Every policy, in one document

1. Purpose

ExcelCare Agency exists to help adults live safely and well in their own homes. Because our staff work alone in people's houses, often with people who are frail, unwell or socially isolated, we carry a heightened duty to notice harm and act on it immediately.

This policy sets out how we prevent, recognise, report and respond to the abuse, neglect and exploitation of adults at risk. It applies to every person working for or on behalf of ExcelCare Agency, including contracted staff, bank and relief workers, volunteers, students and directors.

2. Legal and regulatory framework

• Care Act 2014, sections 42–47 (safeguarding adults)
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13
• Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards
• Human Rights Act 1998, in particular Articles 2, 3 and 8
• Domestic Abuse Act 2021
• Sexual Offences Act 2003 and Protection of Freedoms Act 2012
• Data Protection Act 2018 and the UK GDPR
• CQC Guidance for providers on meeting the regulations

3. The six safeguarding principles

All decisions and actions under this policy are guided by the Care Act principles: empowerment, prevention, proportionality, protection, partnership and accountability. The person's own views must be sought and recorded, unless doing so would place them at greater risk.

4. Definitions

An adult at risk is a person aged 18 or over who has needs for care and support, is experiencing or at risk of abuse or neglect, and as a result of those needs is unable to protect themselves.

Abuse is any single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm. Categories include:

• physical, including restraint or inappropriate moving and handling
• psychological, including threats, humiliation and coercive control
• financial and material, including theft, fraud and misuse of benefits
• sexual, including any non-consensual act
• neglect and acts of omission, including missed calls and untreated pressure damage
• organisational, including poor practice and unsafe systems
• discriminatory abuse based on a protected characteristic
• domestic abuse, including so-called honour-based abuse
• modern slavery and human trafficking
• self-neglect, where the person is unable to care for their own wellbeing

5. Roles and responsibilities

Registered Manager — Designated Safeguarding Lead

• Acts as the single point of contact for all safeguarding concerns.
• Decides whether a referral meets the local authority threshold and makes it within 24 hours.
• Notifies CQC without delay of any allegation of abuse, and informs the local authority and, where relevant, the police.
• Ensures safeguarding is discussed at every supervision and team meeting.
• Reports all concerns and outcomes to the Board quarterly.

All staff

• Take immediate action to make a person safe, calling 999 where there is an immediate risk to life.
• Report any concern, suspicion or allegation — including concerns about a colleague — to the Designated Safeguarding Lead the same working day.
• Record what was seen and heard factually, using the person's own words where possible.
• Never investigate, confront an alleged abuser, or promise confidentiality.

Critical rule: staff must report, not investigate. Questioning the person in detail, contacting the alleged abuser or collecting evidence can compromise a criminal investigation and increase risk.

6. Responding to a concern — procedure

1. Make safe. Ensure the person's immediate safety; call emergency services if there is a risk to life.
2. Listen and reassure. Listen without judgement, do not lead the conversation, and record the person's exact words.
3. Record. Complete a Safeguarding Concern Record the same day, describing facts rather than opinion, and sign and date it.
4. Report. Contact the Designated Safeguarding Lead by telephone the same working day. If they are unavailable, escalate to a director.
5. Refer. The Designated Safeguarding Lead refers to the local authority safeguarding adults team within 24 hours, and to the police where a crime may have been committed.
6. Notify. CQC is notified without delay in line with Regulation 18, and the local authority commissioning team is informed.
7. Support. Offer the person an independent advocate where they would have substantial difficulty being involved, and continue care only where it is safe to do so.
8. Learn. Every concern is reviewed to identify changes to practice, training or the care plan.

7. Prevention

• Person-centred care plans that identify known risks and the person's own protective factors.
• Robust recruitment, including enhanced DBS checks and two references before a start date.
• Mandatory safeguarding training at induction and every year, in line with the Oliver McGowan code of practice.
• A culture in which staff can raise concerns without fear, supported by our Whistleblowing Policy.
• Prompt review of missed calls, late visits and unexplained changes in a person's presentation.

8. Working with other agencies

We work in partnership with local authority safeguarding teams, community nursing, GPs, the police, ambulance services, housing providers and the local authority Deprivation of Liberty Safeguards team. Information is shared on a need-to-know basis under the Data Protection Act 2018 safeguarding exemption.

9. Monitoring and review

Safeguarding data — number of concerns, referrals, outcomes and themes — is reported to the Board quarterly and reviewed at monthly management meetings. This policy is reviewed annually, and immediately following any serious incident, safeguarding adult review or relevant change in legislation.

1. Purpose and scope

This policy governs all support we provide with medicines to people in their own homes. It covers ordering, receipt, storage, administration, prompting, recording, disposal, audit and the management of errors. It applies to all care staff, senior carers, office staff and managers, whether permanent, bank or agency.

Support with medicines is delivered only where it is specified in the person's care plan and has been assessed as safe, following the principles in NICE guideline SC1 (Managing medicines for adults receiving social care in the community).

ExcelCare Agency is registered to provide personal care without nursing. We do not employ nurses and do not deliver clinical treatment. Any clinical task is carried out only where it has been delegated by a community nurse under a written plan, and only by a member of staff assessed as competent for that specific task.

2. Levels of support

• Prompting — reminding a person to take their medicine, without handling it.
• Assisting — opening containers or selecting the correct dose for the person to take themselves.
• Administering — a trained, assessed member of staff gives the medicine, including applying creams, eye drops or patches.
• Specialist techniques — for example PEG feeds, insulin or oxygen, delivered only by staff with documented competency and, where relevant, a clinical delegation from a district nurse.

Where a person lacks capacity to consent to treatment, staff follow the Mental Capacity Act 2005 and our Mental Capacity & Consent Policy.

3. Accountability and training

The Registered Manager is accountable for the safe management of medicines across the service. A named Clinical Lead provides oversight of complex medicines.

Staff may only support medicines after completing medicines training, passing a written assessment and a practical competency observation. Competency is re-assessed annually and whenever a concern arises. Records are held on each staff member's training matrix.

4. Ordering, receipt and storage

1. Repeat prescriptions are ordered at least seven days before the current supply runs out, using the route agreed in the care plan.
2. Medicines are checked on receipt against the prescription, quantity and expiry date, and any discrepancy is reported to the pharmacy and the Registered Manager the same day.
3. Medicines are stored in the original container, in a cool, dry place out of reach, and in a locked cupboard where one is provided or where children or others may be at risk.
4. Medicines requiring refrigeration are kept between 2°C and 8°C with a daily temperature record.
5. Controlled drugs are stored in a locked, fixed receptacle where the person has agreed to one, and are counted at every visit.

5. Administration

Before administering, staff must follow the rights of administration: right person, right medicine, right dose, right route, right time, and right to refuse. Staff must also check the expiry date and read the label in full.

• Staff wear gloves and follow hand hygiene before and after administration.
• Medicines are never decanted or transferred between containers, and tablets are not crushed unless a pharmacist has confirmed that it is safe to do so.
• If a person refuses a medicine, this is respected and recorded, the visit is not prolonged to persuade them, and the refusal is reported to the prescriber and the family or advocate where agreed.
• Where a PRN (as required) medicine is given, the reason, dose and effect are recorded.
• Medicines are never left unattended at the point of administration.

Never administer a medicine that has been prepared by anyone other than the person or the pharmacy, that is unlabelled, or that has been altered from its original form.

6. Recording

Every visit involving medicines is recorded in the electronic medication administration record (MAR) or equivalent at the point of administration — never retrospectively. Records must show the medicine, dose, time, outcome, and the initials of the member of staff. Refusals include the reason stated by the person where they give one.

The paper MAR, if used, is written in black ink, signed in full and corrected with a single line and signature. Correction fluid is never used.

