CQC statutory notifications policy (Reg 18 notifications)

1. What the regulation says

any injury to a service user which, in the reasonable opinion of a health care professional, has resulted in … an impairment of the sensory, motor or intellectual functions of the service user which is not likely to be temporary … changes to the structure of a service user's body … the service user experiencing prolonged pain or prolonged psychological harm, or … the shortening of the life expectancy of the service user.

any abuse or allegation of abuse in relation to a service user.

any incident which is reported to, or investigated by, the police.

an interruption in the supply to premises … of electricity, gas, water or sewerage where that interruption has lasted for longer than a continuous period of 24 hours.

any placement of a service-user under the age of eighteen in a psychiatric unit whose services are intended for persons over that age where that placement has lasted for longer than a continuous period of 48 hours.

The registered person must notify the Commission of … any request to a supervisory body made pursuant to Part 4 of Schedule A1 to the 2005 Act by the registered person for a standard authorisation … any application made to a court in relation to depriving a service user of their liberty pursuant to section 16(2)(a) of the 2005 Act.

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2009/3112/regulation/18. Where this policy and the regulation diverge, the regulation wins.

2. Plain British summary

A long list of "other incidents" must be notified to CQC without delay: serious harm to service users, abuse and allegations of abuse, incidents reported to or investigated by the police, events threatening your ability to continue safely (insufficient staff, lengthy utility interruptions, premises damage, fire-alarm failure), placement of under-18s in adult psychiatric units lasting over 48 hours, and Deprivation of Liberty Safeguards applications and outcomes. For health service bodies, the duty is disapplied where the incident has been reported to NHS England.

Reg 18 is the most-missed CQC requirement in the experience of the founder over thirteen years as a CQC inspector. The miss is rarely deliberate; the gap is in recognition (the team did not realise the event qualified) and process (no system flagged the deadline).

3. Scope

This policy applies to all employees, contractors, and external parties at who may identify or record events that could meet a Reg 18 notification trigger. It covers every regulated activity, every site, every patient pathway, and the cross-link from incidents, complaints, safeguarding concerns, and other source events to the notifications register.

(Tenant updates the angle-bracket placeholder.)

4. Roles and responsibilities

• Registered Manager: accountable for Reg 18 compliance under the registration framework. The Registered Manager's name appears on the audit trail at filing on every notification. Reviews the trailing-12-month notification pattern at the monthly governance meeting.
• Nominated Individual: holds provider-side accountability for Reg 18.
• Notification Lead (named, or the Registered Manager in small services): the day-to-day Reg 18 trigger-recognition authority. Reads each new incident, complaint, and safeguarding concern at log-time to confirm the trigger call. Files the notification with CQC.
• All clinical staff: raise events that may meet a trigger to the Notification Lead the same working day. Do not delay raising on the grounds of "not sure if it qualifies"; the triage decision is a manager-level call.
• All admin staff: raise events affecting the service's ability to operate safely (insufficient staff, premises damage, utility interruption longer than 24 hours, fire-alarm failure, security event) to the Notification Lead the same working day.

(Tenant updates the named role-holders.)

5. Procedure

The Reg 18 procedure operationalises the notification lifecycle from trigger identification through CQC confirmation to closure.

1. Trigger recognition at log-time. When an incident, complaint, or safeguarding concern is logged, the platform's regulatory-trigger map is applied. The Notification Lead confirms the trigger call within the same working day. Events identified by the trigger map as Reg 18 in scope spawn a notification record automatically.
2. Direct triggers (non-incident sources). Some Reg 18 triggers do not flow from an incident: police involvement (any incident reported to or investigated by police), utility interruption longer than 24 hours, prolonged absence of a service user detained under MHA, DoLS applications, fitness-of-the-provider events. These are logged directly as notification records by the Notification Lead.
3. Acknowledge. The Notification Lead acknowledges the notification, confirming the trigger applies and the work is in their queue. Acknowledgement stops the dashboard counting it as unattended.
4. Draft the submission. The Notification Lead drafts the regulator-facing wording using the CQC online notification form (or the equivalent CQC channel). The factual account is checked against the source record; the registered manager reads the wording before submission for any notification involving severe harm, death, or abuse.
5. File with CQC. The notification is filed through CQC's online system. The reference number returned by CQC, the submitter's name, the submission timestamp, and a screenshot or PDF of the confirmation are recorded against the notification.
6. Record confirmation. Where CQC sends a separate confirmation (some channels do not), the confirmation is recorded against the notification.
7. Close. The notification closes when the regulator-side process is complete. The closure paragraph confirms what was filed and when.
8. Not-applicable closure. Where a trigger fired but on review the team concludes the notification is not in fact required (the threshold was misread, the event was outside the regulated activity, the patient was not actually a service user under CQC's definition), the record closes as Not Applicable with reasoning of at least 50 characters explaining why. The reasoning is the defence at inspection.
9. Health-service-body disapplication. For NHS-funded providers where the event has been reported to NHS England, the Reg 18 duty to CQC is disapplied per Reg 18(4A). The Notification Lead records the NHS England reference so the disapplication is auditable.
10. Pattern review. The aggregate notification pattern (count by category, time-from-trigger-to-file, late submissions, not-applicable closures) is reviewed at the monthly governance meeting.

6. Training requirement

• All clinical and admin staff complete CQC Reg 18 awareness training at induction (what the triggers are, what to raise to the Notification Lead, the same-day-raise expectation).
• The Notification Lead completes Reg 18 deeper training at appointment (the trigger map in detail, the CQC notification form, the not-applicable-reasoning standard) and refresher annually.
• The Registered Manager completes the same as the Notification Lead.

Training records held in the tenant's training matrix register.

7. Audit

Compliance with this policy is monitored by the Registered Manager:

• Per-incident sign-off: every incident, complaint, and safeguarding concern closed in the trailing month is checked for the Reg 18 trigger call (notification spawned where one should have been; not-applicable reasoning attached where the trigger fired but was declined).
• Quarterly notification-pattern review: trailing-12-month view of notification count by category, time-from-trigger-to-file pattern, and any late or breach states. Late notifications are reviewed individually for learning.
• Annual policy review: the policy itself is re-read against the live Reg 18 text plus any CQC guidance updates on notification triggers.

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

8. Record-keeping

Notification records (the platform record, the regulator-facing wording filed, the CQC reference number returned, any confirmation correspondence) are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management. Notifications relating to children are retained until the child reaches the age of 25. Notifications related to safeguarding follow the safeguarding retention layered on top.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

9. Related policies in this pack

• Safe Care and Treatment Policy (hscra-reg-12-safe-care-and-treatment)
• Safeguarding Adults Policy (hscra-reg-13-safeguarding-from-abuse)
• Duty of Candour Policy (hscra-reg-20-duty-of-candour)
• Good Governance Policy (hscra-reg-17-good-governance)
• Notification of Death Policy (cqc-reg-16-notification-of-death)

10. Document control

This sample policy template was issued by Verivius as part of the Mock Inspection design partner onboarding pack. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and the live regulation diverge, the live regulation wins.