulation that applies to your service, write down which policy tells staff what to do, and whether that policy describes your service.

Two things can come out of this. Some policies map to nothing, and you can ask why they exist. Some regulations map to nothing, and you have found a gap. Both are worth knowing before anyone else points them out.

It also helps to anchor policies to the regulations rather than to the wording of CQC's assessment framework. In its March update, CQC set out plans to move away from a single assessment framework to separate frameworks for each sector. The framework wording is likely to change. The regulations your policies rest on are the steadier anchor.

What does a policy staff can actually use look like?

It is short, it is in plain English, and it puts the steps in the order they happen. Anyone reading it can see who does what, where the form is and who to call. A good one also separates the policy, which is what the service commits to and why, from the procedure, which is what you do on shift.

Here is one sentence of the kind templates often contain, rewritten. This is my own illustration, not wording from any real service.

Template: "All staff are required to escalate any concerns pertaining to the welfare of service users in accordance with the organisation's procedures."

Plain English: "If you are worried about someone, tell the senior on shift straight away. If the senior is not there, phone the manager on call. Write down what you saw, when, and who you told."

The second version is longer, and it is far more useful. A new starter can follow it on their first shift. That is the test I would apply to every procedure you have.

How often should policies be reviewed?

The Regulation 17 guidance says systems and processes should be continually reviewed to make sure they remain fit for purpose. It also says providers must continually evaluate and seek to improve their governance and auditing practice. It does not hand you a fixed cycle, so build one that fits your service.

In my view, each policy needs a planned review date and a list of triggers that bring the review forward: new guidance, an incident, a complaint, an audit finding, or a change in the people you support or the services you offer. A planned date with no triggers means a policy can be wrong for months before anyone looks.

Version control does not need software. Each policy needs a version number, the date, a line on what changed, who approved it, and how staff were told. Keep earlier versions too. The Regulation 17 guidance says records relating to the management of regulated activities must be created, amended, stored and destroyed in accordance with current legislation and guidance, and an old policy can matter later if you need to show what staff were told at the time.

The last step is the one most often skipped. When a policy changes, the people who follow it need to hear what changed, in a handover or a team meeting, not by finding a new date on the front page.

When is this not the answer?

If staff are not following a good policy because there are not enough of them on shift, a rewrite will not help. That is a staffing question, and it needs a staffing answer.

If the question underneath your policy is a legal one, such as an employment dispute or a data protection breach, take advice from a solicitor or the right specialist body. A consultant can help you write the procedure, not settle the legal point.

And if your policies already name your own service, your staff can explain them and each one has an owner and a review date, you may not need to change much at all. A light check against current guidance once a year may be enough.

Where should I start?

Pick the policy your team uses most. Medicines is usually a good choice, because the Regulation 12 guidance lists exactly what it should cover. Ask two carers on different shifts to explain how it works, then read it against that list. Rewrite the parts nobody could explain.

If you would like help, my policy and procedure development work turns the regulations into policies and procedures that describe your service and that your team can follow on shift. My post on why audits never seem to change anything covers the governance loop your policies sit inside. When you are ready, book some time with me and we can look at one of your policies together.