7. Disposal

Unused or out-of-date medicines are returned to a pharmacy, ideally with the person or their representative present, and a record of disposal is kept. Controlled drugs are destroyed only with an independent witness. Staff never dispose of medicines in household waste or the sink.

8. Errors, near misses and adverse reactions

1. Make the person safe and, if there is any risk, telephone 111 or 999 and call the GP.
2. Inform the person, and their family or advocate where appropriate, immediately.
3. Report the incident to the Registered Manager the same day.
4. Contact the prescriber for advice where a dose was missed, doubled or given late.
5. Record the incident on the incident management system within 24 hours.
6. Where an incident causes, or could cause, serious harm or death, notify CQC under Regulation 18 and consider whether the Duty of Candour applies.
7. Investigate at root cause, agree learning and update the care plan and training where needed.

9. Audit and monitoring

• Monthly medication audits sample records for completeness, time accuracy and signatures.
• Controlled drug balances are checked monthly and at every visit.
• Any person transferring between services has their medicines reconciled before the first visit.
• Audit findings are reported to the Board quarterly and discussed at team meetings.

10. Clinical and professional boundaries

Staff do not alter prescriptions, do not add medicines to a blister pack themselves, and do not advise on treatment. Clinical questions are referred to the GP, pharmacist or district nurse.

1. Statement of intent

ExcelCare Agency accepts its responsibility under the Health and Safety at Work etc. Act 1974 to ensure, so far as is reasonably practicable, the health, safety and welfare of all employees, the people we support, visitors and anyone else affected by our work.

Because we deliver care in the homes of others, we manage risk in spaces we do not own. That makes assessment, reporting and the right to refuse unsafe work especially important.

2. Responsibilities

Directors

• Provide a written safety statement, adequate financial and physical resources, and competent advice.
• Review health and safety performance at every Board meeting.

Registered Manager

• Implements this policy, maintains the risk assessment suite and the accident record.
• Ensures all staff complete mandatory health and safety, fire and manual handling training at induction and annually.
• Investigates every accident and incident and reports to the Board quarterly.

All staff

• Follow safe systems of work, report hazards immediately and never attempt a task they have not been trained or assessed for.
• Report accidents, near misses and equipment faults the same day, including when nothing was damaged.
• Are responsible for their own safety and for stopping work if a situation becomes unsafe.

3. Lone working

• Each visit is scheduled with an expected start time, duration and call length in the rostering system. A missed check-in triggers an automatic monitoring alert.
• Staff carry a charged mobile phone and share their location for the duration of the visit.
• Where a risk assessment identifies risk of violence or aggression, staff do not visit alone and a joint visit is arranged.
• Staff are instructed to leave immediately and call the emergency services if they feel unsafe, then inform the office.
• A daily welfare call-back is made to any lone worker who cannot be contacted.

4. Manual handling and moving and assisting

• Moving and assisting is assessed for every person at the start of their care, using the safer manual handling assessment record held in the care file.
• Hoists, slide sheets and standing aids are checked before each use and subject to a formal inspection every six months by a competent person.
• Staff perform no lift that is not documented in the care plan, and two carers are used wherever the assessment requires it.
• Any change in a person's mobility triggers an immediate reassessment of the moving and assisting plan.

5. Risk assessment

• A home and environmental risk assessment is completed at the first visit and reviewed annually, after any incident and when the person's needs change.
• Assessments record hazards including flooring, stairs, pets, smoking, hoarding, temperature, infection risk and the availability of running water and electricity.
• Identified controls are agreed with the person wherever possible; where residual risk remains unacceptable, the Registered Manager decides whether care can safely continue and records the reasoning.

6. Display screen and office safety

Office and home-working staff complete a workstation self-assessment and are offered a further assessment where they report discomfort. Workstations are adjusted to suit the individual.

7. Electricity, gas and equipment

• Portable electrical equipment is visually checked by staff before use and formally inspected and tested in line with our maintenance schedule.
• Any equipment belonging to a person that we use is checked with their consent and recorded; defective equipment is withdrawn from use, labelled and reported.
• Staff do not use equipment that shows damage to plugs, leads or casing, and do not use extension leads as a permanent solution.

8. Fire safety in people's homes

• Fire risks, escape routes and smoke alarm presence are recorded in the care plan.
• Where a person has a fire risk assessment from the fire service, the relevant control measures are reflected in their care plan.
• Staff do not smoke in a person's home or on duty, and follow our smoke-free working guidance.

9. First aid and accident reporting

• Every care worker holds a current emergency first aid certificate appropriate to their role.
• Accidents, incidents and near misses are recorded on the incident reporting system before the end of the shift. The Registered Manager reviews all reports within 24 hours.
• Under RIDDOR 2013, injuries, occupational diseases, dangerous occurrences and specified incidents are reported to the Health and Safety Executive within 15 days, and deaths or specified injuries without delay.
• Where a person we support is injured, we also notify their family, commissioner and, where required, CQC under Regulation 18.

10. Violence, aggression and challenging behaviour

• Triggers and early warning signs are recorded in the care plan, along with de-escalation approaches that work for that person.
• Staff are trained in breakaway techniques and receive post-incident debrief and supervision after any incident.
• Following any assault on a member of staff, an incident report is completed, the police are informed where appropriate and occupational health support is offered.

11. Monitoring and review

Accident trends, near misses, equipment inspections and training compliance are reviewed monthly by the management team and reported quarterly to the Board. This policy is reviewed annually, or sooner following a notifiable incident or legislative change.

1. Purpose

This policy sets out how ExcelCare Agency prevents and controls infection in the homes of the people we support and in our office. It reflects the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, and the NICE guidance on healthcare-associated infections.

The risk in domiciliary care is real: staff move between several homes each day, sometimes supporting people who are unwell or immunosuppressed. Hand hygiene, personal protective equipment and careful sequencing of visits are our principal defences.

2. Responsibilities

• Registered Manager — owns this policy, acts as Infection Control Lead, investigates outbreaks and reports notifiable diseases to UKHSA as required.
• Senior carers — observe practice, audit hand hygiene and PPE use, and act on gaps immediately.
• All staff — apply standard precautions at every visit, report illness and follow exclusion guidance.

3. Standard precautions

Standard precautions apply to every person we support regardless of diagnosis:

• hand hygiene before and after every episode of care, and after contact with surfaces
• assessment of infection risk at each visit
• appropriate personal protective equipment for the task
• safe handling and disposal of sharps and clinical waste
• cleaning of equipment and shared surfaces between people
• safe management of linen and laundry
• safe handling of body fluids and spillages

4. Hand hygiene

Hands are washed with liquid soap and warm running water, or cleaned with alcohol-based hand rub where hands are visibly clean. The correct technique is applied for at least 20 seconds. Hands are cleaned:

1. on arrival and before leaving a person's home
2. before and after preparing food, medicines or a drink
3. before and after applying or removing PPE
4. after using the toilet or helping someone to use it
5. after contact with body fluids, laundry or waste
6. after touching pets, bins or shared equipment

Staff with skin conditions that make hand washing difficult are referred to the Registered Manager for advice and, where needed, occupational health support.

5. Personal protective equipment

PPE is provided free of charge to all staff, including bank and agency workers.

• Gloves — for contact with body fluids, non-intact skin, invasive procedures, medicines and waste. Gloves are not a substitute for hand hygiene and are never worn from one person to another.
• Aprons — for tasks where clothing may be contaminated.
• Fluid-resistant masks and eye protection — where splashing or aerosol generation is possible, in line with the care plan.
• Aprons and gloves are put on immediately before a task and removed afterwards by the correct doffing sequence, then disposed of as clinical waste.

Where a person's care plan requires respiratory protection, staff are fit-tested and trained.

