CQC statutory notifications policy template

1. What the regulation says

any injury to a service user which, in the reasonable opinion of a health care professional, has resulted in (Reg 18(2)(a), serious harm lead-in)

an impairment of the sensory, motor or intellectual functions of the service user which is not likely to be temporary, (Reg 18(2)(a)(i))

changes to the structure of a service user's body, (Reg 18(2)(a)(ii))

the service user experiencing prolonged pain or prolonged psychological harm, or (Reg 18(2)(a)(iii))

the shortening of the life expectancy of the service user. (Reg 18(2)(a)(iv))

any abuse or allegation of abuse in relation to a service user. (Reg 18(2)(e))

any incident which is reported to, or investigated by, the police. (Reg 18(2)(f))

an interruption in the supply to premises owned or used by the service provider for the purposes of carrying on the regulated activity of electricity, gas, water or sewerage where that interruption has lasted for longer than a continuous period of 24 hours, (Reg 18(2)(g)(ii))

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. (Reg 18(2)(h))

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; (Reg 18(4A)(a), standard authorisation request)

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. (Reg 18(4A)(b), application to court)

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-English 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 standard authorisation requests and Court of Protection applications where the Registration Regulations require notification. 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
• Safeguarding Adults Policy
• Duty of Candour Policy
• Good Governance Policy
• Notification of Death Policy

10. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• Care Quality Commission (Registration) Regulations 2009 (https://www.legislation.gov.uk/uksi/2009/3112)
• CQC Regulation 18: Notification of other incidents (https://www.legislation.gov.uk/uksi/2009/3112/regulation/18)
• CQC Regulation 16: Notification of death of a service user
• CQC Regulation 17: Notification of death or unauthorised absence of a service user detained under the Mental Health Act 1983
• CQC: Notifications guidance for registered providers
• CQC provider portal guidance and service-specific notification forms
• CQC Regulation 20: Duty of candour (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014)
• Coroner guidance and local safeguarding procedures where a death or incident may involve abuse or neglect

11. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

12. 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 live law or regulator guidance diverge, the live source wins.