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Improvement plans: your questions answered

Get answers to frequently asked questions about improvement plans.

Why can you tell me to send an improvement plan?

The legal framework has changed.

The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2006 came into force on 1 July 2006.

This allows us to require registered persons to provide an improvement plan – and makes it an offence if they do not.

This is a major change in the law as previously we could only request that you tell us how you were meeting requirements and recommendations.

If you are a children’s service this change in the law does not apply as it was only for adult services. However we can still require you to provide an improvement plan under our general power in section 31(1) of the Care Standards Act 2000.

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When will I have to provide an improvement plan?

We will always ask for an improvement plan when:

  • your service fails to do what the law says you must do to meet the needs of people using the service
  • if your service is given a quality rating of poor, following a key inspection.

We may ask you for an improvement plan if:

  • your service is given a quality rating of adequate and when we have concerns about your ability to improve outcomes for the people using the service.

We will not ask for an improvement plan if:

  • your service is given a quality rating of either good or excellent following a key inspection.

Whenever we do ask you for an improvement plan our request will have been agreed by one of our managers.

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What's happened to the action plans?

We do not use action plans anymore.

We expect services that are good, excellent and adequate (unless we assess that we do need to ask an adequate service for an improvement plan) to:

  • be able to manage their own improvement
  • take the necessary action to meet requirements and recommendations without sending us an improvement plan.

However, we can always ask you to send us a written response to any requirements we have made - this will not be called an improvement plan.

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What format should my improvement plan be in?

We have designed a template for you to use and will send you this if we ask you for an improvement plan.

You do not have to use our template - you can use any format you like, as long as it answers the questions we ask in our template.

You will not be judged on the format of the improvement plan – only on its content.

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What should I include in the improvement plan?

You should include:

  1. what actions you are going to take to improve your service and to meet all of the requirements that we have made
  2. what you are going to do to make sure that these actions are successful
  3. the date that the actions will be completed by (this must not differ from any timescales we have set for requirements)
  4. the name of the person responsible for the particular action.
  5. the name of the person who has the overall responsibility for co-ordinating your improvement plan (the person who will make sure  required action is taken and keep us informed)
  6. the date that you sent the improvement plan to us.

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How long have I got to complete the plan?

You must return the completed improvement plan within one month of the date of our request.

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What happens next?

We will look at your improvement plan and assess:

  1. how you plan to meet the requirements we have made.
  2. your timescales for each action and whether they are reasonable and realistic.
  3. how you plan to improve your service.
  4. whether you can achieve and maintain your proposed improvements.

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How will you monitor my progress?

We will:

  1. hold an internal management review meeting for your service where we will assess your improvement plan
  2. agree how we will monitor your progress in doing what you have said you will do, which might include random inspections to check what you are doing.
  3. expect you to complete any actions within the timescales and keep us informed about your progress.

Read more about management review meetings.

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What happens if my improvement plan is late, or is not good enough?

If your first improvement plan is not clear, or the timescale is not acceptable to us, we may ask you to provide more detail or improve your timescales.

If you don’t send us an improvement plan when we ask you to, you will be breaking the law.

It is an offence not to comply and we may consider taking enforcement action against you.

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What will happen if I don’t do what I have told you I will in my improvement plan?

  1. Your service’s quality rating will remain poor and you will have a robust inspection programme that will seek compliance
  2. If you fail to meet requirements in your improvement plan we will move on from encouraging and supporting your improvement
  3. We will take enforcement action to make sure that your service meets the needs of the people that you support
  4. We will hold internal management reviews to consider the action we may take.

The action we take could be to:

  • request a meeting with you to discuss progress being made and how you can improve your service
  • send you a warning letter to let you know that you are being considered for statutory enforcement action if you do not make improvements within agreed timescales.

Note: enforcement action could ultimately lead to prosecution or to the cancellation of your registration.

Find out more

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What will happen when I have made all the improvements?

We will:

  • make sure that it is properly recorded
  • not take any enforcement action
  • amend your quality rating at your next key inspection (depending on the outcomes of your improvements).

If you become a good service (or in the majority of cases even an ‘adequate’ service):

  • you will not need to send us another improvement plan
  • you will receive a lighter touch from us.

But, if you are still seen to be a poor service after this key inspection we may request another improvement plan.

Our management review processes will be more vigorous and we will consider taking enforcement action to make sure improvement will be considered.

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Who will you share my improvement plan with?

We may share any relevant information about your improvement plans with local councils and service commissioners, where appropriate as part of our improvement strategy.

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Utilities

Inspection reports

Star ratings