6. Cleaning and equipment

• Shared equipment such as blood pressure monitors, hoists and commodes is cleaned and decontaminated between people.
• Staff never carry linen or reusable equipment between two homes without decontamination.
• Cleaning agents are used at the correct dilution according to the manufacturer's instructions, following COSHH principles and with appropriate gloves.
• Single-use items are never reused.

7. Spillages and sharps

• Body fluid spillages in the home are cleared using the correct spill kit and solution after removing obvious matter with disposable paper rolls.
• Sharps boxes are never overfilled, are closed by the lid mechanism only, and are placed in the person's home or returned to a pharmacy as agreed.
• Needlestick or sharps injuries are attended to immediately, reported as an incident and reported to the Registered Manager, who arranges appropriate clinical follow-up.

8. Waste and laundry

• Clinical waste such as dressings, gloves and incontinence pads is handled as per the local authority's collection arrangements for the person's home.
• Non-clinical waste is placed in household waste and is never left in communal areas without permission.
• Soiled linen is handled with gloved hands and never shaken or placed on the floor. Where the family has agreed to it, staff may launder in a dedicated load at 60°C or above.

9. Incontinence and catheter care

Pads and disposable continence products are changed promptly, skin is cleaned in a front-to-back motion and dried thoroughly. Staff supporting catheters follow the district nurse's documented plan, maintain a closed system and report any change in urine, temperature or pain immediately.

10. Staff health and exclusion

Staff must not work if they have vomiting or diarrhoea; they must be clear of symptoms for at least 48 hours before returning to work. Staff must report certain infections, including norovirus, influenza, chickenpox, shingles, measles and mumps, before attending work. The Registered Manager provides specific return-to-work advice in each case.

11. Outbreaks and notifiable diseases

1. On suspicion of an outbreak (for example, two or more linked cases of vomiting or diarrhoea), the Registered Manager is informed immediately.
2. The person's GP and community infection team are contacted, and care plans are reviewed.
3. The Registered Manager notifies UKHSA of any notifiable disease, and CQC where the outbreak affects the safe delivery of care.
4. Staff movement between affected and unaffected homes is restricted where necessary, and dedicated staff are allocated where possible.
5. The outbreak is reviewed at closure, with learning shared across the team.

12. Audit and training

• Hand hygiene audits at observation and PPE spot checks are completed quarterly by senior staff.
• All staff complete infection prevention and control training at induction and annually.
• The office maintains a hand washing facility and a cleaning schedule with signed records.
• Audit results are reported to the Board quarterly.

1. Purpose and principles

ExcelCare Agency recruits people who are compassionate, reliable and safe to work with vulnerable adults. This policy sets out a consistent, lawful and fully documented process that meets our obligations under Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Recruitment is conducted on the basis of merit, against the requirements of the role. We actively welcome applicants from all backgrounds and apply the Equality Act 2010 throughout, including reasonable adjustments at every stage.

2. Safer recruitment

All roles with regulated activity are treated as within scope of safeguarding. The Registered Manager has completed safer recruitment training and is directly involved in every appointment.

No person starts work in a care role until all pre-employment checks are complete and recorded on the person's file.

3. The recruitment process

1. Job description and person specification are agreed before advertising, and reviewed for language that discourages diverse applicants.
2. Advertising appears on recognised channels, states the rate of pay, hours and requirement for an enhanced DBS check, and invites requests for reasonable adjustments.
3. Shortlisting is carried out by two people against the person specification, with reasons recorded.
4. Interview uses a standard question set based on values and safeguarding scenarios, with notes retained. Where a second interviewer is used, scores are collated.
5. Conditional offer is made subject to satisfactory pre-employment checks.
6. Pre-employment checks are completed and recorded before a start date is confirmed.
7. Induction follows our Staff Training & Development Policy, including a period of shadowing.
8. Probation review takes place at three months and six months with a written record.

4. Pre-employment checks

A DBS disclosure is considered in context: a criminal record does not automatically exclude an applicant, but any decision must be recorded with reasons. Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, we are entitled to ask about spent convictions for these roles.

References are verified as genuine where there is any doubt. Verbal references are taken and then confirmed in writing. References that are vague, evasive or raise concerns are explored with the referee before any decision.

5. Interview and assessment practice

• Values-based questions ask about real situations: dignity, raising concerns, and responding to a safeguarding concern.
• A short written exercise tests comprehension of a care plan and the ability to write factual notes.
• Applicants are asked directly about any safeguarding concerns in their career.
• All discussions relate to the requirements of the role; no question touches age, disability, gender reassignment, marriage status, pregnancy, race, religion, sex or sexual orientation.

6. Shadowing and competency sign-off

Before caring for a person unsupervised, every new carer completes:

1. Induction training covering safeguarding, medicines, moving and assisting, infection control and record keeping.
2. A minimum of three shadowed visits, delivered by a senior carer using the shadowing record.
3. A practical assessment of moving and assisting and, where the role requires it, medicines competence.
4. A signed competency statement by the shadowing senior carer and the Registered Manager.

7. Records

The personnel file for every worker contains the application, job description, interview notes, all pre-employment checks, the contract, induction and training records, supervision and appraisals. Records are retained for the statutory period after the person leaves and stored in line with our Data Protection & Confidentiality Policy.

8. Bank, agency and contracted staff

Bank workers and contracted agency staff are subject to the same checks before their first shift. Agency staff are only engaged from providers on our approved list, and we verify evidence of their DBS, references and training before the first visit.

9. Volunteers and students

Volunteers and students who support regulated activity are checked and supervised to the same standard as paid staff, and always work alongside an experienced carer.

10. Monitoring

We record and review recruitment data, including application outcomes by protected characteristic where the data is voluntarily supplied, to ensure our process is fair. Turnover, reasons for leaving and probation outcomes are reported to the Board quarterly.

1. Purpose

The quality of our care depends entirely on the competence, confidence and wellbeing of our staff. This policy explains how we train, support and develop everyone who works for ExcelCare Agency, from induction through to senior practice.

It reflects Regulation 18 and Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the training requirements of the Care Certificate and the Oliver McGowan code of practice.

2. The Care Certificate

Every new care worker completes the fifteen standards of the Care Certificate during the first twelve weeks of employment, or holds evidence of an equivalent qualification that is verified by the Training Coordinator:

1. Understand your role
2. Your personal development
3. Duty of care
4. Equality and diversity
5. Work in a person-centred way
6. Communication
7. Privacy and dignity
8. Fluids and nutrition
9. Awareness of mental health, dementia and learning disability
10. Safeguarding adults
11. Safeguarding children
12. Basic life support
13. Health and safety
14. Handling information
15. Infection prevention and control

3. Induction

The induction programme runs for the first two weeks and combines e-learning, face-to-face sessions, shadowing and a probation review. It covers:

• our values, code of conduct and the standards expected
• reporting concerns and the difference between poor practice and abuse
• medicines, moving and assisting, and infection control in the home
• using our systems: rostering, visit records and incident reporting
• the Mental Capacity Act and gaining valid consent
• lone working, personal safety and emergency procedures

Each new worker has a named buddy for their first twelve weeks.

4. Mandatory and refresher training

Training completion is tracked on the training matrix at individual and service level. Compliance below 95% triggers an action plan owned by the Registered Manager and reported to the Board.

5. Competency assessment

Certificates alone do not evidence competence. Competency is assessed in practice by a senior carer or manager, using an observation record, for:

• medicines administration and prompting
• moving and assisting, including hoists
• catheter and stoma care, where delegated by a district nurse
• PEG feed and other delegated clinical tasks
• record writing and reporting of concerns

Where competency is not demonstrated, additional supervised practice and a re-assessment are scheduled before the person works unsupervised.

