El Roi Policy

El Roi Ltd
El Roi Ltd also operates under the trading name Trinity Living Care for the provision of domiciliary and community-based services.
Full Policy Manual
More Than Care. We See People
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
1. Absence and Timekeeping Policy
Punctuality and attendance are essential for all El Roi Ltd agency workers. Agency workers must arrive at their booked care home shifts on time and be prepared to work professionally. Reliability is crucial for maintaining trust with client organisations and ensuring continuity of care.
Shift Attendance Expectations
Arrive at the booked care home shift on time and ready to work
Contact the care home directly if running late, following their preferred communication method
Notify El Roi Ltd immediately if you are running late or unwell
Be prepared and professional throughout your shift
Cancelling Shifts
Standard notice: 12-24 hours minimum notice required
Emergency situations: Contact El Roi Ltd immediately for illness, family emergencies, or unforeseen circumstances
Procedure: Contact El Roi Ltd first, then the care home if instructed to do so
Impact on Client Trust
As a care staffing agency, reliability from our agency workers directly impacts our contractual relationships with client organisations. Unreliable attendance:
Damages El Roi's reputation with care homes
Affects continuity of care for vulnerable residents
Places additional burden on care home staff
May result in loss of future placement opportunities
Consequences of Poor Attendance
First instance: Verbal discussion and guidance
Repeated lateness: Formal review and potential reduction in shift offers
No-shows or persistent unreliability: May result in removal from the agency rota
Serious breaches: Immediate termination of agency relationship
Formal disciplinary action will be taken in accordance with El Roi Ltd's Employee Conduct & Disciplinary Policy.
Statutory Sick Pay (SSP)
Agency workers who meet the qualifying criteria are entitled to Statutory Sick Pay (SSP) in accordance with current HMRC regulations. SSP is payable from the fourth consecutive day of sickness absence. Workers must notify El Roi Ltd on the first day of absence and provide a fit note (Med 3 certificate) from their GP for absences exceeding 7 consecutive calendar days.
Fit Notes and Return to Work
A fit note is required for any absence exceeding 7 consecutive calendar days. Upon return from any absence of 3 or more days, a return to work discussion will be conducted by the line manager. Where a fit note indicates the worker "may be fit for work", El Roi Ltd will consider any recommendations made. Phased returns or adjusted duties may be arranged in consultation with the worker.
Record Keeping
Agency workers must maintain accurate records of their working hours and report any discrepancies to El Roi Ltd promptly.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
2. Client & Worker Feedback Policy
El Roi Ltd values feedback from clients and workers as an essential part of maintaining high standards of service and ensuring continuous improvement.
Feedback Principles
We believe open communication helps build trust, strengthen relationships, and identify opportunities to enhance our services. Feedback, both positive and constructive, is encouraged and welcomed at all times.
Feedback Process
Provide Feedback
Clients and workers can provide feedback verbally, in writing, or through the feedback form available on our website or in person.
Management Review
All feedback is reviewed by management within five working days.
Investigate Concerns
Concerns or complaints are logged, investigated, and responded to promptly and fairly.
Share Positive Feedback
Positive feedback is shared with staff to recognise good performance and encourage best practice.
Monitoring and Review
Feedback trends are monitored monthly and form part of the company's quality assurance process. A summary of key findings and improvements is included in quarterly review meetings.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
3. Code of Conduct Policy
We expect high standards of behaviour, professionalism and reliability from our agency workers. Our Code of Conduct is aligned with Skills for Care and CQC expectations. Agency workers must work with integrity, respect, and compassion, always prioritising the welfare of the service users within the host organisations, and adhering to both El Roi Ltd's policies and the host organisation's procedures.
Our Core Values in Action
El Roi Ltd's Code of Conduct reflects our commitment to excellence in providing professional agency staff for care settings. Every agency worker, regardless of role, is expected to embody our values of compassion, integrity, respect, and accountability. These values guide decision-making, shape interactions with service users at host organisations, colleagues, and host organisation staff, and underpin everything we do. Our reputation depends on each person upholding these standards consistently, recognising their dual responsibility to El Roi Ltd and the host organisation.
Compassion
Show kindness and empathy in every interaction with service users and colleagues at host organisations
Honesty
Be truthful and transparent in all communications with El Roi Ltd, host organisations, and service users
Respect
Value diversity and treat everyone, including service users, host organisation staff, and colleagues, with dignity
Reliability
Be punctual, dependable and consistent, fulfilling all commitments to both El Roi Ltd and host organisations
Excellence
Strive for the highest standards in all duties, adhering to both El Roi Ltd's standards and host organisation's procedures
Teamwork
Collaborate effectively with El Roi Ltd, colleagues, and staff at host organisations to ensure seamless service delivery
Expected Standards of Behaviour
Agency workers must arrive on time for shifts at host organisations, properly prepared and equipped for their duties. Communication with service users, their families, host organisation staff, and El Roi Ltd colleagues must be respectful, clear, and professional at all times. Agency workers must maintain confidentiality, follow both El Roi Ltd's policies and the host organisation's procedures diligently, and take responsibility for their actions. Bullying, harassment, discrimination, dishonesty, or behaviour that brings El Roi Ltd or the host organisation into disrepute will not be tolerated. Agency workers must be fit for duty and must not work under the influence of alcohol or non-prescribed drugs.
Personal conduct outside of work should not compromise professional standing or public confidence in the care sector, or negatively impact El Roi Ltd's relationship with client organisations. Agency workers must disclose any criminal convictions, cautions, or investigations promptly to El Roi Ltd. Safeguarding concerns must be immediately reported to both the host organisation's designated safeguarding lead and El Roi Ltd. Social media use must be professional and respectful – never post about service users or staff at host organisations, or content that could bring El Roi Ltd or the client organisation into disrepute.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
4. Communication Policy
El Roi Ltd promotes open, clear, and respectful communication. All verbal and written interactions, both internal and external, must be professional and adhere to our policies and host organisation procedures, especially regarding incident reporting and confidential information.
Effective Communication Principles
Clear, timely communication is vital for safe, person-centred care and effective teamwork. Agency workers must proactively and professionally engage with El Roi Ltd colleagues, host organisation staff, service users, their families, and external professionals to ensure coordinated support and prompt issue resolution.
Active Listening
Give full attention, ask clarifying questions, and demonstrate understanding when interacting with service users and host organisation staff.
Clear Expression
Communicate clearly, avoiding jargon, and adapt your style to the audience, always verifying understanding.
Accurate Recording
Document information objectively, factually, and promptly, adhering to the host organisation's record-keeping policies.
Respectful Dialogue
Maintain professionalism in all conversations, being constructive, non-judgmental, and solution-focused.
Communication Channels and Tools
Use El Roi's internal systems (secure messaging, email, phone) and the host organisation's methods (handovers, care records, incident forms). Select channels based on urgency and confidentiality. Urgent safeguarding concerns require immediate verbal and written reporting to both organisations. Confirm receipt of critical communications.
All written communication must be professional and objective. Use accessible language with service users and families, checking understanding and using interpreters when needed.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
5. Complaints Policy
We value all feedback and aim to resolve complaints promptly and fairly. El Roi Ltd staff must respond professionally to any dissatisfaction expressed. Agency workers, client organisations, and stakeholders are encouraged to report concerns using our complaints process. Records of all complaints will be kept and reviewed to improve services and ensure regulatory expectations are met.
Policy Statement
El Roi Ltd views complaints as opportunities to learn and improve. We welcome feedback from agency workers, client organisations, and El Roi staff. Every complaint is taken seriously and handled with sensitivity and professionalism. We aim to resolve issues at the earliest possible stage, maintaining open communication throughout the process, and adhering to all CQC requirements.
Raise Concern
Complaint received verbally or in writing from an agency worker, client organisation, service user, or their representative.
Acknowledge
Formal acknowledgement issued within 3 working days to the complainant.
Investigate
Fair and thorough review of all evidence, engaging relevant parties from El Roi and/or the client organisation, with due regard to the nature of the complaint.
Resolve
Outcome communicated within 20 working days, with clear actions to address the complaint and prevent recurrence. Extensions will be communicated with justification.
Making a Complaint
Agency workers, client organisations, service users, or their representatives can make complaints verbally to any member of El Roi staff or in writing to the registered manager. We will acknowledge receipt within three working days. Our aim is to provide a full response within 20 working days. If we need more time for complex investigations, we will communicate the reasons for the delay and provide an updated timeframe. Throughout the process, we offer support to complainants, ensuring they are informed of progress and their concerns are heard. The process is adaptable to different types of complaints, whether they relate to service delivery, staff conduct, or administrative issues, always focusing on fairness and thoroughness.
Documentation and Record-Keeping
All complaints, regardless of their nature or outcome, will be recorded in a central log. This includes details of the complaint, the investigation steps taken, any communication with the complainant, and the final resolution. All records will be maintained securely and confidentially, in compliance with data protection regulations, and accessible for review by regulatory bodies.
Learning from Complaints and Service Improvement
El Roi Ltd is committed to continuous improvement. We regularly review all complaints to identify underlying causes, recurring themes, and areas for improvement in our services, policies, and staff training. Findings from complaint investigations will be used to implement corrective actions, update procedures, and share lessons learned across the organisation to enhance the quality and safety of care and service delivery.
Annual Complaints Analysis and Reporting
An annual report will be compiled, summarising the types and volume of complaints received, key findings, and actions taken as a rewsult. This report will be reviewed by senior management and shared with relevant stakeholders to demonstrate accountability and our commitment to learning and improvement.
Escalation and Independent Review
Independent Support and Escalation: If you are not satisfied with our response regarding a complaint, particularly those related to regulated care services provided via an agency worker, you have the right to escalate your concern to independent bodies for review.
Local Government and Social Care Ombudsman (LGSCO): Investigates complaints about adult social care and local government services. You can contact them after you have completed our complaints process. 
Website: www.lgo.org.uk 
Phone: 0300 061 0614 
Address: PO Box 4771, Coventry CV4 0EH
Care Quality Commission (CQC): The independent regulator of all health and social care services in England. While the CQC cannot investigate individual complaints, they welcome information about services, which helps them decide when, where, and what to inspect. 
Website: www.cqc.org.uk 
Phone: 03000 616161 
Address: CQC National Customer Service Centre, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
Advocacy Services: Service users requiring assistance in making a complaint can access independent advocacy services. These services provide support to express your views, wishes, and concerns. Information on local advocacy services can be provided upon request from El Roi Ltd staff, or by contacting your local council.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
6. Confidentiality and GDPR Policy
All personal information related to agency workers, client organisations, and any individuals encountered within host care settings must be handled with care and only shared on a need-to-know basis. El Roi Ltd complies with the Data Protection Act 2018 and UK GDPR. El Roi staff are not to disclose agency worker, client organisation, or sensitive information from host settings without proper authorisation. Breaches will result in disciplinary action.
Lawfulness and Fairness
We process personal data lawfully, fairly and transparently. Agency workers and client organisations are informed about how their information is used and have the right to access their records.
Purpose Limitation
Personal data is collected only for specified, explicit and legitimate purposes, primarily for recruitment, placement, and ensuring regulatory compliance. We do not use information in ways incompatible with those purposes.
Data Minimisation
We collect only the information necessary for our agency operations and business purposes. Excessive or irrelevant data is not retained.
Security and Accountability
Appropriate technical and organisational measures protect personal data from unauthorised access, loss, or damage. We maintain records of all processing activities and ensure agency workers understand their responsibilities regarding data in host settings.
Handling Confidential Information
Agency workers must never discuss confidential information in public or with unauthorised persons, except for safeguarding purposes. Workers must follow both El Roi's and host organisation's confidentiality policies. Documents must be stored securely, electronic records password-protected, and sensitive emails encrypted where possible.
Any confidentiality breach must be reported immediately to your line manager and El Roi's Data Protection Officer. Host organisation breaches must also be reported to the relevant contact within that organisation. Serious breaches may require ICO reporting within 72 hours. Deliberate breaches will result in disciplinary action up to dismissal.
Secure Handling of Client Records in Homes (Domiciliary Care)
When providing domiciliary care, agency workers are responsible for securely handling client records within the client's home. Physical records must be kept out of sight, protected from unauthorised access by family members or visitors, and never left unattended. Records should be stored in a secure location during the visit and removed from the premises upon departure, unless otherwise specified by a formal agreement with the client organisation. Confidential discussions must take place in a private setting to prevent eavesdropping.
Mobile Device Security and Data Protection
All mobile devices used for El Roi Ltd work, whether company-issued or personal (if approved under a 'bring your own device' policy), must be secured. This includes strong password/PIN protection, encryption of the device and any stored data, and up-to-date security software. Sensitive client information should not be stored directly on mobile devices unless absolutely necessary and, if so, must be within secure, encrypted applications. Remote wipe capabilities must be enabled for company devices. Any loss or theft of a mobile device used for work must be reported immediately.
Information Sharing Rules (Domiciliary Care)
Information sharing must always be on a strict "need-to-know" basis. When sharing client information with healthcare professionals (e.g., GPs, nurses), it must be for the purpose of direct care or treatment and in the client's best interest. Sharing with family members or other third parties requires explicit, documented consent from the client or their legal representative, unless there is a clear safeguarding concern or legal obligation to disclose. Workers must always verify the identity of individuals requesting information.
