1. Governance
1.1. This is the Capability Policy and Procedure for The Good Place Home Care Services Limited.
1.2. The Good Place Home Care Services Limited will be referred to in this document as "The Good Place Home Care Services Limited","The Good Place","We","Us", or "Our".
1.3. Our registered address is: 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ.
1.4. We can be contacted by:-
- a. Telephone: 01283 296 337
- b. Email: [protected:ahello][protected:athegoodplace.care]
- c. Post: The Good Place, 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ
1.5. Words importing one gender include all genders, and words in the singular include the plural and vice versa, unless the context requires otherwise.
1.6. Document control sheet:-
| Metadata | Value |
|---|---|
| Document fingerprint | HR-2123-V1 |
| Document owner | Dean Hill (Registered Manager) |
| Document version | 1 |
| Document status | Approved on 18/03/2026 by the Dean Hill (Registered Manager) |
| Document review cycle | Annually or sooner if legislation or guidance changes. Next review planned for March 2027 |
2. Purpose
2.1. To ensure that we fulfil the legal and regulatory responsibilities.
2.2. To support us to meet, and be able to evidence compliance with, the following CQC Single Assessment Framework quality statements:-
| Safe | |
|---|---|
Learning culture | We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices. |
Safeguarding | We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately. |
Safe and effective staffing | We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development. They work together effectively to provide safe care that meets people’s individual needs. |
| Effective | |
How staff and teams work together | We work effectively across teams and services to support people. We make sure they only need to tell their story once by sharing their assessment of needs when they move between different services. |
| Caring | |
Workforce wellbeing and enablement | We care about the wellbeing of our staff, and we support and enable them to deliver person-centred care. |
| Well-led | |
Capable, compassionate and inclusive leaders | We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty. |
Freedom to speak up | We foster a positive culture where people feel that they can speak up and that their voice will be heard. |
Workforce equality, diversity and inclusion | We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us. |
Governance, management and sustainability | We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate. |
Learning, improvement and innovation | We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research. |
3. Scope
3.1. This policy and procedure applies to all employees of The Good Place, including full-time, part-time, fixed-term and zero-hours staff, and to bank or relief staff engaged directly by The Good Place.
3.2. This policy does not apply to agency workers or independent contractors who are managed under the terms of their agency or service contracts, although concerns about their capability must still be escalated to the Registered Manager and, where appropriate, to the supplying organisation.
3.3. This policy covers issues of capability arising from skills, competence, performance, health or other factors that affect an individual’s ability to carry out their role safely and effectively. It is distinct from the Disciplinary Policy, which addresses misconduct or deliberate breaches of rules.
3.4. This policy applies to all roles within the domiciliary care service, including care staff, supervisors, coordinators, managers and office-based staff whose work may impact the safety and quality of care provided to people using our service.
4. Policy Statement
4.1. The Good Place is committed to ensuring that all staff have the skills, knowledge, competence and support they need to perform their roles safely, effectively and in line with our values and regulatory requirements.
4.2. The purpose of this policy is to provide a fair, consistent and supportive framework for identifying, managing and resolving concerns about an employee’s capability, including performance, skills, competence and health-related capability issues.
4.3. We will always seek to address capability concerns informally in the first instance, wherever appropriate, through supervision, training, mentoring and support, before moving to formal procedures.
4.4. Where formal capability procedures are necessary, they will be conducted in line with relevant employment legislation and with regard to the ACAS Code of Practice on Disciplinary and Grievance Procedures, ensuring that staff are treated fairly and with dignity.
4.5. We will ensure that capability concerns that may impact the safety or quality of care are identified promptly, risk-assessed and managed in a way that protects people using our service, in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
4.6. Where a capability issue has contributed to, or creates a risk of, serious harm, abuse, neglect or a notifiable safety incident, we will ensure that any required statutory notifications are made to the Care Quality Commission and other relevant bodies in line with the Care Quality Commission (Registration) Regulations 2009 and our Duty of Candour obligations under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
4.7. We will make reasonable adjustments for staff with disabilities or health conditions, in line with the Equality Act 2010. This includes, where appropriate, adjustments to duties, working arrangements, capability procedures and the way information is provided (for example, accessible formats, interpreters or additional time), taking into account occupational health advice where relevant.