6. Supervision and appraisal

• Supervision takes place every three months for every worker, delivered by a senior carer or manager. It covers wellbeing, caseload, safeguarding, incidents, learning and any training needs, and is recorded on a signed supervision record.
• Appraisal is completed annually against the Care Certificate standards, the values of the organisation and the objectives set for the year.
• Spot checks observe at least one visit per worker per year, focused on dignity, practice and record quality.
• Debrief is offered after any incident, safeguarding concern or difficult visit.

7. Development and career pathway

We support progression from Support Worker to Senior Carer, Team Leader and management through funded qualifications, including Level 2 and Level 3 Diplomas in Health and Social Care, and the Level 5 Diploma in Leadership and Management for Adult Care for those moving into management.

We also provide:

• specialist training in dementia, end of life care and positive behaviour support
• paid study time and support for functional skills where needed
• a leadership development programme for senior carers
• access to a hardship fund for travel and childcare costs linked to training

8. Apprenticeships and student placements

We offer apprenticeship places and placements to local colleges and universities. Students are supervised at all times by an experienced nurse or senior carer and are never counted in safe staffing numbers.

9. Records and evidence

Training and competency records are held on the personnel file and the training matrix, and are available for inspection. Certificates record the subject, date, duration, provider and the learner's name. Records are retained for the statutory period and in line with our Data Protection & Confidentiality Policy.

10. Monitoring and review

Training compliance, supervision completion, spot check findings and appraisals are reviewed monthly by the management team and reported quarterly to the Board. Where a gap affects the safety of the service, action is taken immediately and the risk is recorded.

1. Our approach

ExcelCare Agency provides personal care without nursing to adults in their own homes. When someone we support, a family member, an advocate or a professional is unhappy with our service, we want to hear about it early. A complaint is information: it shows us where care is falling short and gives us the chance to put it right.

No one will be treated less favourably, or have their care reduced, because they have made a complaint. Staff who raise a concern on a person's behalf are supported, not criticised.

2. What counts as a complaint

A complaint is any expression of dissatisfaction about our service, whether made verbally, in writing, by telephone, by email, through a survey or by a third party. It may concern:

• the quality or timing of care
• the conduct, attitude or competence of a member of staff
• a missed or shortened visit
• medicines support, record keeping or communication
• the way a safeguarding concern or an incident was handled
• discrimination, dignity or privacy
• billing and administration

A concern raised and resolved on the spot is recorded as a comment, but is still logged so that themes can be identified.

3. How to complain

A complaint can be made directly to any member of staff or to the office. Where a person needs help to express their complaint, we will arrange an independent advocate or communicate in their preferred format and language.

ExcelCare Agency · Telephone 0333 090 3885 · excelcareagency.com

There is no time limit for raising a complaint with us, although we may be unable to investigate events from several years ago where records are no longer held.

4. Timescales

Where an investigation will take longer, we write to explain why and give a revised date. We do not extend beyond 28 days more than once without the complainant's agreement.

5. Investigation

1. The Complaints Lead records the complaint on the complaints register with a unique reference.
2. The person's records, visit logs, medicines records and staff statements are reviewed.
3. Staff involved are interviewed and asked for a written account.
4. Where the complaint concerns a safeguarding matter, our Adult Safeguarding Policy applies and safeguarding takes precedence over the complaints process.
5. Findings are shared with the complainant in plain language, with a clear explanation of what went wrong, what we have done, and what will change.
6. The complainant is told how to escalate if they remain dissatisfied.

6. Duty of candour

Where a complaint reveals that harm or potential harm has occurred, we apply the Duty of Candour under Regulation 20: we apologise, explain what happened and what we will do, and keep a written record of the discussion. An apology is not an admission of liability.

7. Records and confidentiality

Complaints are recorded on the complaints register and the person's file, held securely and retained for at least six years. Information is shared only with those who need it to investigate, and confidentiality is respected throughout.

8. Learning and improvement

The management team reviews every complaint at its monthly meeting and reports themes, outcomes and actions to the Board quarterly. Learning is shared with the whole team through briefings, supervision and training updates. Where a complaint identifies a gap in a policy or procedure, that document is revised immediately.

9. Other routes

People can also complain to the local authority that funds their care, to their integrated care board, or to the Local Government and Social Care Ombudsman, which is free and independent. Complaints involving a possible crime can be reported to the police, and concerns about our registration can be raised with the Care Quality Commission.

10. Monitoring

We monitor the number of complaints, the proportion upheld, response times and repeat themes. A rising trend, or a single serious complaint, triggers a review of the relevant policy and staff training.

1. Purpose

This plan sets out how ExcelCare Agency will maintain essential care and meet the needs of the people we support during a disruption. Because our service is delivered in people's homes by individual carers, a lost rota, a snowstorm or a single unplanned absence can put a person at risk within hours.

The plan applies to every part of the service, including out-of-hours arrangements.

2. Critical functions and priorities

In any disruption, we protect functions in this order:

1. Life-sustaining and time-critical care — medicines, moving and assisting, continence and pressure care, nutrition and hydration, and anyone assessed as high risk.
2. Safeguarding — identifying and responding to increased risk during the incident.
3. Communication with people we support and their families.
4. Communication with commissioners, the local authority and CQC.
5. Record keeping and evidence of care delivered.
6. Business administration, payroll and invoicing.

3. Identifying the people most at risk

We maintain a live list of people whose care cannot safely be missed, including those who receive:

• insulin or time-critical medicines
• two-carer moving and assisting
• support with eating and drinking
• catheter, stoma or PEG care delegated by a community nurse
• end of life or rapid-response support

This list is reviewed monthly and is available in hard copy in the office and in the emergency grab bag.

4. Types of disruption and response

Staff shortage

• The duty manager contacts all available bank staff, then approved agency partners.
• Visits are reprioritised: critical visits are covered first and non-essential tasks deferred with the person's agreement.
• Senior carers and managers deliver care where needed.
• Where a visit cannot be covered, the person and their family are telephoned immediately and alternatives agreed; the missed visit is recorded and reported.

Severe weather and travel disruption

• Staff are contacted by 6:30am and routes are reallocated to the nearest available worker.
• Vulnerable people receive a welfare telephone call where a visit cannot be made.
• Local resilience forum guidance is followed, and a 4x4 or community volunteer arrangement is used where it is safe to do so.

Loss of premises or utilities

• Where the office is inaccessible, the duty manager operates from home using the emergency contact list and mobile access to the rostering system.
• Where a person's home loses heating, water or power, we contact the utility provider, the local authority and the family, and consider emergency accommodation with the person's consent.

IT, telephony or cyber incident

• Care continues on paper using the printed emergency visit sheets, and records are transcribed into the electronic system once service is restored.
• Data backups are held securely and tested quarterly.
• A suspected cyber incident is reported to the Business Continuity Lead immediately and to the Information Commissioner within 72 hours where personal data is affected.

Loss of key people

• Every critical role has a named deputy with access to the systems and information needed.
• The Registered Manager's responsibilities transfer to the nominated deputy, who informs CQC of any change in management.

Pandemic or infectious disease outbreak

Our Infection Prevention & Control Policy applies, with staffing contingency for higher absence and cohorting of visits to affected homes.

5. Activation and command

The Business Continuity Lead declares an activation when a disruption is likely to affect care for more than four hours. The Lead:

1. opens the incident log and records decisions with times
2. activates the call tree within one hour
3. briefs the Board and, where relevant, the local authority and commissioners
4. notifies CQC under Regulation 18 where the incident affects the safe delivery of care
5. stands the plan down formally and chairs a debrief within ten working days

6. Communication

• Internal: a WhatsApp-free cascade using the staff call tree, plus a recorded message on the office line.
• People we support and families: telephone calls to those affected, prioritising the at-risk list.
• External: local authority adult social care emergency duty team, commissioners, CQC, and utility or emergency services as needed.