Consent for Information Sharing (Domiciliary Care)
El Roi Ltd obtains and documents explicit consent from clients, or their legal representatives, for sharing their personal and sensitive information with individuals beyond their direct care team (e.g., specific family members). Clients are fully informed about what information will be shared, why, and with whom, ensuring consent is freely given, specific, informed, and unambiguous. Clients have the right to withdraw their consent at any time, and this withdrawal will be respected and recorded, impacting future information sharing as appropriate.
Data Breach Procedures and Notification (Domiciliary Care)
In addition to general breach procedures, specific protocols are in place for domiciliary care. This includes procedures for lost or stolen physical records during transit, unauthorised access to electronic records on mobile devices, or accidental disclosure in a client's home. All potential breaches, no matter how minor, must be reported immediately to the line manager and El Roi's Data Protection Officer. We will assess the risk to individuals' rights and freedoms and, if required, notify the Information Commissioner's Office (ICO) within 72 hours and inform affected individuals without undue delay.
Secure Transportation of Records Between Locations
When physical client records are transported between a client's home, El Roi Ltd's office, or any other approved location, they must be securely contained (e.g., in a locked bag or secure folder). Transport should be direct, and records must never be left unattended in vehicles or public spaces. Digital records are preferred for transport and must always be encrypted and accessed via secure, authenticated systems. The aim is to minimise the transportation of physical sensitive data as much as possible.
Access Controls for Electronic Records
Access to electronic client records, including those managed by El Roi Ltd or through client organisation systems, is strictly controlled on a role-based access system. Only authorised personnel with a legitimate need-to-know can access specific client data relevant to their role. Each staff member will have a unique user ID and password, and access will be regularly reviewed and revoked upon changes in role or employment. All access and modifications to electronic records are subject to audit trails to ensure accountability.
Retention and Disposal of Personal Data (Domiciliary Care)
Personal data related to domiciliary care clients is retained only for as long as necessary to fulfil the purposes for which it was collected, and in compliance with legal and regulatory requirements (e.g., CQC guidelines, local authority contracts). Once the retention period expires, all personal data, whether physical or electronic, is securely disposed of. Physical records are shredded or incinerated by approved methods, and electronic data is permanently deleted using secure erasure techniques that prevent recovery.
Client Rights Under GDPR
Clients receiving domiciliary care have several rights under GDPR, which El Roi Ltd fully respects and supports: the right to be informed about data processing, the right to access their personal data, the right to rectification of inaccurate data, the right to erasure ('right to be forgotten'), the right to restrict processing, the right to data portability, and the right to object to processing. Information on how clients can exercise these rights will be clearly provided, and requests will be handled promptly and transparently.
Privacy Notices and Consent Procedures (Domiciliary Care)
All domiciliary care clients, or their legal representatives, will receive a clear and concise privacy notice outlining how El Roi Ltd collects, uses, stores, and shares their personal data. This notice will explain their rights under GDPR. Where necessary, specific consent will be obtained for processing activities not covered by contractual obligations or legitimate interests, such as for marketing purposes or sharing with specific third parties. Consent forms are designed to be easily understood and include options for withdrawing consent.
Staff Training on Data Protection in Community Settings
All El Roi Ltd staff involved in domiciliary care receive mandatory and regular training on data protection and confidentiality, specifically tailored to the unique challenges of working in community and client home settings. This training covers GDPR principles, secure handling of records, mobile device security, information sharing protocols, identifying and reporting data breaches, and respecting client rights. Refresher training is provided annually and whenever there are significant changes to legislation or policy, ensuring staff are fully aware of their responsibilities.

El Roi Ltd – Policy Manual | Version 1.1 | February 2026
7. Contractual and Fee Structure Policy
El Roi Ltd maintains transparent, fair, and legally compliant contractual and financial arrangements with all clients, staff, and partners, clearly defining obligations and rates.
Scope
This policy applies to all agreements with clients, staff (Healthcare Assistants, Support Workers, Nurses), and partner organisations.
Key Aspects of Our Contractual & Fee Structure
Client Agreements
Written Service Level Agreements (SLA) and Rate Sheets provided.
Rates include statutory costs; reviewed and updated regularly.
Clients are notified of any changes.
Worker Agreements
Workers are engaged on Zero-Hour Contracts with weekly/fortnightly pay.
Pay complies with UK employment law and national minimum wage.
Deductions (tax, NI, pension) are per HMRC regulations; holiday pay rolled up where applicable.
Fee Structure
Rates reflect staff pay, statutory costs, and operational overheads.
Competitive, transparent, and regularly reviewed rates.
El Roi Ltd aims to match or beat verified competitor rates.
Invoicing and Payment
Weekly invoices issued with authorised timesheets.
Payment terms are 14 days from invoice date.
Late payments may incur administrative fees.
All transactions via El Roi Ltd's registered business account.
Dispute Resolution
Payment or rate disputes are handled promptly by management as per our Complaints Policy.
This policy is reviewed annually or upon regulatory changes.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
8. Dementia Awareness Policy
Purpose
Purpose
El Roi Ltd is committed to ensuring all staff understand the needs, experiences, and dignity of people living with dementia.
Policy Statement
Policy Statement
Dementia affects memory, communication, and behaviour in different ways for every individual. Our approach is grounded in empathy, patience, and respect. We expect all staff to adopt person-centred care practices that promote comfort, inclusion, and safety.
Our Commitment
Staff Training
Staff will complete dementia awareness training before placement.
Calm Communication
Communication should always be calm, clear, and reassuring.

No Arguments
Staff should avoid correcting or arguing with individuals who are confused.
Recognise Triggers
Staff should recognise and record behavioural or environmental triggers.
Dignity and Choice
Staff must support dignity, privacy, and choice at all times.
Individualised Care
The care provided should reflect the individual's life history and preferences.
Monitoring and Review
Monitoring and Review
Training compliance and staff feedback will be reviewed annually.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
9. Net Zero and Environmental Sustainability Policy
Purpose
El Roi Ltd recognises its responsibility to protect the environment and reduce its carbon footprint through responsible business operations.
Policy Statement
We aim to operate in a way that minimises environmental impact while maintaining high standards of service delivery. Sustainability is a shared responsibility across our organisation.

Our Commitments
Reduce paper use
Through digital documentation wherever possible.
Encourage recycling
And proper waste segregation in all work settings.
Promote energy conservation
By turning off lights and equipment when not in use.
Encourage eco-friendly transport
Staff and partners are encouraged to use eco-friendly transport options.
Engage responsible suppliers
Who demonstrate environmentally responsible practices.
Review environmental impact annually
And update targets accordingly.
Long-Term Goal
El Roi Ltd is committed to supporting the UK's Net Zero strategy by 2050 through continuous improvement in sustainability practices.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
10. Third-Party Referral Policy
Purpose
This policy ensures transparency and integrity in all referral arrangements made by El Roi Ltd involving clients, care homes, or candidates.
Policy Statement
El Roi Ltd may occasionally receive or make referrals to other organisations. These will always be handled professionally, ethically, and in accordance with data protection and confidentiality laws.
Guidelines
All referral agreements must be transparent and documented.
No referral will take place without the individual's consent.
El Roi Ltd will never sell, trade, or misuse personal data.
Any referral fees or incentives will be clearly declared and compliant with relevant regulations.
Information shared with third parties must be limited to what is necessary for safe and lawful operation.
All data transfers must comply with UK GDPR and confidentiality policies.
Monitoring and Review
This policy will be reviewed annually to ensure compliance with CQC standards and data protection law.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
11. Specialist Training Policy
Purpose
Purpose
El Roi Ltd is committed to ensuring that all staff receive training beyond mandatory requirements, supporting them to deliver safe, effective, and person-centred care in specialist areas.
Policy Statement
Policy Statement
Specialist training covers additional subjects such as Dementia Care, Learning Disabilities, Autism Awareness, Challenging Behaviour, Mental Health, Diabetes, Epilepsy, and End-of-Life Care.
Our Approach
All staff will complete mandatory training before being offered placements.
Specialist training needs will be identified during induction and supervision.
Courses will be delivered by accredited training providers such as Careskills Academy.
Training certificates will be verified and recorded on the staff training matrix.
Staff are encouraged to request further training to enhance their professional development.
Refresher training for specialist areas will be provided every 12–24 months, depending on the topic.
Compliance
Compliance
This policy supports the CQC Single Assessment Framework quality statements on workforce competence, induction, and ongoing training.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
12. Conflict of Interest Policy
Purpose
The purpose of this policy is to protect the integrity and reputation of El Roi Ltd by ensuring that all employees and representatives act in the best interests of the company and its clients.
Definition
A conflict of interest occurs when personal, financial, or other considerations could compromise or appear to compromise an individual's professional judgement or integrity.
Examples of Potential Conflicts
Working for or having financial interest in another care provider without disclosure.
Making decisions that could benefit family or friends over clients.
Accepting gifts, hospitality, or benefits with a value exceeding £25 without prior declaration and management approval. All gifts received must be recorded in the Gifts & Hospitality Register.
Procedure
Employees must declare any potential conflict immediately to management.
Management will review the situation and determine if action is needed.
Breaches of this policy may result in disciplinary action.
Gifts & Hospitality Register
El Roi Ltd maintains a Gifts & Hospitality Register. All staff must declare any gift, hospitality, or benefit received in connection with their role, regardless of value. The register is reviewed quarterly by management. Gifts under £25 may be accepted but must still be declared. Gifts over £25 must be declared and approved by a director before acceptance or must be declined or donated to charity.
Register of Interests
All staff and representatives must complete a Declaration of Interests form upon joining El Roi Ltd and update it annually or whenever a new interest arises. The Register of Interests is maintained by management and reviewed annually. Failure to declare a conflict may result in disciplinary action.
Responsibility
All staff and representatives are expected to act with honesty, transparency, and accountability in all dealings on behalf of El Roi Ltd.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
13. COVID-19 Guidelines
El Roi Ltd continues to follow public health guidance on infection prevention, including COVID-19 protocols. All agency workers must remain vigilant and follow current guidelines to protect themselves, colleagues, and the vulnerable individuals they support.
Health Monitoring and Reporting
Report any COVID-19 symptoms immediately to El Roi Ltd before attending any shift
Follow current isolation guidelines if experiencing symptoms or testing positive
Inform both El Roi Ltd and the placement setting of any positive test results
Do not attend work if unwell, even with mild symptoms
Personal Protective Equipment (PPE)
Wear PPE as required by the placement setting and current guidelines
Follow proper donning and doffing procedures
Report any PPE shortages to the care home and El Roi Ltd immediately
Maintain good hand hygiene practices at all times
Testing and Vaccination
Adhere to testing requirements as instructed by placement settings or El Roi Ltd
Follow any vaccination requirements where applicable
Keep El Roi Ltd informed of your vaccination status if required for specific placements
Workplace Protocols
Follow all COVID-19 protocols specific to each placement setting
Maintain appropriate social distancing where possible
Support infection control measures within care environments
El Roi Ltd will continue to monitor public health guidance and update protocols as necessary to ensure the safety of all agency workers and the individuals they support.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
14. Equality, Diversity and Inclusion Policy
El Roi Ltd promotes inclusion, equality, and respect across all operations, agency workers, and client interactions. Discrimination, harassment, or victimisation will not be tolerated. Agency workers must treat others fairly regardless of protected characteristics and uphold these principles in all placements.
Our Commitment to Equality
El Roi Ltd celebrates diversity and believes everyone deserves dignity and respect. We actively challenge discrimination and ensure agency workers are equipped to operate in inclusive environments across all placements.
Age
Equal treatment and opportunities for agency workers of all age groups, within El Roi and client settings
Disability
Reasonable adjustments and inclusive practices for agency workers, in collaboration with client organisations
Gender
Fair treatment for all agency workers regardless of gender identity or expression, reflecting El Roi's values and those of client organisations
Race & Religion
Respect for cultural backgrounds and beliefs among agency workers and within client organisation environments
Sexual Orientation
An inclusive environment for all agency workers, ensuring respect and understanding in all placements
Pregnancy & Maternity
Supportive treatment and protection for agency workers who are pregnant or on maternity leave, in line with equality duties and client policies
Marriage & Civil Partnership
Equal treatment for agency workers regardless of marital or civil partnership status
Challenging Discrimination
Agency workers experiencing discrimination must report it immediately to their El Roi line manager. All complaints will be investigated thoroughly. Workers are encouraged to challenge inappropriate behaviour constructively. Training is provided on Equality Act 2010 duties and client organisation policies.
El Roi Ltd also ensures that reasonable adjustments are made to accommodate the needs of service users with disabilities or other protected characteristics, ensuring equitable access to care and support.

El Roi Ltd – Policy Manual | Version 1.1 | February 2026
15. Health and Safety Policy
The health, safety and welfare of El Roi's staff, agency workers, and the public are paramount. El Roi agency workers are required to comply with the health and safety policies and procedures of both El Roi Ltd and the client organisations they are placed with. We aim to provide safe working conditions, conduct risk assessments, and comply with the Health and Safety at Work Act 1974. All agency workers must follow procedures, use PPE correctly, and report any hazards or incidents without delay.