7. Emergency resources

The office holds an emergency grab bag containing printed rotas, the at-risk client list, contact details for all staff and people supported, paper visit record forms, torches, a charged power bank, first aid supplies and spare PPE. Contents are checked quarterly and after every use.

8. Recovery

Normal service resumes when critical functions are stable. The Lead confirms that all deferred visits are rescheduled, records are complete, the at-risk list is current and any missed care has been reported and followed up.

9. Testing and review

• A tabletop exercise is run annually, involving the management team and a sample of senior carers.
• The plan is reviewed after every activation and annually by the Board.
• Contact details are verified every three months.

1. Purpose and scope

ExcelCare Agency holds some of the most sensitive information there is: health conditions, medication, personal care needs, family circumstances, and sometimes safeguarding and financial details. This policy explains how we collect, use, store, share and delete that information lawfully and respectfully.

It applies to all staff, bank workers, volunteers, students, contractors and directors, and to every format — paper, electronic, email, text message, photograph and verbal conversation.

2. Lawful basis

We process personal data as a data controller under the UK GDPR and the Data Protection Act 2018.

• Personal data is processed on the basis of contract and legal obligation, and where necessary our legitimate interests in delivering safe care.
• Special category data (health, ethnicity, religion, sexual orientation) is processed under Article 9(2)(h) — the provision of health and social care — and Article 9(2)(g) where safeguarding duties apply.
• Criminal offence data is processed only where the law permits, for example in safeguarding.

We do not rely on consent for the delivery of care itself, because care must not be conditional on it. Consent is used for optional things such as photographs, newsletters and marketing.

3. The principles we apply

1. Lawfulness, fairness and transparency — people are told what we hold and why, in a privacy notice given at the start of care.
2. Purpose limitation — information is used for care, safety, safeguarding and legal duties, not for anything else.
3. Data minimisation — we record what is needed to deliver safe care and nothing more.
4. Accuracy — records are factual, dated, signed and corrected properly; opinion is labelled as opinion.
5. Storage limitation — records are kept only for the periods set out below.
6. Integrity and confidentiality — access is controlled, devices are encrypted and paper is locked away.
7. Accountability — the Data Protection Lead maintains the record of processing and handles requests and breaches.

4. Confidentiality in practice

• Conversations about a person take place out of earshot of others, including in shared corridors, lifts and waiting rooms.
• Care records are never left in view in a person's home, in a car or on a printer.
• Staff never discuss people we support on social media, in group chats, or with their own family and friends.
• Photographs are taken only with explicit consent, on agency devices, and are never stored on personal phones.
• Staff use only their own named accounts and never share passwords or log-ins.

5. Sharing information

Information is shared with other professionals — GPs, district nurses, hospitals, the local authority, ambulance crews — on a need-to-know basis, applying the Caldicott principles.

Where there is a safeguarding concern, we share information without consent where necessary to protect an adult at risk, relying on the safeguarding exemption in the Data Protection Act 2018. We record what was shared, with whom, and why.

Where a person lacks capacity to decide about sharing, we act in their best interests under the Mental Capacity Act 2005.

6. Subject access and other rights

People we support, or their authorised representatives, can ask to see their records or ask for information to be corrected or erased.

• Requests may be made verbally or in writing to any member of staff and must reach the Data Protection Lead the same working day.
• We respond within one calendar month, free of charge, and may extend by two months for complex requests, telling the requester why.
• Where a request involves another person's information, or would cause serious harm, limited information may be withheld and the reason explained.
• Records are not altered or deleted to avoid a request.

7. Retention

Records are securely destroyed at the end of the retention period, and destruction is logged.

8. Data breaches

A breach is any loss, theft, unauthorised access, disclosure or accidental destruction of personal data — including a lost phone, a misdirected email or a lost paper visit sheet.

1. Contain the breach immediately and inform the Data Protection Lead without delay.
2. Record it on the breach log with what happened, what data was involved and who was affected.
3. Assess the risk to those affected, and inform them where the risk is high.
4. Report to the Information Commissioner's Office within 72 hours where the breach is likely to result in a risk to people's rights and freedoms.
5. Notify CQC where the breach affects the safe delivery of care.
6. Review the cause and change practice, training or systems accordingly.

9. Information security

• Mobile devices used for rostering and records are provided by the agency, encrypted and PIN or biometric protected.
• Systems use multi-factor authentication where available.
• Access rights are role-based and removed within 24 hours of a person leaving.
• Paper records in the office are stored in locked cabinets; the office is alarmed.
• Data is backed up daily and the restore process is tested quarterly.

10. Roles, training and review

The Registered Manager is the Data Protection Lead and the point of contact for the Information Commissioner's Office. All staff complete data protection training at induction and annually, and receive a briefing after any breach. This policy is reviewed annually and when the law or our systems change.

1. Statement of commitment

ExcelCare Agency is committed to equality of opportunity and to delivering care that respects each person's identity, culture, faith, relationships and preferences. We support older adults, people living with dementia, adults with a learning disability or autism, people with physical disabilities, sensory loss and mental health needs — and we recognise that each person's needs are shaped by who they are, not only by their diagnosis.

We will not discriminate on the grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, or sexual orientation.

2. Our legal duties

• Equality Act 2010 — the public sector equality duty where we deliver services on behalf of a public body, and the prohibition on discrimination, harassment and victimisation throughout employment and service delivery.
• Human Rights Act 1998 — in particular the right to private and family life, freedom of thought, conscience and religion, and freedom from inhuman or degrading treatment.
• Accessible Information Standard — identifying and meeting people's communication needs and recording them.
• Care Act 2014 — the wellbeing principle and the duty to have regard to the person's individual circumstances.

3. Delivery of care

Care is planned around the person, not the service. At assessment and at every review we ask about and record:

• preferred name, pronouns and how the person wishes to be addressed
• language, communication needs and any need for an interpreter, British Sign Language or easy-read information
• faith, cultural practice, diet, dress and personal care preferences, including same-gender care requests
• sexual orientation and gender identity, where the person wishes to share it, and how their privacy is protected
• family, relationships and who they wish to be involved
• any support needed to access the community, advocacy or religious observance

These preferences are written into the care plan and respected by every member of staff. Where a request cannot be met, we explain why, record the discussion and offer an alternative.

Reasonable adjustments are made proactively: larger print, hearing loops, extra time on visits, dementia-friendly communication and consistent, familiar carers where this supports the person's wellbeing.

4. Equality in employment

• Recruitment, promotion, training and pay decisions are based on merit and the requirements of the role.
• Job adverts are placed where they will reach a diverse audience, and shortlisting is carried out by two people against the person specification.
• Interview questions never touch a protected characteristic, and reasonable adjustments are offered at every stage, including alternative formats and times.
• Flexible working requests are considered fairly and only refused for a clear business reason, recorded in writing.
• Pay is set by role and experience, with no differential by sex or any other protected characteristic.

5. Harassment, bullying and victimisation

We have zero tolerance of harassment, bullying, discrimination or victimisation by staff, people we support, their families or visitors.

• Staff who experience or witness it should report it to their manager, or to a director where the manager is involved.
• Reports are investigated promptly and confidentially under our disciplinary and grievance procedures, with support offered to the person raising the concern.
• Any discriminatory behaviour by someone we support is addressed as part of behaviour support planning, while recognising the person's capacity and needs.

6. Accessibility of our own information

Our policies and public information are written in plain English, available digitally, and provided in alternative formats — large print, easy-read, audio and translated — on request. Our website aims to meet WCAG 2.2 AA accessibility standards.

7. Monitoring

We collect equality monitoring data voluntarily at recruitment and use aggregated, anonymised data to check that our processes are fair. We publish an annual summary of our workforce profile, our EDI objectives and progress against them. Care quality data is reviewed by protected characteristic to ensure no group receives a poorer experience.

8. Roles and training

The Registered Manager holds EDI lead responsibility. All staff complete EDI training at induction and annually, along with dementia, learning disability and autism awareness training that reflects the Oliver McGowan code of practice. Managers receive additional training on handling complaints and grievances that involve discrimination.

9. Review

This policy is reviewed annually, and immediately following any discrimination complaint, employment tribunal or change in legislation.

1. Why this policy exists

The people we support cannot always speak for themselves. Staff are often the only people who can see unsafe practice, and the first to spot that something is wrong. This policy exists so that raising a concern is straightforward, safe and effective, and so that nobody is punished for doing the right thing.

It applies to all staff, bank and agency workers, volunteers, students and contractors.

2. What can be raised

• abuse, neglect or poor practice towards a person we support
• unsafe medicines practice, missed visits or falsified records
• staff working outside their competence or without necessary training
• inadequate staffing that puts people at risk
• bullying, harassment or discrimination
• unsafe equipment, premises or lone working arrangements
• a manager or colleague concealing a mistake
• a breach of data protection, or of this policy set
• any concern that the service is breaking the law or a regulatory requirement

3. Protection for the person raising a concern

A protected disclosure under the Public Interest Disclosure Act 1998 gives legal protection where a worker reasonably believes there is wrongdoing and raises it through an appropriate route. Under this policy, any concern raised in good faith — even if it turns out to be mistaken — will not result in dismissal, disciplinary action, loss of shifts, demotion, harassment or any other detriment.

Concerns may be raised anonymously. Anonymous concerns are investigated, although the investigation may be more limited.

4. How to raise a concern

You can raise a concern in whichever way you feel able:

1. Your line manager or senior carer — for most day-to-day concerns.
2. The Registered Manager — where the concern involves your manager, or is serious.
3. A director of the company — where the concern involves the Registered Manager or a director.
4. The Freedom to Speak Up Guardian — an independent person nominated by the Board who is not part of the management line. Contact details are displayed in the office and in the staff handbook.
5. CQC, the local authority safeguarding team, the Health and Safety Executive, the police or the Information Commissioner — at any time, where you believe the concern has not been addressed, or where it is so serious that external reporting is appropriate. Whistleblowing to a prescribed person in these circumstances is protected by law, and you do not have to tell us first.
6. Protect — the independent whistleblowing charity, offers free confidential advice on 020 3117 2520.

5. What happens next

1. The person receiving the concern records it in writing within 24 hours, with dates, times, people involved and any evidence.
2. Acknowledged to the person raising it within two working days, with the name of whoever is handling it.
3. An investigation is carried out proportionate to the seriousness, by someone not implicated in the concern, with a written record.
4. The person raising the concern is updated on the outcome and the action taken, subject to confidentiality and, where relevant, a police investigation.
5. Where the concern involves the safety of a person we support, our Adult Safeguarding Policy applies immediately and CQC is notified under Regulation 18 where required.

6. Serious incidents

Where a concern suggests a person has suffered serious harm, the Duty of Candour applies: we will be open with the person and their family, apologise, explain what happened and say what we are doing about it.

7. Records and confidentiality

Concerns are logged on a confidential register held by the Freedom to Speak Up Guardian, with only aggregated themes shared with the Board. Identity is disclosed only where necessary for the investigation or required by law.

8. Culture and learning

The Board reviews all concerns quarterly. We monitor whether staff feel confident to speak up through the annual staff survey, and we report numbers, themes and outcomes. A decline in concerns being raised is treated as a possible sign of a closed culture, not as an improvement.

Managers are trained to respond to a concern with thanks, not defensiveness, and this expectation is part of every manager's appraisal.

9. Review

This policy is reviewed annually and after any serious incident, and staff are briefed on it at induction and every two years.

1. Purpose

Every day we support people with decisions: whether to get up, what to eat, whether to take a medicine, who comes into their home. This policy sets out how we ensure those decisions are made by the person wherever they can be, and in their best interests only where they cannot.

It applies to all care staff, managers, volunteers and students, and covers every decision made in the delivery of personal care.

2. The five statutory principles

1. A person must be assumed to have capacity unless it is established that they lack it. A diagnosis of dementia, a learning disability or a mental health condition is never, by itself, evidence of lacking capacity.
2. A person must be supported to make their own decision before it is concluded that they cannot. This means time, information in the right format, an interpreter, an advocate, or a familiar face.
3. A person is not to be treated as lacking capacity merely because they make an unwise decision. People are entitled to make choices we would not make for them.
4. Any act done for a person who lacks capacity must be done in their best interests.
5. Before the act is done, consider whether a less restrictive option would achieve the same outcome.

3. The two-stage capacity test

For the specific decision in question:

Stage 1 — Is there an impairment of, or disturbance in the functioning of, the mind or brain? This may be temporary, for example due to infection, delirium, pain, shock or the effects of medication.

Stage 2 — If so, can the person:

• understand the relevant information?
• retain that information long enough to use it?
• use or weigh the information as part of the decision?
• communicate their decision by any means?

If the answer to any of these is no, the person lacks capacity for that decision at that time. The assessment and its reasoning are recorded, along with the date, time and the method used to support the person.

4. Everyday consent

Consent must be informed, voluntary and given by someone with capacity. Staff seek consent at the point of care, not once on a form.

• Explain what you are about to do, in plain language, before you do it.
• Offer choice in how and when care is given.
• Accept refusal. A refusal of a particular task is respected and recorded, and the consequences are discussed with the person, the family and, where relevant, the GP or district nurse.
• Be alert to fluctuating capacity, which is common in infection, delirium and some mental health conditions. Reassess at each visit if needed.

For personal care and medication support, the care plan records the person's expressed wishes, including advance decisions and any Lasting Power of Attorney.

5. Best interests decisions

Where a person lacks capacity, a best interests decision is made using the statutory checklist:

• the person's past and present wishes, feelings, beliefs and values
• any advance statement or advance decision to refuse treatment
• the views of anyone named by the person, carers, family and attorneys
• whether capacity might return (for example after an infection is treated)
• the least restrictive option that meets the need
• the person's age, appearance, condition and behaviour only where genuinely relevant

The decision, who was consulted, the options considered and the reasons are recorded in the care record. Decisions are reviewed as circumstances change.

Staff make everyday best interests decisions within their competence. Significant decisions — for example a change of accommodation, a serious medical procedure or the use of restraint — are escalated to the Registered Manager and the relevant professional, with an Independent Mental Capacity Advocate appointed where the law requires one.

6. Deprivation of liberty

A person is deprived of their liberty where they are under continuous supervision and control and are not free to leave. In a person's own home, this can arise through locked doors, constant observation or the removal of a walking aid.

• Any restriction must be the least restrictive option, proportionate, and recorded with its rationale, review date and the name of the decision maker.
• Where a deprivation of liberty may be occurring in a care home or hospital, an authorisation under the Deprivation of Liberty Safeguards must be sought from the supervisory body.
• For people living in their own home, the position remains governed by the Mental Capacity Act and case law while the Liberty Protection Safeguards are implemented; we seek legal and local authority advice in every case and record it.
• Every use of restraint is recorded as an incident, and our Adult Safeguarding Policy applies where restraint is used improperly.

7. Covert medicines

Medicines are never given covertly without a documented best interests decision involving the GP, pharmacy and family, and a recorded plan reviewed at least annually. Our Medication Management Policy applies.

8. Roles and training

The Registered Manager is the MCA Lead, is responsible for the quality of capacity assessments and best interests records, and acts as the point of contact for the local authority MCA team. All staff complete MCA and DoLS training at induction and annually, with refresher case discussions in supervision.

9. Monitoring

A sample of capacity assessments and best interests records is audited quarterly. Restrictive practice is reviewed monthly by the management team and reported to the Board, along with any applications for authorisation and their outcomes.