Our Commitment
El Roi Ltd takes its legal and moral obligations seriously. We conduct regular risk assessments of our own operational activities, premises, and equipment. El Roi agency workers receive comprehensive training on health and safety procedures relevant to their roles, encompassing both El Roi's policies and general best practices for care settings. We maintain up-to-date records of incidents, near misses, and corrective actions taken involving our agency workers.
1
Identify Hazards
Be constantly aware of potential risks in your working environment, adhering to both El Roi and host organisation guidelines.
2
Assess Risks
Evaluate the likelihood and severity of potential harm in line with host organisation policies.
3
Implement Controls
Put measures in place to eliminate or minimise risks, following host organisation and El Roi procedures for safe practice.
4
Report and Review
Report all incidents, hazards, or near misses immediately to both the host organisation and El Roi Ltd, and continuously improve safety procedures.
Agency Worker Responsibilities
Agency workers must ensure their own safety and that of others by following both El Roi and host organisation procedures, using equipment properly, wearing PPE, and reporting incidents to both parties. Workers must only undertake tasks they are trained for and follow host setting protocols for medication, infection control, and care procedures.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
16. Induction and Training Policy

All new agency workers must complete a comprehensive induction and mandatory training before undertaking unsupervised work. Training must be refreshed according to legislation, El Roi Ltd's policies, and client needs. Agency workers are responsible for actively engaging with all required training to ensure continued professional development and compliance for placement.
Comprehensive Induction Programme
New agency workers undertake a structured induction, aligned with the Care Certificate framework, preparing them for professional placements. It covers El Roi's policies, health and safety, safeguarding, person-centred care, communication, equality/diversity, duty of care, and role-specific competencies. Induction includes guided learning, scenarios, and assessments, tailored to experience and placement requirements.
1
Mandatory Training Modules
Key training includes safeguarding adults, health and safety, infection control, safe moving and handling, first aid, food hygiene, GDPR, equality/diversity, mental capacity/consent, and medication administration (where applicable). Emphasis is placed on adhering to client organisation policies.
2
Refresher Training Schedule
Most mandatory training requires annual refreshers, with specific modules having defined renewal periods dictated by regulatory bodies. Agency workers receive advance notification and are responsible for prioritising attendance to remain eligible for placement.
3
Continuous Professional Development
El Roi Ltd encourages agency workers to pursue additional learning relevant to professional growth and care setting demands, such as specialist training or qualifications, to enhance skills for future placements.
Training Records and Accountability
El Roi Ltd maintains accurate training records. Agency workers are responsible for attending all scheduled training and completing e-learning modules on time. Failure to maintain up-to-date mandatory training may lead to temporary suspension from placement opportunities or disciplinary action. We invest significantly in our agency workers' development and expect active engagement to enhance care quality.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
17. Infection Control Policy
El Roi Ltd's agency workers must adhere to stringent infection prevention and control (IPC) procedures, including diligent hand hygiene, appropriate PPE use, and safe waste disposal. This applies equally to care provided in residential settings and within clients' own homes (domiciliary care). Agency workers must always follow the specific COVID-19 and other infection-specific protocols of the client organisation they are placed with, in addition to El Roi Ltd's general guidance. Compliance with the client organisation's Standard Infection Control Precautions (SICP) is everyone's responsibility and a legal requirement for safe care delivery, protecting all individuals within the care setting and the wider community.
Standard Infection Control Precautions (SICP) in Domiciliary Care
When working in a client's home, agency workers must adapt IPC principles to the home environment, respecting the client's living space while ensuring safety. This includes.
Hand Hygiene: Always perform hand hygiene before and after each client contact. Where dedicated handwashing facilities with soap and running water are not readily available or accessible, agency workers must utilise portable hand sanitising solutions (at least 60% alcohol-based) provided by El Roi Ltd or the client organisation.
PPE Requirements: Agency workers must assess the risk for each care activity to determine the appropriate PPE (e.g., gloves, aprons, fluid-resistant masks). PPE must be donned and doffed safely, in line with training and client organisation policy, and never reused. Dispose of used PPE correctly.
Waste Disposal in Clients' Homes: All waste generated during care, particularly infectious or clinical waste, must be segregated and disposed of safely and responsibly, following the client organisation's specific procedures, and local authority guidelines for domestic waste. Sharps bins must be provided for needles and other sharp instruments and disposed of by a licensed waste carrier.
Environmental Cleaning: While respecting the client's home, maintain high standards of cleanliness for areas directly involved in care delivery (e.g., bathroom, kitchen surfaces used for food preparation). Use cleaning products provided by the client or recommended by El Roi Ltd, following manufacturer guidelines and client organisation protocols. Any equipment brought into the home by the agency worker must be clean before use and cleaned appropriately before being transported to another home.
Laundry Handling: Soiled linen, clothing, or other fabrics in the client's home should be handled with care, minimising agitation to prevent aerosolisation of contaminants. Follow client organisation guidelines on laundering (e.g., washing temperatures) or bagging for off-site cleaning, ensuring clear communication with the client or their family.
Food Hygiene and Preparation Safety: When assisting with food preparation, follow strict food safety principles to prevent contamination. This includes thorough hand washing, ensuring clean preparation surfaces, proper storage of food, and cooking to the correct temperatures, in line with client organisation and general food safety guidelines.
Transportation of Equipment: All equipment transported between clients' homes (e.g., hoists, mobility aids) must be thoroughly cleaned and disinfected according to El Roi Ltd's and the client organisation's IPC protocols before and after each use to prevent cross-contamination.
Managing Outbreaks and Specific Infections in Community Settings
El Roi Ltd's agency workers must be alert to signs of infection in the individuals they support within the client organisation's setting (e.g., fever, cough, rash). Suspected infections must be reported immediately to both the relevant contact at the client organisation and El Roi Ltd for appropriate measures. During outbreaks or when managing specific infectious diseases in a client's home, strict adherence to client-directed additional precautions (e.g., restricted movement, enhanced PPE, increased cleaning) is mandatory.
COVID-19 and Other Infectious Diseases: Agency workers must follow the specific COVID-19 protocols of the client organisation they are placed with, staying updated on testing, isolation, and mask requirements. For other infectious diseases (e.g., Norovirus, influenza), follow specific guidelines provided by the client organisation, El Roi Ltd, and public health authorities.
Symptom Management and Exclusion: If symptoms of an infectious illness develop, do not attend work; notify both the client organisation and the El Roi Ltd office immediately, and follow NHS guidance regarding isolation and testing. Return to work only when medically cleared and compliant with national and client organisation guidance.
Staff Health Monitoring and Exclusion Criteria
El Roi Ltd prioritises the health of its agency workers and the safety of clients. Agency workers are responsible for monitoring their own health and promptly reporting any signs of illness that could pose an infection risk to clients. This includes:
Reporting symptoms of infectious diseases (e.g., fever, cough, vomiting, diarrhoea, rash) to El Roi Ltd and the client organisation immediately.
Adhering to exclusion criteria as advised by medical professionals, public health guidance (e.g., NHS), or El Roi Ltd, which may require temporary removal from duties to prevent transmission.
Maintaining up-to-date immunisations as recommended for healthcare workers (e.g., influenza, MMR), where required by client organisations or advised for personal protection.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
18. Lone Working Policy
Agency workers engaged in lone working must inform El Roi management and the host organisation of their location and expected return times, and have access to a phone and emergency procedures. All lone working situations require a joint risk assessment by El Roi and the host organisation to ensure safety, balancing care delivery independence with worker wellbeing.
Managing Lone Working Risks
Risk Assessment
Collaborate with host organisations on individual risk assessments for each lone working situation. Agency workers must be familiar with both El Roi's and the host organisation's assessments.
Communication Protocol
Agency workers must carry a charged mobile phone and inform both El Roi and the host organisation of their location and completion time.
Check-In Procedures
Follow agreed regular check-in calls or messages with both El Roi and the host organisation, with escalation if contact is not made.
Emergency Response
Agency workers must be aware of and follow both El Roi's and the host organisation's emergency procedures, accessing relevant contacts and summoning help when needed.
Agency Worker Responsibilities
Before lone working, ensure you have received appropriate training from both El Roi and the host organisation and have access to necessary safety equipment. Always inform El Roi and the host organisation of your schedule. If a situation feels unsafe or circumstances change, contact both immediately and do not proceed. Trust your instincts – your safety is our priority. Never put yourself at risk.
Emergency Situations: If you feel threatened or unsafe during a lone working placement, leave immediately and contact emergency services if necessary. Then inform both El Roi management and the host organisation. We will support you fully.
Mandatory Check-in/Check-out Procedures for Home Visits
For all domiciliary care visits, agency workers must adhere to mandatory electronic or verbal check-in upon arrival at the client's home and check-out upon departure. This system ensures El Roi and the host organisation are aware of the worker's presence and safe completion of the visit. Non-compliance or missed check-ins will trigger escalation protocols to ensure worker safety.
Emergency Protocol and Escalation Procedures
Agency workers must be fully conversant with the emergency protocol provided by El Roi and the host organisation. This includes clear steps for various emergencies (e.g., medical, fire, personal threat). Escalation procedures involve immediate notification to the designated contacts at both El Roi and the host organisation, followed by a detailed incident report. Critical emergencies may require direct contact with emergency services before informing management.
Staff Safety During Home Visits: Personal Safety Measures
Agency workers must adopt personal safety measures when conducting home visits. This includes being aware of their surroundings, avoiding carrying valuables, ensuring their mobile phone is charged and accessible, and planning their route to and from the client's home, especially during unsocial hours. Workers should trust their instincts and withdraw from any situation they perceive as unsafe.
Risk Assessment for Lone Working in Different Client Homes
Prior to any lone working assignment in a client's home, a comprehensive, client-specific risk assessment must be conducted jointly by El Roi and the host organisation. This assessment will identify potential hazards related to the client's environment, condition, history, and the nature of the care required. Agency workers must review and understand these assessments before commencing care and report any discrepancies or new risks identified during the visit.
Communication Systems and Emergency Contact Procedures
Agency workers are required to carry a fully charged mobile phone with adequate signal during all lone working visits. They must have immediate access to a list of emergency contact numbers for both El Roi and the host organisation, as well as local emergency services. Communication protocols will outline how and when to use these contacts, ensuring timely support and intervention.
Procedures for Dealing with Aggressive or Threatening Situations
El Roi has a zero-tolerance policy for aggression or threats towards its agency workers. In the event of an aggressive or threatening situation, agency workers must: prioritise their personal safety, withdraw from the situation if possible, and immediately report the incident to both El Roi and the host organisation. If immediate danger exists, emergency services must be contacted without delay. Support and debriefing will be provided to affected workers.
Environmental Risk Assessment in Clients' Homes
While respecting client privacy, agency workers should conduct a basic environmental assessment upon arrival at a client's home, noting any immediate safety concerns (e.g., trip hazards, accessibility issues, lack of lighting). Any significant environmental risks that could compromise worker or client safety must be reported immediately to the host organisation and El Roi for resolution.
Buddy System and Support Networks
Where appropriate and feasible, El Roi encourages the use of a buddy system or informal support networks for agency workers engaged in lone working, particularly for new assignments or complex care situations. This involves a designated colleague or supervisor maintaining regular contact and offering peer support. Workers are encouraged to utilise internal El Roi support channels for advice and assistance.
Technology Solutions for Lone Worker Safety
El Roi may implement or recommend approved technology solutions to enhance lone worker safety, such as dedicated lone worker apps with GPS tracking, panic buttons, or automated check-in reminders. Agency workers are expected to familiarise themselves with and utilise any provided safety technology as part of their lone working duties.
Incident Reporting for Lone Working Safety Concerns
Any incident, near-miss, or concern related to lone working safety, no matter how minor, must be promptly and accurately reported through both El Roi's and the host organisation's incident reporting systems. This includes environmental hazards, challenging client behaviour, or issues with communication systems. Reporting ensures continuous improvement of safety policies and practices.
Training Requirements for Lone Working Safety
All agency workers undertaking lone working assignments must complete mandatory training on lone working safety. This training will cover risk assessment, personal safety techniques, communication protocols, emergency procedures, and the use of any specific safety equipment or technology. Refresher training will be provided periodically to ensure knowledge and skills remain current.
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19. Medication Support Policy
El Roi Ltd agency workers may only administer medication where they have received appropriate training and where the client organisation has provided clear guidance and authorisation. Agency workers must follow the specific medication policy and procedures of the host organisation at all times.
Training, Competency & Assessment
All agency workers involved in medication support must complete "Safe handling of medication" training as a pre-condition before undertaking any medication-related duties. This training must be refreshed as required by legislation and El Roi standards.
Staff Competency Assessment
Agency workers' competency in medication administration will be assessed during initial training and through ongoing supervision and spot checks in line with El Roi's and the host organisation's policies. Any identified gaps will be addressed through further training or direct supervision.
Recording and Documentation
Accurate and timely recording is crucial for safe medication management. Agency workers must adhere to the following:
Medication Administration Record (MAR) Charts
All medication administration, including dosages, times, and routes, must be recorded accurately on the host organisation's MAR chart immediately after administration.
Any refusal, omission, or partial dose must be clearly documented on the MAR chart with an explanation.
Signatures and initials must be clear and legible, corresponding to the agency worker's full name.
Ensure all required fields on the MAR chart are completed as per the host organisation's policy.
Follow the host organisation's specific recording procedures and timings.
Any errors, omissions, or concerns must be reported immediately to both the host organisation's designated person and El Roi Ltd.
PRN (As Required) Medication Protocols
When administering PRN medication, agency workers must:
Confirm the last dose administered and ensure the prescribed interval has elapsed.
Assess the individual's need for the medication based on their care plan and the reason for administration.
Document the reason for administration, the effect of the medication, and the individual's response on the MAR chart and relevant care records.
Report PRN administration to the host organisation's designated staff as per their procedures.
Medication Refusal Protocol
When an individual refuses medication, agency workers must:
Respect the person's right to refuse.
Follow the host organisation's refusal protocol, including offering alternatives if appropriate and possible.
Record the refusal accurately on the MAR chart, noting the reason if known.
Report the refusal to the appropriate person within the host organisation.
Inform El Roi Ltd if required by the host organisation's procedures.
Safe Storage Requirements
When medication is stored in a client's home, agency workers must ensure:
Medication is stored securely to prevent unauthorised access, ideally in a locked cabinet or box, as per the host organisation's policy and client risk assessment.
Medication is stored at the correct temperature and away from direct sunlight, moisture, and extreme temperatures.
Only current medication is stored; expired or discontinued medication must be returned to the host organisation or pharmacy for safe disposal according to local guidelines.
Medication Reconciliation Procedures
Agency workers will participate in medication reconciliation processes as required by the host organisation, which includes:
Verifying medication details (name, dose, frequency, route) against prescriptions, MAR charts, and actual medication.
Reporting any discrepancies to the host organisation's designated person immediately.
Ensuring accurate information is available for all transfers of care.
Controlled Drugs (CDs) Handling
If required to handle controlled drugs, agency workers must:
Adhere strictly to the host organisation's Controlled Drug policy and procedures, which must comply with current legislation.
Ensure dual signing for administration, receipt, and disposal of CDs where required.
Report any discrepancies or concerns with CD stock levels immediately.
Covert Medication Administration
Covert medication administration will only be undertaken if:
A formal mental capacity assessment has determined the individual lacks capacity to make decisions about their medication.
A best interests decision has been made and documented, involving relevant healthcare professionals and, where appropriate, family members.
It is legally authorised and explicitly detailed in the individual's care plan by the host organisation. Agency workers must never initiate covert administration without clear, documented authorisation.
Liaison with Healthcare Professionals and Pharmacies
Agency workers are expected to:
Liaise effectively with GPs, pharmacists, and other healthcare professionals as directed by the host organisation regarding medication queries, issues, or changes.
Ensure all communication is documented as per the host organisation's procedures.
Emergency Medication Procedures
Agency workers must be aware of and follow the host organisation's procedures for:
Emergency medication, such as rescue medication for epilepsy or anaphylaxis.
Knowing the location of emergency medication and how to administer it safely and effectively.
Documenting emergency medication administration and reporting it promptly to the host organisation and relevant healthcare professionals.
Host Organisation Responsibility
The client organisation retains full responsibility for their medication policy, procedures, and oversight. Agency workers are expected to work within these established systems and seek guidance from the host organisation's designated staff when needed.
Incident Reporting
Any medication incidents, errors, or near misses must be reported immediately to both El Roi Ltd and the host organisation's designated contact, following both organisations' incident reporting procedures. This includes:
**Immediate Reporting:** All incidents, including near misses, must be reported as soon as they are discovered.
**Documentation:** Complete all required incident reports accurately and comprehensively, including date, time, type of incident, individuals involved, and actions taken.
**Timescales:** Adhere to the host organisation's stipulated timescales for reporting and follow-up, typically within 24 hours for major incidents.
**Learning and Review:** Participate in any investigations or reviews as required, contributing to learning and preventing recurrence.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
20. Mental Capacity and Consent Policy for Agency Workers
El Roi Ltd agency workers must operate within the framework of the Mental Capacity Act 2005. This includes always assuming an individual has capacity to make their own decisions unless formally assessed otherwise, and seeking consent for all care and support. If an individual lacks capacity for a specific decision, agency workers must ensure decisions made on their behalf are in their best interests, in collaboration with the host organisation's team.
The Five Statutory Principles
1
1. Presumption of Capacity
Assume capacity unless proven otherwise through formal assessment.
2
2. Support to Decide
Take all practical steps to help individuals make their own decisions, guided by host procedures.
3
3. Unwise Decisions
Individuals have the right to make what others might consider unwise decisions; this does not imply a lack of capacity.
4
4. Best Interests
Any decision for someone lacking capacity must be in their best interests, as determined by host processes.
5
5. Least Restrictive
Consider less restrictive options before any actions impacting an individual's liberty or autonomy.
Assessing Capacity and Best Interests in Host Settings
Capacity is decision-specific and time-specific. When concerns arise, El Roi Ltd agency workers must follow the host organisation's procedures for capacity assessment, which evaluates the person's ability to understand, retain, weigh, and communicate a decision. Best interests discussions, involving family and professionals, must respect the individual's wishes and values, using the least restrictive option. Agency workers must also be aware of and adhere to host organisation policies regarding Deprivation of Liberty Safeguards (DoLS) and complete Mental Capacity Act (MCA) training, seeking guidance from both El Roi Ltd and host management when necessary.
When and How to Assess Capacity
Agency workers must initiate a capacity assessment when there is a reasonable belief that an individual may have impaired decision-making ability for a specific decision. This should always be in line with the host organisation's policy and conducted using the two-stage functional test:
Diagnostic Test: Does the person have an impairment of the mind or brain, whether permanent or temporary?
Functional Test: Does the impairment mean the person is unable to:
Understand the information relevant to the decision?
Retain that information long enough to make a decision?
Use or weigh that information as part of the decision-making process?
Communicate their decision (by any means)?
The assessment must focus on the specific decision at hand and be conducted at the time the decision needs to be made, always seeking guidance from the host organisation's designated lead.
Step-by-Step Best-Interest Decision-Making Process
If an individual is deemed to lack capacity for a specific decision, agency workers must contribute to a best-interest decision-making process as guided by the host organisation. This typically involves:
**Consider all relevant circumstances:** This includes the individual's past and present wishes, feelings, beliefs, and values.
**Involve the individual:** Support the person to participate as much as possible in the decision, even if they lack capacity.
**Consult relevant people:** Engage family, friends, carers, and other professionals who know the person well.
**Avoid discrimination:** Do not make assumptions based on age, appearance, or condition.
**Consider less restrictive options:** Explore if the same outcome can be achieved in a way that is less restrictive of the person's rights and freedom of action.
**Weigh up factors:** Balance all relevant factors to determine the decision that is in the individual's best interests.
Recording Requirements for Capacity Assessments and Best-Interest Decisions
Accurate and comprehensive record-keeping is critical. Agency workers must ensure that all discussions, assessments, and decisions related to mental capacity and best interests are fully documented within the host organisation's systems. This includes:
The specific decision being made.
Evidence of the two-stage capacity test.
Details of all practical steps taken to support the individual in making their own decision.
A clear rationale if capacity is determined to be lacking.
Records of all individuals consulted during the best interests decision-making process.
The outcome of the best interests decision and the reasons for it.
Any less restrictive options considered and why they were chosen or rejected.
Involvement of Family, Advocates, and Relevant Professionals
El Roi Ltd agency workers must actively support and facilitate the involvement of key individuals in capacity and best-interest decisions, in accordance with the host organisation's policies. This includes:
**Family and Friends:** Consulting those close to the individual who can offer insight into their past wishes, feelings, beliefs, and values.
**Independent Mental Capacity Advocates (IMCAs):** Referring for IMCA involvement where required by law (e.g., serious medical treatment, long-term change of accommodation, and in cases of Deprivation of Liberty Safeguards), and as per host procedures.
**Other Professionals:** Collaborating with doctors, nurses, social workers, and other specialists to gather all necessary information for a robust decision.
Specific Considerations for Domiciliary Care Settings
In domiciliary care settings, agency workers often work more autonomously. It is crucial to:
Be vigilant for subtle changes in an individual's capacity.
Ensure all capacity assessments and best interests decisions are made in conjunction with the host organisation and relevant family/professionals.
Understand the individual's home environment and routines as part of assessing their best interests.
Recognize that decisions about daily living (e.g., what to eat, wear) may still require capacity assessments.
Adhere strictly to the host organisation's communication protocols regarding capacity and consent with family and other care providers.
Documentation Templates and Record-Keeping Requirements
Agency workers must utilise the host organisation's approved documentation templates for all capacity assessments and best-interest decisions. These templates ensure consistency and compliance. All records must be:
Dated and signed/initialed by the agency worker and any other professionals involved.
Clear, concise, and factual.
Stored securely and confidentially, in line with GDPR and host organisation policies.
Accessible for review and audit purposes.
Review Processes for Capacity Decisions
Capacity is not static and can fluctuate. Agency workers must:
Be aware of and support the host organisation's schedule for reviewing capacity assessments and best-interest decisions.
Promptly report any changes in an individual's condition or circumstances that may impact their capacity to the host organisation's designated lead.
Advocate for re-assessment of capacity if there is reason to believe the individual's ability to make decisions has changed.
Understand that a lack of capacity for one decision does not mean a global lack of capacity for all decisions.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
Candour
20a. Duty of Candour Policy
Purpose: El Roi Ltd is committed to being open and honest when things go wrong in the provision of domiciliary care services.
Policy Statement: We will be transparent with service users, families, and relevant authorities when incidents occur that may have caused or could cause harm.
Key Requirements:
Immediate verbal apology and explanation when incidents occur
Written follow-up within 10 working days
Clear documentation of all duty of candour communications
Notification to CQC where required
Learning from incidents to prevent recurrence
Procedures:
Staff must immediately inform their line manager of any incident
Service users and families must be informed as soon as reasonably practicable
All communications must be documented
Follow-up meetings arranged where appropriate
Incident investigation and learning outcomes shared
This policy applies to all staff providing domiciliary care services and ensures compliance with CQC Regulation 20.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
20b. Care Planning and Risk Assessment Policy
Purpose: To ensure person-centred care planning and comprehensive risk assessment for all domiciliary care service users.
Policy Statement: All service users will receive individualised care plans based on thorough assessment of their needs, preferences, and risks, with regular reviews to ensure continued appropriateness.
Person-centred assessment process
Outcomes-focused care planning
Comprehensive risk assessment
Family and advocate involvement
Regular review requirements
Assessment Process:
Initial assessment within 48 hours of service commencement
Holistic assessment covering physical, mental, social, and environmental needs
Risk assessment covering personal safety, environmental hazards, and safeguarding
Service user preferences and desired outcomes identified
Family/carer input where appropriate and consented
Care Planning Requirements:
Clear, measurable outcomes
Specific interventions and approaches
Risk mitigation strategies
Emergency procedures
Communication preferences
Review Process:
Minimum monthly reviews or when needs change
Service user and family involvement in reviews
Documentation of any changes
Updated risk assessments as required
This policy ensures compliance with CQC Regulations 9 and 12.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
21. Modern Slavery & Human Trafficking Policy
Purpose
El Roi Ltd is committed to preventing modern slavery and human trafficking across all operations and supply chains.
Policy Statement
We maintain a zero-tolerance approach to modern slavery, acting ethically and transparently with robust controls to prevent exploitation.
Our Commitment
Ensure rigorous safer recruitment checks for all staff.
Partner only with suppliers upholding anti-slavery standards.
Provide staff training on exploitation signs and reporting.
Investigate and report all suspicions of slavery or trafficking.
Signs to Look Out For
Workers who appear controlled or fearful
Workers who don't hold their own ID documents
Workers living in poor or overcrowded conditions
Workers who seem unaware of their rights or pay arrangements
Workers who are dropped off/collected by the same person
Designated Lead
El Roi Ltd has appointed a designated Modern Slavery Lead responsible for overseeing compliance with this policy, coordinating training, and acting as the first point of contact for any concerns. The current designated lead is the Managing Director of El Roi Ltd.
Transparency in Supply Chain Statement
In line with best practice under the Modern Slavery Act 2015, El Roi Ltd produces an annual Modern Slavery and Human Trafficking Transparency Statement, which is reviewed and approved by the Board/Directors and published on our website. This statement outlines the steps taken during the year to prevent modern slavery in our operations and supply chains.
Responsibility
This policy applies to all employees, agency staff, contractors, and partners, with annual review by management.
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22. Professional Boundaries Policy
El Roi Ltd staff must maintain clear, respectful, and appropriate boundaries with agency workers and professional boundaries with client organisations at all times. Personal relationships, financial involvement, or overfamiliarity are not permitted with agency workers. All contact must be professional and within the scope of your role as a representative of El Roi Ltd.
Why Boundaries Matter
Professional boundaries protect El Roi Ltd, its staff, and its agency workers. They ensure that the relationship remains professional, purposeful, and in the best interests of the agency worker, aligning with the needs of client organisations. Clear boundaries maintain professional integrity, prevent exploitation, and uphold public trust in care staffing services. While we encourage supportive and professional relationships with agency workers, these must always remain within professional limits. Boundaries are not about being cold or distant – they are about maintaining a safe and respectful framework for engagement.