1. Purpose and principles

ExcelCare Agency provides personal care without nursing to adults in their own homes. Risk cannot be removed from someone's own home, and it should not be: a life with no risk is not a life of quality. Our task is to understand risk, reduce it where that is possible, and support the person to make informed choices about the risk that remains.

Our approach is risk enablement:

• the person is at the centre of every assessment and their views are recorded in their own words
• risk is balanced against independence, dignity and quality of life
• decisions are made with the person, and where they lack capacity, in their best interests under the Mental Capacity Act 2005
• assessments are practical and specific to the individual home and routine

2. Types of risk assessment we hold

3. The five-step method

1. Identify the hazard — what could cause harm, to whom, and when.
2. Decide who might be harmed and how — the person, staff, family, visitors.
3. Evaluate the risk and decide on controls — eliminate, substitute, reduce, or accept with monitoring. Controls must be things we actually do, not aspirations.
4. Record the findings — assessment, date, assessor, person's views, controls, residual rating.
5. Review and update — at the stated review date, after any incident, and whenever the person's needs or home changes.

4. Rating risk

Risk is rated by combining likelihood (1 rare to 5 almost certain) with impact (1 negligible to 5 severe) on a 5x5 matrix.

5. Positive risk taking

Where a person chooses to accept a risk — for example, continuing to smoke at home, declining a walking aid, or refusing a visit at a particular time — we:

1. discuss the risk with them in plain language and record their decision
2. offer alternatives without pressure
3. agree a plan that reduces harm as far as the person will accept
4. record the decision and the person's capacity to make it
5. review the decision regularly

A documented, informed decision is not a failing. An undocumented one is.

6. Dynamic risk assessment

At every visit, staff assess the situation on arrival: has anything changed? Are there new hazards — a fall, a smell of gas, a new pet, a person who is more unwell than usual? Staff have the authority to stop a task, leave a situation and call for advice. A dynamic assessment that changes the plan is recorded and reported to the office the same day.

7. Escalation

Any risk rated high or critical, any new hazard that cannot be controlled within the care plan, and any situation where staff feel unsafe is escalated to the Registered Manager immediately. Where an employer cannot control a risk to staff, the visit is suspended until it can be made safe.

8. Organisational risk register

The Registered Manager maintains a risk register covering strategic and operational risks: staffing capacity, regulatory compliance, information security, finance, safeguarding, and business continuity. Each risk has an owner, a rating, controls, and a review date. The register is reviewed quarterly by the Board and updated after any significant incident.

9. Training and competence

All staff complete risk assessment training at induction and annually, covering the five-step method, dynamic assessment, lone working and the use of the matrix. Competence is observed during shadowing and spot checks.

10. Monitoring

The management team audits a sample of risk assessments monthly for completeness, quality of controls and evidence of the person's involvement. Audit findings, incident trends and register movements are reported to the Board quarterly.

1. Statement

ExcelCare Agency does not tolerate modern slavery or human trafficking in any part of our business or supply chain. Modern slavery includes forced labour, debt bondage, human trafficking, domestic servitude and forced criminality. It is a crime, a serious safeguarding matter and a breach of human rights.

This statement is made under section 54 of the Modern Slavery Act 2015 and is reviewed and signed annually by the Board. Although the agency may fall below the statutory turnover threshold, we publish it voluntarily because our sector carries a real risk.

2. Risk in social care

Domiciliary care carries specific risks:

• a large, dispersed, low-paid workforce with high turnover
• recruitment through informal networks and social media
• overseas recruitment and sponsorship, where workers may be tied to one employer
• contracted cleaning, laundry and transport services
• people we support who are themselves vulnerable to exploitation by family members, "friends" or organised groups

3. Our workforce commitments

• We never charge a worker a fee for recruitment, training, uniform, DBS checks or sponsorship.
• We never retain a worker's passport, visa or other identity documents. Originals are verified and returned immediately, and only copies are retained.
• Every worker has a written contract, in a language they understand, setting out pay, hours, holiday and the right to leave.
• Wages are paid directly into the worker's own bank account, at or above the National Living Wage, with itemised payslips.
• Workers are told, in writing, that they can leave at any time and can raise a concern without fear — through our Whistleblowing Policy or to an external body such as the Modern Slavery Helpline, the Gangmasters and Labour Abuse Authority, or the police.
• We verify right to work in person, and never accept documents that appear to belong to someone else.
• No worker is required to live in accommodation tied to their employment, or to repay accommodation costs from wages without a written agreement.

4. Recruitment and sponsorship checks

For every appointment we verify identity, right to work, qualifications and references, and we interview in person or by video so the applicant can be seen and spoken to directly. Where we sponsor overseas workers, we:

• use a licensed sponsor process and pay all associated costs as required by the Home Office
• ensure the worker understands their rights, their rate of pay and their right to change employer
• never ask a worker to repay sponsorship costs
• monitor for signs of coercion in the first twelve months of employment

5. Supply chain due diligence

• All suppliers complete a labour standards questionnaire before appointment and annually thereafter.
• Contracts require compliance with the Modern Slavery Act, payment of at least the National Living Wage, and the right to audit.
• High-risk categories — cleaning, laundry, transport, IT equipment and uniforms — are reviewed annually with a documented risk rating.
• Any supplier unable or unwilling to evidence compliance is not appointed, or is removed from our list.

6. Recognising exploitation in the people we support

Signs may include:

• another person speaking for them, holding their documents or controlling their money
• unexplained injuries, fear, or reluctance to be alone with staff
• poor living conditions, malnutrition, or being denied access to healthcare
• unpaid work, or being made to care for others in the household
• a "friend" or relative who is unusually present, and who resists private conversation
• signs of debt, threats, or threats against family abroad

Staff never confront a suspected exploiter. They record what they observe and report it to the Registered Manager immediately.

7. Responding to a concern

1. Make the person safe and, where there is an immediate danger, call 999.
2. Report to the Registered Manager the same day, who applies our Adult Safeguarding Policy.
3. Refer the person to the National Referral Mechanism through the Single Competent Authority, with their consent where they have capacity to give it.
4. Notify the local authority safeguarding adults team, and CQC under Regulation 18 where required.
5. Consider immediate protection: a change of care arrangements, an advocate, and support to access healthcare and legal advice.
6. Record all actions, including the referral reference.

Modern Slavery Helpline: 08000 121 700 · Police: 999 (emergency) or 101

8. Training and reporting

All staff, managers and Board members complete modern slavery awareness training at induction and every two years, including how to spot the signs and how to refer. Recruitment and procurement staff receive additional training.

The Board reviews this statement and our supply chain assessment annually, and receives a report on any concerns raised, referrals made and actions taken.

1. Commitment

ExcelCare Agency recognises that the health of the people we support depends on the health of the environment around them. We are committed to reducing our environmental impact, meeting our legal obligations and contributing to the wider ambition of a net zero health and care system.

This policy sets out how we manage that commitment in the practical realities of domiciliary care: a dispersed workforce, many small journeys, and care delivered in other people's homes.

2. Our legal and regulatory obligations

• Environmental Protection Act 1990 — duty of care for waste
• Waste (England and Wales) Regulations 2011 — the waste hierarchy
• Hazardous Waste Regulations 2005 — clinical and infectious waste
• Waste Electrical and Electronic Equipment Regulations 2013
• COSHH Regulations 2002 — safe use and disposal of chemicals
• Climate Change Act 2008 — the national net zero target

3. Energy and water

• Office energy use is metered and read monthly, with the consumption recorded on the environmental dashboard.
• Lighting is LED; equipment is switched off at the end of the day rather than left on standby.
• Heating is set to a maximum of 21°C in occupied areas, and the office is draught-proofed.
• The agency purchases electricity on a renewable tariff and reviews the tariff annually.
• Water use is monitored, and leaks are reported and repaired promptly.