Prohibited Behaviours (with Agency Workers)
Accepting gifts of significant value or money
Borrowing or lending money
Entering into business arrangements
Romantic or sexual relationships
Sharing excessive personal information
Contact outside work duties (calls, social media)
Taking agency workers on personal outings
Appropriate Behaviours (with Agency Workers & Client Organisations)
Warm, friendly, professional manner
Respect for personal space and dignity
Cultural sensitivity and awareness
Clear communication about your role as an El Roi Ltd representative
Declining gifts politely or seeking permission
Maintaining confidentiality
Reporting boundary concerns promptly
Managing Difficult Situations
El Roi Ltd staff may occasionally face situations where maintaining boundaries is challenging, particularly when dealing with agency workers or representatives from client organisations. If an agency worker becomes overfamiliar, makes inappropriate requests, or offers gifts, you must politely decline and explain your professional obligations as an El Roi Ltd employee. Document the incident and inform your line manager immediately. If you feel uncomfortable or unsafe, remove yourself from the situation and seek support. We provide training and supervision to help staff navigate these complex interpersonal dynamics whilst maintaining compassionate and professional support for our agency workers.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
23. Quality Assurance Policy
Purpose
The purpose of this policy is to ensure that El Roi Ltd consistently delivers high-quality staffing services that meet the expectations of our clients, uphold CQC standards, and promote continuous improvement.
Commitment to Quality
We define quality as providing safe, reliable, and person-centred staffing support. Quality assurance is embedded into every aspect of our work — from recruitment and training to feedback and ongoing review.
Our Quality Standards
All staff are fully vetted and trained before placement.
Regular performance reviews and spot checks are conducted.
Clients are encouraged to provide ongoing feedback to monitor satisfaction.
Lessons learned from any concerns or incidents are shared and used to improve service delivery.
Monthly Audit Schedules and Checklists
Detailed monthly audit schedules are implemented across all service areas, utilising comprehensive checklists to ensure compliance with internal policies, CQC regulations, and best practice guidelines. Findings from these audits are documented, reviewed, and inform corrective actions.
Spot Check Procedures for Home Visits
We conduct unannounced spot checks on home visits to objectively assess the quality of care delivery, staff adherence to care plans, and the overall experience of service users. These checks are carried out by senior staff and include direct observation and service user engagement.
Incident Review Processes and Learning Outcomes
All incidents, concerns, or near misses are thoroughly investigated using a structured review process. The focus is on identifying root causes and extracting key learning outcomes, which are then disseminated to relevant staff and integrated into training and policy updates to prevent recurrence.
Continuous Improvement Cycles and Action Plans
El Roi Ltd operates a continuous improvement framework where quality findings, feedback, and incident reviews feed into regular action planning. These plans outline specific, measurable, achievable, relevant, and time-bound (SMART) objectives for enhancing service quality.
Service User Feedback Collection and Analysis
A systematic approach is employed to collect feedback from service users and their families through various channels, including surveys, direct communication, and reviews. This feedback is regularly analysed to identify trends, inform service development, and ensure person-centred care.
Staff Performance Monitoring and Development
Staff performance is continuously monitored through appraisals, supervision, observations, and feedback. Individual development plans are created to address training needs, promote professional growth, and ensure all staff possess the necessary skills and competencies.
Compliance Monitoring with CQC Regulations
Dedicated processes are in place to monitor ongoing compliance with all Care Quality Commission (CQC) fundamental standards and regulations. Regular internal audits and external inspections ensure that El Roi Ltd consistently meets or exceeds regulatory requirements.
Risk Management and Mitigation Strategies
Comprehensive risk assessments are conducted for all aspects of service delivery, from individual care plans to operational procedures. Robust mitigation strategies are developed and implemented to minimise potential risks to service users, staff, and the organisation.
Quality Metrics and Key Performance Indicators
Key Performance Indicators (KPIs) and quality metrics are established to quantitatively measure various aspects of service quality, including incident rates, service user satisfaction, staff retention, and training completion. These metrics are tracked and reviewed regularly.
Management Oversight and Governance Structures
Our governance structure includes clear lines of responsibility for quality assurance. Senior management provides direct oversight, ensuring that quality policies are implemented effectively, and all quality-related matters are regularly reported and addressed at the highest level.
External Quality Assurance and Benchmarking
El Roi Ltd actively participates in external quality assurance programs and benchmarking initiatives. This allows us to compare our performance against industry best practices and identify areas for further improvement based on broader sector insights.
Annual Quality Reports and Improvement Plans
An annual quality report is produced, summarising all quality assurance activities, findings, and performance against KPIs over the year. This report informs the development of the subsequent year's comprehensive quality improvement plan.
Monitoring and Review
Quality audits are completed quarterly, with findings reported to the Managing Director. This policy will be reviewed annually or sooner if required by regulatory change.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
24. Recruitment and Selection Policy
El Roi Ltd is committed to fair, transparent and safe recruitment of agency workers. All applicants for agency worker roles are subject to thorough checks, including right to work and Enhanced DBS. Shortlisting and interviews are based on merit, ensuring candidates are suitable for placement within our client organisations. We ensure compliance with safer recruitment practices in health and social care settings. Where any placements may involve contact with children, additional child protection checks and considerations apply, including Children's Barred List checks and compliance with statutory child protection guidance.
Safer Recruitment Principles
Recruiting the right agency workers is fundamental to supporting our client organisations in delivering safe, high-quality care. Our recruitment process is designed to attract, select, and appoint individuals who share our values and possess the competence to fulfil their roles effectively in diverse care settings. We follow best practice guidance from Skills for Care, the CQC, and the Disclosure and Barring Service.
1
Application Review
Scrutinise applications for gaps in employment history and verify qualifications relevant for agency worker roles.
2
Interview Assessment
Structured interviews exploring values, competencies, and scenarios relevant to working as an agency worker in various care settings.
3
Reference Checks
Obtain and verify references, exploring any concerns or gaps in employment history, crucial for agency worker suitability.
4
DBS and Right to Work
Enhanced DBS checks and verification of identity and eligibility to work in the UK for all prospective agency workers.
5
Conditional Offer
Employment offered conditional on satisfactory completion of all pre-employment checks, leading to placement eligibility.
Comprehensive Right to Work Checks and Documentation
All prospective agency workers undergo stringent Right to Work checks in accordance with UK legislation. This involves verifying original identity documents, confirming eligibility to work, and maintaining clear, auditable records of all documentation. Regular follow-up checks are conducted for individuals with time-limited visas to ensure continuous compliance.
Enhanced DBS Checking Procedures and Renewal Requirements
An Enhanced Disclosure and Barring Service (DBS) check is mandatory for all roles due to the nature of working with vulnerable individuals. We follow specific procedures for requesting and reviewing DBS certificates, including a robust risk assessment process for any disclosures. All agency workers are also checked against the Adults' Barred List, and where placements may involve children, the Children's Barred List, in line with the Safeguarding Vulnerable Groups Act 2006 and CQC regulations. We also ensure timely renewal of DBS checks in line with regulatory guidance to guarantee ongoing suitability.
Reference Checking Process with Minimum Requirements
A minimum of two satisfactory professional references are required, covering the last five years of employment or relevant experience. References are obtained directly from previous employers and validated. Specific questions are asked to ascertain suitability for care roles, honesty, reliability, and any disciplinary history. Any gaps in employment are thoroughly explored.
Competency Assessment Procedures
Beyond interviews, competency assessments are conducted to evaluate practical skills, knowledge, and judgment relevant to specific care roles. These may include practical tests, simulations, or scenario-based questions to ensure candidates possess the necessary capabilities to deliver safe and effective care.
Interview Processes and Assessment Criteria
Our interview process is structured and competency-based, designed to objectively assess candidates against role-specific criteria and our organisational values. All interviews are conducted by trained personnel using standardised questions and scoring matrices to ensure fairness and consistency in assessment. All interview panels must include at least two members, one of whom must be a senior manager or director of El Roi Ltd, and all panel members must have completed safer recruitment training.
Induction Requirements and Timescales
All new agency workers complete a comprehensive induction program before commencing any placements. This induction covers company policies, safeguarding, health and safety, relevant care standards, and client-specific protocols. The induction is completed within specified timescales and tailored to the individual's role and previous experience.
Probationary Period Procedures
New agency workers are subject to a probationary period, typically lasting three months, during which their performance, conduct, and suitability are closely monitored. Regular reviews are conducted, and support is provided to ensure successful integration and adherence to our standards.
Ongoing Suitability Checks
The suitability of all agency workers is continuously monitored through regular supervision, performance reviews, feedback from clients, and annual appraisals. Any concerns regarding performance or conduct are addressed promptly through established disciplinary procedures.
Professional Registration Verification where Applicable
For roles requiring professional registration (e.g., Nurses, Allied Health Professionals), we verify current registration with the relevant professional body (e.g., NMC, HCPC) before placement and monitor its ongoing validity. Any lapse in registration immediately invalidates placement eligibility.
Health Clearance Requirements
All agency workers are required to undergo health assessments to ensure they are medically fit to perform their duties without posing a risk to themselves or others. This includes vaccination status for certain communicable diseases as required by health and social care settings.
Online and Social Media Checks
As part of safer recruitment, El Roi Ltd may conduct proportionate online searches and review publicly available social media profiles of shortlisted candidates. Any information gathered through these checks is assessed fairly, consistently, and in line with GDPR requirements and equal opportunities principles.
Equal Opportunities in Recruitment
All recruitment decisions are based solely on merit, skills, qualifications, and suitability for agency worker roles within client organisations. We do not discriminate on the basis of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, or sexual orientation. Interview panels receive regular training on fair selection practices and unconscious bias. Job descriptions and person specifications clearly define the essential requirements for each agency worker role. We actively welcome applications from diverse candidates and are committed to making reasonable adjustments for disabled applicants throughout the recruitment process, ensuring an inclusive and accessible selection experience.
Record Keeping for Recruitment Decisions
Detailed and accurate records are maintained for every stage of the recruitment and selection process. This includes application forms, interview notes, assessment outcomes, DBS certificates, Right to Work documentation, references, and professional registration verification. These records are securely stored, accessible for audit, and retained in accordance with data protection regulations and CQC requirements.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
25. Reference Policy
El Roi Ltd requires at least two references for agency workers during recruitment for placement with client organisations. While employment references are preferred, character references or recent payslips may be accepted in specific circumstances, ensuring a balance between safe recruitment and confidentiality.
Reference Requirements and Verification
References are crucial for assessing an agency worker's suitability and work history. We typically seek two employment references covering the most recent two years, ideally from supervisors with direct knowledge of performance.
Employment References
Written references from previous employers confirming employment dates, role, performance, conduct, attendance, and reason for leaving. We investigate any concerns or employment gaps.
Character References
Accepted when employment references are unavailable (e.g., new entrants). These must verify integrity, reliability, and suitability for care work from professional contacts.
Payslip Verification
A recent payslip may be accepted as proof of employment for confidentiality reasons, supplemented by other verification methods.
Reference Verification Process
All references are verified for authenticity by contacting referees directly using independently sourced details. We ask specific questions regarding suitability for working with vulnerable adults, disciplinary history, and re-employment prospects. Vague responses prompt further investigation, and concerns may lead to withdrawal of a placement offer.
For internal promotions or role changes, external previous employer references are still required if the agency worker has been with El Roi Ltd for less than two years, ensuring a complete work history.
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26. Safeguarding Policy
El Roi Ltd is committed to safeguarding vulnerable individuals. Agency workers must report any concerns about abuse or neglect immediately to both their El Roi line manager and the host organisation's safeguarding lead. We operate in accordance with the Care Act 2014 and expect workers to follow both El Roi's and client organisation's safeguarding policies. All allegations will be investigated promptly. Mandatory safeguarding training is required for all agency workers.
Immediate Reporting Obligation
Report all concerns about abuse or neglect without delay to your El Roi line manager, the designated safeguarding lead within the host client organisation, and the local authority safeguarding team.
Compliance & Adherence
Agency workers must comply with the Care Act 2014, local safeguarding authority requirements, and the safeguarding policies of both El Roi and the host client organisation.
Mandatory Training
Regular safeguarding training and refresher courses are required for all El Roi agency workers to meet CQC standards and ensure up-to-date knowledge and skills.
Key Responsibilities of Agency Workers
Every El Roi agency worker has a personal responsibility to protect vulnerable individuals from harm within the client organisations where they are placed. This includes being vigilant to signs of abuse, whether physical, emotional, financial, sexual, or neglect. Agency workers must maintain professional boundaries whilst building trusting relationships with the individuals they support.
Any suspicion or disclosure must be documented accurately and reported through proper channels to both El Roi and the host client organisation, as well as the relevant local authority, without delay. El Roi Ltd takes a zero-tolerance approach to abuse and will work closely with client organisations, local authorities, police, and regulatory bodies to ensure swift and appropriate action for any reported incidents involving our agency workers.
Safeguarding During Home Visits
When working in domiciliary care settings, agency workers must be particularly vigilant to signs of abuse or neglect within the individual's home environment. This includes observing the living conditions, interactions with family members or other household members, and the individual's overall well-being. Any concerns regarding potential abuse involving family members or others in the household must be reported immediately, following the same dual reporting obligation to El Roi, the client organisation, and the local authority.
Escalation Pathway for Safeguarding Concerns
If you have a safeguarding concern:
Immediately report the concern to your El Roi line manager and the host client organisation's designated safeguarding lead.
If immediate action is required to prevent harm, contact emergency services (e.g., 999) or the local authority adult social care team directly.
Document all observations, actions taken, and communications accurately and promptly.
El Roi will review the report and escalate to the relevant local authority safeguarding team if not already done, and collaborate on further investigation and action.
If you feel your concerns are not being adequately addressed, you must escalate internally within El Roi Ltd to a senior manager or designated safeguarding officer.
Local Authority Safeguarding Procedures
El Roi Ltd adheres to the local authority safeguarding adults procedures in the areas where our services are provided. Agency workers must familiarize themselves with these procedures, which outline the specific steps for reporting concerns, multi-agency responses, and support available for vulnerable adults. Contact details for local authority safeguarding teams will be provided during induction and are available via your El Roi line manager.
Documentation Requirements for Safeguarding Incidents
Accurate and timely documentation is crucial for all safeguarding concerns. Agency workers must record:
Date, time, and location of the incident or concern.
Description of the concern, including specific observations and any direct disclosures.
Details of the individual(s) involved.
Actions taken, including who was informed, when, and by what method.
Any immediate risks identified and steps taken to mitigate them.
All documentation must be factual, objective, and retained securely in accordance with data protection guidelines.
Multi-Agency Working Protocols
El Roi Ltd is committed to effective multi-agency working to safeguard vulnerable individuals. We will cooperate fully with local authorities, police, health services, and other relevant agencies in the investigation and management of safeguarding concerns. Our protocols ensure that information is shared appropriately, within legal frameworks, to facilitate coordinated responses and positive outcomes for those at risk.
Remember: Safeguarding is everyone's responsibility. As an El Roi agency worker, if you see something concerning, speak up immediately to both El Roi, the host organisation, and the local authority. Your vigilance could protect someone's life and wellbeing.
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27. Supervision and Appraisal Policy
El Roi Ltd provides regular supervision and annual appraisals for all agency workers. These sessions offer essential support, feedback, and opportunities for performance review and training discussions, tailored to roles within client organisations. Supervision is a recorded, two-way process, often conducted remotely to accommodate off-site placements.
Purpose of Supervision
Supervision is crucial for professional development and quality care. It allows agency workers to reflect on their practice, discuss challenges, identify learning needs, and feel supported and valued. It also enables El Roi managers to monitor performance, address concerns early, incorporate client feedback, and ensure compliance with all policies.
1
Supervision Frequency
Agency Support Workers and Health Care Assistants receive supervision at least every 6-8 weeks, with increased frequency for new or probationary workers. Senior staff and managers have quarterly supervision, often via remote communication.
2
Supervision Agenda
Sessions cover workload, performance, adherence to procedures, training needs, wellbeing, and policy updates. Client feedback is discussed, and workers are encouraged to contribute agenda items.
3
Annual Appraisals
Comprehensive annual reviews evaluate performance against objectives, incorporating client feedback. They identify career aspirations, set future goals, and ensure continuous professional development and adherence to standards.
Effective Supervision Practice
Supervision sessions should be confidential and free from interruptions. Both supervisor and supervisee must prepare by reflecting on key issues and feedback. Discussions should be honest, constructive, and solution-focused. Records are confidential, and agreed actions must be followed up.
Your Wellbeing Matters: Supervision is an important opportunity to discuss your wellbeing, work-life balance, and any personal circumstances affecting your work. We aim to ensure you feel fully supported to perform effectively and safely in any placement.
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28. Training Requirements Policy
All El Roi Ltd agency workers must complete comprehensive training before undertaking any unsupervised work within client organisations. Training ensures competency, safety, and regulatory compliance across all placements. This policy outlines the mandatory training requirements in line with Care Quality Commission (CQC) regulations and best practice.
Comprehensive Mandatory Training
El Roi Ltd mandates a comprehensive training program for all agency workers. This includes induction training and ongoing mandatory refreshers, with specific timescales to ensure continued competence and compliance.
Mandatory Induction Training
New agency workers must complete mandatory induction training covering the following essential topics. This training must be completed and competencies assessed prior to any unsupervised work:
1
Safeguarding vulnerable adults (within 2 weeks)
2
Moving and handling (within 2 weeks)
3
Infection prevention and control (within 2 weeks)
4
Health and safety awareness (within 2 weeks)
5
Equality, diversity, and inclusion (within 2 weeks)
6
Professional boundaries and conduct (within 2 weeks)
7
Confidentiality and GDPR compliance (within 2 weeks)
8
Basic Life Support/First Aid (within 4 weeks)
9
Fire Safety (within 4 weeks)
10
Food Hygiene (if applicable, within 4 weeks)
Home-Specific Training
Additional training may be required by client organisations to ensure workers are familiar with their specific care procedures, emergency plans, medication policies, and equipment use. This training is mandatory for working in that particular environment.
Shadowing
Agency workers may be required to complete shadowing with experienced staff for familiarity with specific practices and client needs before undertaking independent work. The duration of shadowing will be determined by the client organisation and El Roi Ltd manager.
Annual Refresher Training Requirements
All mandatory training modules must be refreshed annually or more frequently as dictated by legislative changes, client requirements, or industry best practice. Key annual refreshers include:
Safeguarding vulnerable adults
Moving and handling
Infection prevention and control
Basic Life Support/First Aid
Fire Safety
Health and Safety awareness
Training must be refreshed according to:
Legislative requirements
(typically annual)
El Roi Ltd standards
Client requirements
Industry best practice
Supervision Structure and Frequency
In addition to formal appraisals (as per Policy 27), all agency workers will receive regular supervision sessions, ideally on a monthly basis, or more frequently for new workers or those requiring additional support. These sessions provide an opportunity for reflection, feedback, and identification of further training needs related to CQC requirements and worker performance.
Observed Competency Checks and Assessment Procedures
Practical skills and theoretical knowledge are assessed through various methods, including written assessments, practical demonstrations, and direct observation of practice in a simulated or real work environment. Competency checks are conducted at induction, during refresher training, and whenever a specific need is identified, to ensure skills meet the required standards.
Training Records and Documentation Requirements
Comprehensive records of all training undertaken, including dates, modules completed, assessment results, and any identified development needs, are maintained in each worker's personnel file. Workers are responsible for providing certificates or evidence of external training, which will be logged and verified by El Roi Ltd. These records are subject to regular audits for CQC compliance.
Specialist Training for Specific Client Needs
Where a client's needs require specialist care that goes beyond standard mandatory training (e.g., peg feeding, tracheostomy care, advanced dementia care), El Roi Ltd will ensure that workers deployed to such roles receive specific, certified training prior to commencing work. This training is tailored to the individual client's care plan and is mandatory for these specific assignments.
Emergency Training and Procedures
All workers receive training on emergency procedures relevant to healthcare settings, including but not limited to fire safety, evacuation procedures, basic life support, and incident reporting. Client-specific emergency plans are also covered during home-specific training. Regular drills and refreshers are conducted as appropriate.
Continuous Professional Development (CPD) Requirements
El Roi Ltd encourages and supports the continuous professional development of its agency workers. Workers are expected to engage in ongoing learning to enhance their skills and knowledge, keeping abreast of new practices and regulations. CPD activities, such as attending workshops, seminars, or completing e-learning modules, should be recorded and discussed during supervision and appraisal.
Training Evaluation and Effectiveness Monitoring
The effectiveness of all training programs is regularly evaluated through feedback from workers and client organisations, assessment results, and observations of practice. This continuous monitoring helps to identify areas for improvement, ensure training content remains relevant, and demonstrates its impact on service quality and safety in line with CQC expectations.
External Training Providers and Quality Assurance
Where external training providers are utilised, El Roi Ltd conducts due diligence to ensure they meet high standards of quality and deliver CQC-compliant content. Providers are assessed based on their accreditation, trainer qualifications, course content, and feedback from previous participants. Only approved providers are used to ensure the integrity of our training program.
Staff Training Matrices and Tracking Systems
El Roi Ltd maintains a robust training matrix and tracking system to monitor each worker's training status, upcoming refreshers, and identified development needs. This system ensures that all workers remain compliant with mandatory training requirements and are appropriately matched to placements based on their competencies. Managers regularly review the matrix to ensure compliance and plan future training initiatives.
Workers are responsible for attending scheduled training and maintaining competency.
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29. Uniform and PPE Policy
Where applicable, El Roi Ltd will provide uniform and required PPE. Agency workers are responsible for keeping uniforms clean and wearing them appropriately. PPE must be worn according to health and safety guidance provided by El Roi Ltd and the client organisation. Damaged PPE should be reported immediately.
Professional Appearance
Uniforms promote a professional image and help client organisations identify El Roi Ltd agency workers. Where uniforms are provided, they must be worn for all duties within client organisations' settings unless otherwise instructed. Uniforms should be clean, well-maintained, and worn with appropriate footwear.
Disposable Gloves
Single-use gloves must be worn for all personal care tasks and when handling bodily fluids, adhering to the client organisation's infection control policies. Change between tasks and never wash and reuse disposable gloves. Dispose of in clinical waste bins.
Disposable Aprons
Wear aprons during personal care, food preparation, and cleaning tasks, as per the client organisation's guidelines. Change aprons between different service users within a client organisation's setting and different tasks. Remove carefully to avoid contamination and dispose of properly.
Face Masks
Use appropriate face masks when indicated by the client organisation's infection control procedures or when working with immunocompromised service users. Follow current public health guidance and client-specific care plans and procedures.
PPE Stock and Maintenance
El Roi Ltd provides adequate supplies of PPE to all agency workers and ensures regular replenishment. Agency workers must check PPE supplies before shifts and request additional stock in advance if running low. Any defective or damaged PPE must be reported immediately and replaced before use. Never use damaged or ill-fitting PPE as it compromises both your safety and infection control procedures. Training on correct PPE usage is mandatory and will be refreshed regularly to ensure competence and confidence. Agency workers must also adhere to the PPE maintenance and storage policies of the client organisation during their placement.
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29a. Home Visit Protocol Policy
Purpose: To ensure safe, professional, and respectful conduct during all home visits while maintaining service user dignity and safety.
Policy Statement: All staff must follow established protocols when visiting service users' homes, respecting their privacy and maintaining professional standards at all times.
Staff Identification Requirements
All staff must carry and display official El Roi Ltd identification
Staff must introduce themselves and show ID before entering any home
Identification must include photo, name, and contact details
Replacement ID must be requested immediately if lost or damaged
Arrival and Departure Procedures
Log arrival time and any relevant observations
Complete departure log with time and summary of visit
Report any concerns or changes in client condition immediately
Ensure all documentation is completed before leaving
Respecting Clients' Homes
Remove shoes if requested by client or family
Respect house rules and cultural preferences
Maintain cleanliness and tidiness
Ask permission before using facilities or moving items
Respect privacy and personal belongings
Environmental Risk Reporting
Assess and report any safety hazards in the home
Document environmental risks that could affect care delivery
Report maintenance issues that could impact client safety
Escalate urgent safety concerns immediately
Emergency Procedures
Know location of emergency exits and contact numbers
Understand client-specific emergency procedures
Have access to emergency services contact information
Follow lone working safety protocols at all times
This policy ensures safe, respectful, and professional home visits in compliance with CQC requirements.
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30. Whistleblowing Policy
El Roi Ltd agency workers are encouraged to raise concerns about wrongdoing, risks, or malpractice observed within their placement with client organisations. You can report issues to your El Roi manager, or confidentially to a senior leader. We protect whistleblowers from victimisation under the Public Interest Disclosure Act 1998.
Protecting Agency Workers
El Roi Ltd is committed to maintaining high standards of honesty, openness, and accountability. We recognise that agency workers may sometimes need to raise serious concerns about practices that could harm vulnerable individuals, other staff, client organisations, or El Roi Ltd itself.
What to Report
Danger to health and safety of individuals in care settings
Criminal activity or fraud (e.g., within the client organisation or by other staff)
Failure to comply with legal or regulatory obligations (e.g., CQC, local authority)
Miscarriages of justice or abuse
Environmental damage
Breaches of care procedures or policies within the host setting
Deliberate concealment of wrongdoing
How to Report
Speak to your El Roi line manager
Contact an El Roi senior manager or director
Use El Roi's confidential hotline
Submit a written report to El Roi Ltd
For safeguarding concerns, report immediately to both El Roi Ltd and the host organisation's designated safeguarding lead.
Contact external bodies (e.g., CQC, police, local authority safeguarding teams) if internal routes are not appropriate or adequately addressed
Your Protection
Confidentiality maintained wherever possible
No victimisation or dismissal for genuine concerns raised by agency workers
Support provided throughout the process by El Roi Ltd
Legal protection under PIDA 1998
Anonymous reporting options available
Our Response
All whistleblowing concerns will be taken seriously and investigated promptly in conjunction with relevant client organisations. You will receive acknowledgement and updates where possible. El Roi Ltd will not tolerate harassment or victimisation of whistleblowers. Agency workers raising genuine concerns in good faith will be supported, even if unfounded. Malicious allegations may result in disciplinary action.