4. Travel and mileage

Travel is our largest source of emissions, because carers move between homes throughout the day.

• Rotas are planned by geography so that each carer works within a defined patch.
• The rostering system flags unnecessary journeys between distant visits.
• Staff are encouraged to walk, cycle or use public transport where the round allows, and we provide a cycle-to-work scheme.
• Electric and hybrid vehicles are preferred for any pool or leased vehicle, and charging is available at the office.
• Lift-sharing is arranged for training and meetings, and meetings default to video where the purpose allows.

5. Waste and single-use plastics

• We apply the waste hierarchy: prevent, reuse, recycle, recover, dispose.
• Single-use gloves and aprons are clinical necessities and are used only where infection control requires them; we avoid unnecessary double-gloving.
• Single-use plastic cups, cutlery, plates and bottles are not purchased for the office.
• Paper use is minimised through digital care records and digital-first communication; where printing is needed, it is double-sided and on recycled stock.
• Ink cartridges, batteries, IT equipment and mobile phones are recycled through a licensed contractor, with a waste transfer note retained.
• Clinical waste in people's homes is managed under our Infection Prevention & Control Policy and the local authority's arrangements.

6. Procurement

• Suppliers are asked about environmental credentials, packaging and take-back schemes before appointment and annually thereafter.
• We prefer concentrated cleaning products, refillable containers and products with recognised environmental certification.
• Local suppliers are preferred where quality and value are equal, reducing delivery miles.
• Uniforms and equipment are repaired before replacement, and surplus equipment is offered to other providers before disposal.

7. Digital sustainability

• Data storage is consolidated with suppliers who publish renewable energy commitments for their data centres.
• Devices are kept in use for their full working life and securely wiped and recycled at end of life.
• We avoid unnecessary storage of duplicate files and large attachments.

8. People and culture

Every member of staff completes environmental awareness as part of induction, covering waste segregation, energy saving and travel choices. Staff are invited to suggest environmental improvements through team meetings, and the Sustainability Lead coordinates an annual improvement plan with named actions and owners.

9. Measurement and reporting

We record, at minimum:

• electricity and gas consumption and cost
• water consumption
• business and commuting mileage
• weight and type of waste, and recycling rate
• the proportion of suppliers who have provided environmental information

Performance is reported to the Board annually and published alongside our Carbon Reduction Plan. Targets are reviewed each year with the aim of year-on-year reduction against our baseline.

10. Review

This policy is reviewed annually by the Sustainability Lead and approved by the Board, and updated whenever legislation or our operations change.

1. Commitment to achieving net zero

ExcelCare Agency is committed to achieving net zero greenhouse gas emissions by 2040 across Scope 1, Scope 2 and the material categories of Scope 3 that we can measure and influence. We have set an interim target of a 50% reduction by 2030 against our 2024/25 baseline.

This plan is prepared in line with the reporting requirements of PPN 06/21 and the GHG Protocol Corporate Standard, so that it can be supplied to commissioners and as part of public sector procurement.

2. Baseline emissions footprint

Reporting period: 1 April 2024 to 31 March 2025. Figures are calculated from energy bills, mileage records, water bills and procurement spend, using UK Government conversion factors for the relevant year.

*Figures are the agency's current best estimate for the baseline year and are recalculated each year as data quality improves. They are reviewed against energy bills, fuel records and mileage reports before publication.*

Excluded from this baseline, and reported separately as data improves: employee homeworking energy, upstream distribution of purchased goods, and the carbon embedded in the homes of the people we support.

3. Emissions reduction targets

4. Carbon reduction projects

Completed

• Moved all care records and rotas to digital systems, eliminating paper visit sheets and postage.
• Installed LED lighting and smart heating controls in the office.
• Switched the office electricity supply to a 100% renewable tariff.
• Introduced geographic rostering, reducing average daily mileage.

Planned

5. Governance and reporting

The Sustainability Lead (a nominated member of the management team) collects data monthly and reports to the Board quarterly. The Board approves this plan annually and signs the published statement. Progress against each target is reported against the baseline, with an explanation of any variance.

Emissions are recalculated and published on the agency website each year alongside the Environmental Sustainability Policy. Where a target is missed, the Board records the reason and an additional action.

6. Offsetting

Offsetting is not used to meet interim targets. It is considered only for genuinely residual emissions after reduction measures, using verified schemes aligned with the UK Woodland or Peatland Carbon Codes, and is reported separately from reduction.

7. Declaration

This Carbon Reduction Plan is approved by the Board of Directors of ExcelCare Agency and is reviewed at least annually.

Signed on behalf of the Board · Registered and providing care in England · Reviewed April 2026

1. Purpose

Quality assurance is how we know — not assume — that care is safe, effective and kind. This policy sets out the systems we use to monitor our own performance, act on what we find, and evidence it to the Care Quality Commission, commissioners and the people we support.

It applies to every part of the service and is owned by the Registered Manager.

2. The governance framework

• Daily — visit completion checks, missed visit escalation, and review of incident reports submitted in the previous 24 hours.
• Weekly — management huddle: staffing, safeguarding, complaints, incidents and any open actions.
• Monthly — management meeting: audit results, key performance indicators, complaints and compliments, training compliance, and progress on the improvement plan.
• Quarterly — Board meeting: quality report, risk register, safeguarding data, workforce data and financial performance.
• Annually — self-assessment against the Single Assessment Framework, mock inspection, review of all policies, and the annual statement published on our website.

3. Audit calendar

4. Key performance indicators

We monitor and set targets for:

• percentage of visits delivered as planned (target 97% or above)
• percentage of calls starting within the agreed window (target 95% or above)
• care plans reviewed within the last 12 months (target 100%)
• medicines errors per 1,000 visits, and the proportion with actions closed
• safeguarding referrals made within 24 hours (target 100%)
• complaints answered within 28 days (target 100%)
• mandatory training compliance (target 95% or above)
• supervision completed every three months (target 100%)
• staff turnover, and vacancy rate
• number of compliments received, and themes

Any indicator outside its target for two consecutive months triggers a written improvement action with an owner and a date.

5. Listening to people

• An annual survey sent to every person we support and, with consent, their family.
• A quarterly telephone check-in with a sample of people and families.
• Comments captured at every review.
• Complaints and compliments analysed for themes, and reported in the quality report.
• A "you said, we did" summary published and shared with staff.

6. Care record and practice assurance

Senior carers complete a minimum of one unannounced spot check per worker per year, observing dignity, respect, communication, infection control, medicines practice and record quality. Findings are discussed in supervision and recorded. Where practice falls short, we act immediately and consider whether the concern meets the safeguarding threshold.

7. Learning from incidents and safeguarding

Every incident, complaint and safeguarding concern is reviewed to identify root cause. Learning is captured on a single action log with owner and due date, and shared with the whole team. We check that actions have actually changed practice at the next audit cycle — completing a form is not the same as fixing a problem.

8. Inspection readiness

We maintain an evidence file mapped to the CQC Single Assessment Framework, containing for each quality statement:

• the policy and procedure relied on
• the records that demonstrate it in practice
• the audit results and actions taken
• feedback from the people we support and staff

An annual mock inspection is carried out using the CQC assessment framework, and the resulting action plan is approved by the Board. We also notify CQC of all events required under Regulation 18 without delay.

9. Roles

• Registered Manager — accountable for quality and for this policy; reports to the Board.
• Quality Lead — coordinates the audit calendar, collates indicators and maintains the improvement plan.
• Senior carers — carry out audits, observations and spot checks.
• All staff — report incidents, contribute to reviews and take part in improvement.

10. Review

This policy, the audit calendar and the indicator set are reviewed annually, and whenever regulation, guidance or the needs of the service change.