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31. Employee Conduct & Disciplinary Policy
El Roi Ltd is committed to fostering a fair, respectful, and productive working environment for all its employees and agency workers. This policy outlines the standards of conduct expected and the procedures that will be followed when these standards are not met. Our aim is to address issues consistently, transparently, and in a manner that supports both individual development and the integrity of our services. We adhere strictly to the ACAS Code of Practice on Disciplinary and Grievance Procedures and the Employment Rights Act 1996, ensuring all actions are legally compliant and just.
Scope
This policy applies to all employees and agency workers engaged by El Roi Ltd, covering their conduct both when working directly for El Roi Ltd and during assignments with client organisations. All individuals are expected to familiarise themselves with and adhere to this policy.
Informal Resolution
For minor issues of conduct or performance, El Roi Ltd encourages an initial informal approach. Where appropriate, line managers should first seek to resolve concerns through a constructive conversation with the employee or agency worker. This informal discussion should aim to clarify expectations, offer support or training, and agree on a clear path for improvement without resorting to formal procedures. Documentation of such informal discussions may be kept but will not form part of a formal disciplinary record unless the matter escalates.
Formal Disciplinary Procedure
When informal resolution is unsuccessful, or the nature of the misconduct warrants a formal approach, El Roi Ltd will follow a structured disciplinary procedure. This ensures fairness and due process at every stage.
Investigation
A thorough and impartial investigation will be conducted to establish the facts. This may involve reviewing documents, collecting evidence, and interviewing the individual concerned and any relevant witnesses. The purpose is to gather all necessary information before deciding if disciplinary action is appropriate.
Invitation to Disciplinary Hearing
If the investigation suggests there is a case to answer, the individual will receive a written invitation to a disciplinary hearing. This notice will be provided with at least 48 hours' notice, clearly stating the alleged misconduct, the potential consequences, and advising of the right to be accompanied by a colleague or trade union representative.
Disciplinary Hearing
The hearing provides an opportunity for the individual to respond to the allegations, present their version of events, and ask questions about any evidence presented. The accompanying person may also address the hearing, sum up the individual's case, and confer with them. The hearing will be conducted by a manager who has not been involved in the investigation where possible.
Decision and Outcome
Following the hearing, a decision will be made based on the balance of probabilities and communicated in writing. This letter will detail the findings, the disciplinary sanction (if any), the reasons for the decision, and clearly explain the right of appeal.
Right of Appeal
Individuals have the right to appeal any formal disciplinary decision. Appeals must be submitted in writing, stating the grounds for appeal, within 5 working days of receiving the decision. The appeal will be heard by a more senior manager (or an independent panel where appropriate) who has not previously been involved in the case.
Disciplinary Sanctions
The level of sanction applied will depend on the seriousness of the misconduct and any previous disciplinary record. El Roi Ltd employs a progressive approach, though certain acts of gross misconduct may lead directly to summary dismissal.
First Written Warning
Issued for minor misconduct or unsatisfactory performance. It will outline the issue, expected improvements, a review period, and a warning that further misconduct may lead to a Final Written Warning. Typically remains active for 6-12 months.
Final Written Warning
Issued for more serious misconduct, failure to improve after a First Written Warning, or repeated minor infractions. It will reiterate the issues, consequences of further misconduct (including dismissal), and a final opportunity for improvement. Typically remains active for 12 months.
Dismissal with Notice
Applied in cases where a Final Written Warning has not led to the required improvement, or for serious misconduct that is not gross misconduct. The individual's employment or engagement will be terminated with appropriate notice.
Summary Dismissal (Gross Misconduct)
This is immediate dismissal without notice for acts of gross misconduct. The employment or engagement relationship is terminated instantly due to a fundamental breach of contract or trust, making continued employment untenable.
Gross Misconduct
Gross misconduct is behaviour so serious that it fundamentally breaches the contract of employment or engagement and justifies immediate dismissal without notice. Examples include, but are not limited to:
Theft or fraud.
Physical violence, threats of violence, or serious verbal abuse.
Serious safeguarding breaches or actions that endanger the safety or well-being of service users or colleagues.
Working under the influence of alcohol or illegal drugs, or drug/alcohol misuse at work.
Serious breaches of confidentiality, including inappropriate disclosure of sensitive information.
Falsification of records, timesheets, or qualifications.
Serious insubordination or refusal to carry out reasonable instructions.
Harassment or bullying of colleagues, service users, or client staff.
Serious damage to company property or client property.
Grievance Procedure
El Roi Ltd is committed to resolving grievances fairly and promptly. Employees and agency workers who have a grievance relating to their employment or engagement (e.g., terms and conditions, working environment, relationships with colleagues or management) should first attempt to resolve it informally with their line manager.
If informal resolution is not possible or appropriate, a formal grievance should be raised in writing to their El Roi Ltd line manager or a senior manager. This written grievance should outline the nature of the complaint and any desired outcome.
El Roi Ltd will acknowledge receipt of the formal grievance within 5 working days and arrange a grievance hearing as soon as reasonably practicable. The employee or agency worker has the right to be accompanied at this hearing. Following the hearing, the outcome will be communicated in writing, and there will be a right of appeal to a more senior manager.
This policy does not form part of any contract of employment or engagement and may be reviewed and updated by El Roi Ltd at its discretion. All procedures outlined herein are compliant with the ACAS Code of Practice on Disciplinary and Grievance Procedures and the Employment Rights Act 1996.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
32. Anti-Bribery & Corruption Policy
El Roi Ltd maintains a steadfast commitment to conducting all business dealings with the highest standards of integrity and ethics. We operate with a zero-tolerance approach to bribery and corruption in all its forms, whether direct or indirect. This policy outlines our position on preventing and prohibiting bribery and corruption, ensuring compliance with legal and ethical obligations in every jurisdiction where we operate.
This policy applies to all employees, agency workers, contractors, consultants, and any third parties acting on behalf of El Roi Ltd, regardless of their location, seniority, or role. Strict adherence to these principles is mandatory for everyone associated with our organisation.
We are governed by the principles of the Bribery Act 2010, which provides a comprehensive legal framework for preventing and prosecuting bribery offenses. Breaches of this Act carry severe criminal penalties, including imprisonment for up to 10 years for individuals and unlimited fines for corporate entities. Furthermore, engaging in bribery or corruption can lead to significant reputational damage, loss of trust, and potential commercial repercussions for El Roi Ltd and its stakeholders.
Defining Bribery and Corruption
Bribery involves offering, promising, giving, requesting, or accepting a financial or other advantage with the intent to induce or reward the improper performance of a function or activity. This improper performance refers to any activity connected with a business, employment, or a public function that is expected to be performed impartially, in good faith, or in accordance with a position of trust. Corruption, in a broader sense, encompasses any dishonest or fraudulent conduct by those in power, typically involving bribery.
Types of Bribery Offences under the Bribery Act 2010
Bribing Another Person
This offence covers situations where an individual offers, promises, or gives a financial or other advantage to another person, intending to induce them to perform a relevant function or activity improperly, or as a reward for doing so.
Being Bribed
This relates to situations where a person requests, agrees to receive, or accepts a financial or other advantage for performing a relevant function or activity improperly. It includes both direct receipt and instances where a third party receives the advantage on their behalf.
Bribing a Foreign Public Official
This specific offence targets bribery of officials in other countries to obtain or retain business or an advantage in the conduct of business. It occurs when a person offers, promises, or gives a financial or other advantage to a foreign public official intending to influence them in their capacity as a public official.
Failure of a Commercial Organisation to Prevent Bribery
This corporate offence holds El Roi Ltd strictly liable if a person associated with it (e.g., an employee, agent, or subsidiary) bribes another person intending to obtain or retain business or an advantage for El Roi Ltd. The only defence is if El Roi Ltd had adequate procedures in place to prevent such bribery.
What is NOT Bribery
While El Roi Ltd maintains a strict stance against bribery, we recognise that certain legitimate business practices are not considered bribery. These include:
Reasonable and Proportionate Hospitality: Providing or accepting reasonable and proportionate hospitality (e.g., meals, attendance at sporting events) that serves a legitimate business purpose, such as building relationships, promoting services, or networking, and is not intended to influence improper performance. Such hospitality should be infrequent, moderate in value, and transparently accounted for.
Promotional Gifts of Nominal Value: Offering or accepting promotional gifts (e.g., branded pens, calendars) of nominal value (typically under £25) that are part of legitimate marketing or promotional activities and are not intended to influence improper performance.
Charitable Donations: Making charitable donations that are transparent, made in good faith to bona fide charities, and not linked to any expectation of business advantage or improper influence.
Any gifts, hospitality, or donations outside these guidelines must be approved by a senior manager and documented.
Red Flags to Watch For
To assist in identifying potential bribery or corruption, all personnel should be alert to the following "Red Flags":
Requests for cash payments or payments to unusual bank accounts.
Unusual payment arrangements, such as requests for payments to be made through a third country or to a different entity than the service provider.
Excessive or lavish gifts, hospitality, or entertainment offered or requested.
Requests to falsify invoices, records, or expense claims.
Third parties or business partners with a poor reputation for ethics, or those who insist on dealing with public officials on our behalf without clear justification.
Unjustified sole-source contracts or preferential treatment for certain suppliers.
Responsibilities
Refuse Bribes: All individuals must actively refuse any offer or request for a bribe, and promptly report it.
Report Suspicions: Promptly report any suspicions or concerns about bribery or corruption, even if they are not directly involved.
Declare Conflicts of Interest: Declare any potential conflicts of interest that could be perceived to influence business decisions improperly.
Maintain Accurate Records: Ensure all financial records, invoices, and expense reports are accurate, transparent, and reflect the true nature of transactions.
Reporting Procedures
If you suspect any act of bribery or corruption, or if you are unsure whether a particular action might constitute a breach of this policy, you must report your concerns immediately. Initially, you should report to your line manager. If this is not appropriate or if you feel unable to do so, you should utilise El Roi Ltd's Whistleblowing Policy, which provides a confidential mechanism for reporting serious concerns.
All reports will be treated with the utmost confidentiality and investigated thoroughly and impartially. El Roi Ltd assures that no individual will suffer any detrimental treatment as a result of reporting genuine concerns in good faith, even if, after investigation, no wrongdoing is found.
Consequences of Breach
Any breach of this Anti-Bribery & Corruption Policy by an employee, agency worker, or contractor will be considered a serious disciplinary matter, potentially leading to disciplinary action up to and including immediate dismissal without notice. In cases where criminal activity is suspected or confirmed, El Roi Ltd may report the matter to the appropriate law enforcement authorities.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
33. Social Media Policy
El Roi Ltd recognises the powerful role social media plays in modern communication, offering valuable opportunities for engagement, networking, and sharing positive news. However, this power must be balanced with the critical need to protect our organisation, the privacy and dignity of our service users, and the professional integrity of our staff. This policy outlines the expected standards of conduct when engaging with social media, ensuring responsible and ethical use at all times.
Scope of Policy
This policy applies to all individuals associated with El Roi Ltd, including employees, agency workers, and contractors. Its scope extends to both professional and personal use of social media platforms, specifically where such use relates to El Roi Ltd, our client organisations, our service users, or any activities undertaken in connection with our business. This includes any online content that could reasonably be associated with El Roi Ltd, whether directly or indirectly.
Definition of Social Media
For the purposes of this policy, "social media" encompasses a broad range of online communication tools and platforms. These include, but are not limited to: Facebook, Instagram, X (formerly Twitter), TikTok, LinkedIn, WhatsApp groups, YouTube, blogs, discussion forums, wikis, and any other current or future online platforms that facilitate user-generated content and interaction.
Key Rules for Social Media Engagement
Protect Service User Privacy
Never post, share, or disclose any information about service users, including photos, videos, or any identifiable personal details, regardless of privacy settings. Maintaining confidentiality is paramount.
Uphold Organisational Reputation
Refrain from posting any content that could bring El Roi Ltd or our client organisations into disrepute, including negative comments, criticism, or sensitive information. Professionalism must always be maintained.
Safeguard Confidential Information
Under no circumstances should confidential or commercially sensitive information belonging to El Roi Ltd, our clients, or our service users be shared on any social media platform.
Avoid Defamatory & Discriminatory Content
Do not make defamatory, discriminatory, harassing, or bullying comments about colleagues, clients, service users, or competitors. Treat all individuals with respect and dignity.
Manage Work-Time Usage
Do not use social media for personal purposes during working hours unless explicitly authorised by your line manager or specified as part of your role (e.g., managing official company accounts).
Professional Use of Social Media
When using professional social media platforms, such as LinkedIn, or if your personal profiles are publicly linked to your association with El Roi Ltd, it is crucial that your online presence reflects the values and professional standards of the company. Staff are permitted to share positive news, achievements, or publicly available information about El Roi Ltd. However, no individual is authorised to make claims, statements, or representations on behalf of El Roi Ltd without prior written consent from senior management.
Personal Use of Social Media
El Roi Ltd respects the right of its staff to a private life outside of work. However, individuals must be aware that content posted on personal social media accounts, even with privacy settings, can often be traced back to the organisation. Therefore, you must exercise caution and good judgment. If you express personal views that could be misinterpreted as representing El Roi Ltd, you must clearly state that these are your own personal opinions and not those of the company.
Safeguarding and Social Media
Safeguarding our service users is a top priority. When using social media, staff must strictly adhere to the following safeguarding rules:
Never accept "friend" requests or engage in direct communication with service users or their family members on personal social media platforms.
Never share photos, videos, or any personal information relating to service users or their environments on social media, even if anonymised, as this could inadvertently lead to identification.
Immediately report any safeguarding concerns, inappropriate content, or potential policy breaches identified through social media to your line manager or the designated safeguarding lead.
Monitoring
El Roi Ltd reserves the right to monitor the use of company-provided devices and networks for social media activity to ensure compliance with this policy and other internal regulations. Furthermore, in circumstances related to recruitment or investigations into potential misconduct, El Roi Ltd may conduct proportionate online searches of publicly available information. Such monitoring will be conducted in accordance with applicable data protection laws and privacy regulations.
Consequences of Breach
Any breach of this Social Media Policy will be regarded as a serious disciplinary matter, potentially leading to disciplinary action up to and including immediate termination of employment or contract. In cases where a breach constitutes a criminal offence, such as the sharing of sensitive service user information, El Roi Ltd will not hesitate to report the matter to the appropriate regulatory bodies, including the Information Commissioner's Office (ICO) or the Care Quality Commission (CQC), as well as law enforcement authorities.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
34. Business Continuity & Disaster Recovery Policy
El Roi Ltd is steadfastly committed to ensuring the uninterrupted delivery of critical services to our valued client organisations and service users, even in the face of significant disruptions. This Business Continuity and Disaster Recovery (BCDR) Policy outlines our proactive strategies and reactive measures designed to mitigate risks, minimize downtime, and maintain operational resilience, safeguarding the well-being of those we serve and the integrity of our operations.
Scope of Policy
This policy applies to all potential operational disruptions that could impact El Roi Ltd, its staff, and its service delivery. This includes, but is not limited to, IT system failures, loss of key personnel, cyber-attacks, extreme weather events, public health emergencies such as pandemics, fire, utility outages, or the loss of physical premises. Our comprehensive approach ensures preparedness across a wide spectrum of unforeseen circumstances.
Business Impact Assessment (BIA)
A thorough Business Impact Assessment (BIA) has been conducted to identify and evaluate the criticality of all functions within El Roi Ltd. Key functions identified include staff scheduling and deployment, payroll processing, client communication and relationship management, maintenance of compliance records, and management of service user data. For each critical function, we have determined the Maximum Tolerable Downtime (MTD) – the maximum period a process can be unavailable before significant harm is caused to the organisation or service users. This assessment forms the foundation for prioritizing recovery efforts and resource allocation during a disruption.
Business Continuity Response Steps
Identify & Assess Disruption
Rapidly detect the nature, scale, and potential impact of the incident.
Activate BCP
Initiate the Business Continuity Plan, mobilizing the response team.
Communicate Effectively
Provide timely updates to staff, clients, and all relevant stakeholders.
Implement Recovery Procedures
Execute pre-defined actions to restore critical operations.
Review & Restore Normalcy
Oversee the transition back to full operational status systematically.
Post-Incident Review
Conduct a comprehensive analysis to capture lessons learned and improve future responses.
IT & Data Recovery
All critical data essential for El Roi Ltd's operations and compliance is backed up daily to secure, geographically dispersed cloud storage facilities. In the event of an IT system failure, El Roi Ltd has established protocols for switching to manual or paper-based processes where necessary to ensure minimal interruption to urgent services. Our Recovery Time Objective (RTO) for critical systems and data is set at 24 hours, meaning we aim to have essential IT infrastructure operational within this timeframe following a major incident.
Key Personnel & Succession
To mitigate the impact of the unavailability of key personnel, El Roi Ltd maintains a robust succession plan. Deputies are identified for all critical roles, and comprehensive cross-training programs are in place to ensure that multiple staff members are capable of performing essential tasks. Contact details for all key personnel and their designated backups are maintained in an accessible, regularly updated, and secure format, reviewed quarterly.
Communication Plan
In the event of any significant disruption, the Managing Director will assume overall responsibility for leading internal and external communications. All staff, client organisations, and relevant stakeholders will be notified within four hours of a significant disruption being identified. A designated communication channel, such as a specific email address, telephone line, or status page, will be established and communicated to ensure clear and consistent information flow during the incident.
Pandemic & Public Health Emergency Preparedness
Drawing lessons from global events such as the COVID-19 pandemic, El Roi Ltd has developed specific protocols for public health emergencies. These include established remote working arrangements for administrative staff, a strategic stockpiling of essential Personal Protective Equipment (PPE) for frontline workers, and robust systems for monitoring and supporting staff welfare during extended periods of crisis. We prioritize the health and safety of our employees and service users while striving to maintain critical service delivery.
This Business Continuity & Disaster Recovery Plan is subject to an annual review and is rigorously tested through regular tabletop exercises involving key stakeholders, ensuring its continued relevance and effectiveness.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
35. Compliance & Legal Policy
Purpose
El Roi Ltd is unreservedly committed to achieving and maintaining full compliance with all applicable laws, regulations, and statutory requirements that govern the provision of care staffing services within the United Kingdom. This policy underpins our operational framework, ensuring that every aspect of our service delivery, from recruitment and training to staff deployment and client engagement, adheres to the highest legal and ethical standards. Our primary objective is to safeguard the well-being of our service users, uphold the professional integrity of our agency workers, and protect the reputation and operational viability of El Roi Ltd. By fostering a culture of rigorous compliance, we aim to provide a safe, ethical, and transparent environment for all stakeholders.
Policy Statement
El Roi Ltd operates strictly in accordance with all relevant legislation and regulatory frameworks applicable to the UK health and social care sector. This comprehensive approach encompasses a wide array of legal instruments designed to protect individuals, ensure fair employment practices, and maintain service quality. Our adherence includes, but is not limited to, the following key acts and standards:
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including the fundamental standards of care.
Care Act 2014, outlining duties to promote well-being, prevent abuse and neglect, and ensure person-centred care.
Equality Act 2010, prohibiting discrimination and promoting equality of opportunity for all individuals.
Data Protection Act 2018 / UK GDPR, ensuring the lawful and secure processing of personal data.
Modern Slavery Act 2015, combating modern slavery and human trafficking within supply chains.
Health and Safety at Work etc. Act 1974, ensuring a safe working environment for all staff and service users.
Employment Rights Act 1996, protecting the rights of employees and agency workers.
Bribery Act 2010, establishing clear anti-bribery and corruption standards.
CQC Fundamental Standards, providing a framework for the quality and safety of care.
We are dedicated to upholding the spirit and letter of these laws, ensuring transparency, accountability, and the highest standards of professional conduct across all our operations.
Responsibilities
Effective compliance is a shared responsibility across El Roi Ltd:
El Roi Ltd Management: The leadership team is ultimately responsible for establishing, implementing, and overseeing this policy. This includes continuously monitoring changes in legislation and regulatory requirements, ensuring that all policies and procedures are updated accordingly, allocating necessary resources for training and compliance, and fostering a robust culture of ethical practice and legal adherence throughout the organisation.
All Staff and Agency Workers: Every individual associated with El Roi Ltd, regardless of their role, is required to understand, adhere to, and uphold the principles and specific requirements of all relevant legal obligations and internal policies. This includes maintaining professional conduct, protecting sensitive information, reporting any identified breaches or concerns, and actively participating in mandatory training and development programs to ensure ongoing competence and awareness.
Regulatory Compliance
El Roi Ltd maintains its registration and actively engages with the Care Quality Commission (CQC) as our primary regulatory body, ensuring continuous adherence to their rigorous standards for quality and safety in health and social care. Furthermore, we comply with requirements set by other pertinent regulatory bodies, including the Disclosure and Barring Service (DBS) for criminal record checks and relevant local authorities. Any actual or suspected breaches of legal or regulatory requirements, whether by an employee, agency worker, or third party associated with our services, must be reported immediately to management. All reports will be handled with utmost confidentiality and investigated thoroughly. Appropriate corrective actions will be taken promptly, which may include internal disciplinary measures, re-training, or, where necessary, reporting to external regulatory bodies or law enforcement authorities, as outlined in our other relevant policies.
Policy Review
This Compliance & Legal Policy is subject to a comprehensive review on an annual basis to ensure its continued relevance, effectiveness, and alignment with current legislative and regulatory landscapes. Furthermore, the policy will be proactively reviewed and updated whenever there are significant changes in UK legislation, regulatory guidance, or upon identification of new risks or operational learning. This iterative review process ensures that El Roi Ltd remains agile and responsive to evolving compliance demands, thereby maintaining our commitment to legal excellence and best practice in care staffing.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026
16. Child Protection Policy
El Roi Ltd is deeply committed to protecting the welfare and safety of all children encountered in the course of its staffing operations. This policy aligns rigorously with all statutory guidance, legislation, and best practices relevant to child safeguarding within the United Kingdom. Our unwavering commitment ensures that every engagement involving children is conducted with the highest levels of responsibility, vigilance, and ethical conduct.
Policy Statement
El Roi Ltd upholds an unequivocal zero-tolerance approach to child abuse and neglect in all its manifestations. This includes physical, emotional, and sexual abuse, as well as neglect and exploitation. All agency workers placed in settings where they may come into contact with children, including those in vulnerable situations, are mandated to act in the paramount best interests of the child at all times. This comprehensive policy is firmly underpinned by key legislative and guidance frameworks, including:
Children Act 1989 and 2004: Establishing the legal framework for child protection and welfare.
Working Together to Safeguard Children (2023): The statutory guidance on inter-agency working to safeguard and promote the welfare of children.
United Nations Convention on the Rights of the Child (UNCRC): Recognising the fundamental rights of every child.
Keeping Children Safe in Education (KCSIE): Where applicable to educational settings, guiding our practices.
Scope
This policy extends to all El Roi Ltd staff, agency workers, and any representatives who may work in or visit settings where children are present. This broad scope includes, but is not limited to, placements in residential care homes, supported living accommodations, community care environments, educational institutions, or any other setting where children may be encountered as service users or residents. Adherence is non-negotiable for all personnel, irrespective of their contractual status or length of service.
Responsibilities
Agency Workers
All agency workers have a direct and immediate duty to report any concerns, suspicions, or disclosures regarding a child's welfare. Such reports must be made without delay to their El Roi line manager and, crucially, to the host organisation's designated safeguarding lead. Workers must never attempt to investigate allegations themselves, nor should they promise confidentiality if a child is at risk. Their role is to observe, record, and report factually.
El Roi Ltd Management
El Roi Ltd management bears ultimate responsibility for ensuring all staff receive robust and up-to-date child protection awareness and safeguarding training. They are responsible for establishing clear reporting pathways, reviewing all reported concerns, and escalating them promptly to the appropriate local authority Children's Services, relevant statutory bodies (e.g., NSPCC helpline), or law enforcement authorities when necessary. Management will ensure that all actions are taken in accordance with legal and regulatory requirements.
Recognising Abuse
It is imperative that all agency workers are proficient in recognising the diverse signs and indicators of child abuse and neglect. This understanding encompasses:
Physical Abuse: Unexplained injuries, bruising, burns, or a pattern of injuries.
Emotional Abuse: Persistent low self-esteem, withdrawn behaviour, aggression, or developmental delays caused by neglect of emotional needs.
Sexual Abuse: Inappropriate sexual knowledge or behaviour, physical symptoms, or disclosures.
Neglect: Persistent hunger, poor hygiene, inadequate clothing, lack of medical care, or insufficient supervision.
Any suspicion or direct disclosure must be taken seriously, recorded accurately with factual details, dates, and times, and reported promptly as per the responsibilities outlined above. Workers must never engage in investigative actions themselves, as this can compromise subsequent official investigations.
Safer Recruitment
El Roi Ltd adheres to stringent safer recruitment practices for all personnel engaged in roles where they may have contact with children. This includes a mandatory requirement for all agency workers working in child-related settings to possess a valid Enhanced Disclosure and Barring Service (DBS) check, which explicitly includes a check against the children's barred list. No worker will be considered or placed in any child-related setting without appropriate and satisfactory clearance obtained prior to deployment.
Confidentiality
Information pertaining to child protection concerns is treated with the utmost sensitivity and shared strictly on a 'need-to-know' basis. This ensures that only relevant authorities and individuals directly involved in the safeguarding process have access to sensitive details. However, it is crucial to understand that confidentiality will not, and cannot, be maintained where there is any perceived or actual risk of harm to a child. The welfare and safety of the child always take precedence over confidentiality.
Training
All agency workers are required to complete comprehensive child protection and safeguarding children training as an integral part of their induction process. This initial training is supplemented by mandatory refresher training, which must be undertaken regularly in line with prevailing legislative requirements, regulatory guidance, and El Roi Ltd’s internal organisational schedules. This continuous professional development ensures workers remain aware of current practices and can effectively identify and respond to safeguarding concerns.
Policy Review
This Child Protection Policy undergoes a thorough and systematic review on an annual basis. Furthermore, the policy will be proactively reviewed and updated in direct response to any significant changes in UK child protection legislation, the issuance of new statutory or regulatory guidance, or upon the identification of new risks or lessons learned from serious incidents. This commitment to regular review ensures the policy remains current, effective, and fully aligned with evolving best practices in child safeguarding.
El Roi Ltd – Policy Manual | Version 1.1 | February 2026