4.8. Decisions made under this policy will be based on objective evidence, will be documented clearly, and will be subject to appropriate review and appeal processes.
5. Legal & Regulatory Framework
5.1. This policy is guided by:-
- a. Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulations 17 (Good governance), 18 (Staffing) and 19 (Fit and proper persons employed).
- b. Care Quality Commission (Registration) Regulations 2009.
- c. CQC Single Assessment Framework and associated guidance for providers of regulated domiciliary care services.
- d. Employment Rights Act 1996.
- e. Equality Act 2010.
- f. ACAS Code of Practice on Disciplinary and Grievance Procedures and relevant ACAS guidance on managing performance and capability.
- g. Working Time Regulations 1998 and other relevant employment regulations as applicable.
5.2. The Good Place is fully committed to meeting the requirements of the Accessible Information Standard (AIS), as set out by NHS England. This means we will ensure that people with a disability, impairment, or sensory loss receive information and communication support that they can understand and use effectively. This may include large print, easy-read versions, audio formats, or the use of interpreters and communication aids. See our Accessible Information Standard (AIS) Policy and Procedure for further details.
5.3. We also comply with the Equality Act 2010 and are fully committed to promoting diversity, and human rights in all aspects of our service provision and employment practices. We are dedicated to ensuring that all individuals, including staff, service users, and stakeholders, are treated fairly, with dignity and respect, and without discrimination. We will also make reasonable adjustments so that no individual is treated less favourably when using our service. This includes supporting people with protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. See our Equality, Diversity and Human Rights Policy and Procedure for further details.
6. Roles & Responsibilities
6.1. Registered Manager:-
- a. Has overall responsibility for ensuring that this policy is implemented effectively and that capability concerns are managed in a way that protects people using the service and complies with legal and regulatory requirements.
- b. Ensures that managers and supervisors are trained and competent to apply this policy fairly and consistently.
- c. Reviews serious or complex capability cases, including those that may result in dismissal or referral to external bodies (e.g. the Disclosure and Barring Service (DBS) or professional regulators where applicable).
- d. Ensures that, where capability concerns have resulted in or contributed to notifiable safety incidents, serious harm, abuse or neglect, appropriate statutory notifications (including to the Care Quality Commission and safeguarding authorities) and Duty of Candour requirements are met in line with relevant regulations and our incident reporting policies.
6.2. Line Managers/ Supervisors:-
- a. Monitor staff performance and competence through supervision, observation, spot checks and feedback from people using the service and others.
- b. Identify capability concerns at an early stage and address them informally where appropriate, including arranging training, coaching or additional supervision.
- c. Initiate and manage formal capability procedures where informal measures have not resolved concerns, or where there are serious concerns about safety or quality of care.
- d. Ensure that all discussions, decisions and actions taken under this policy are documented accurately and stored securely.
6.3. Human Resources/ HR Function (where applicable):-
- a. Provide advice and support to managers on the fair and lawful application of this policy.
- b. Support the coordination of formal capability meetings, documentation and appeals.
- c. Monitor the use of this policy to identify trends, equality impacts and opportunities for learning and improvement.
6.4. All Staff:-
- a. Are responsible for maintaining the required standards of performance and competence for their role, including completing mandatory training and following agreed care plans, policies and procedures.
- b. Must engage constructively with supervision, appraisal, training and any support or improvement plans put in place under this policy.
- c. Have the right to be informed of concerns about their capability, to respond to those concerns, to be accompanied at formal meetings in line with this policy, and to appeal formal decisions.
- d. Must raise concerns promptly if they believe that a colleague’s capability may be placing people using the service at risk, in line with our Whistleblowing / Freedom to Speak Up Policy.
7. Data Protection & Confidentiality
7.1. At The Good Place, we recognise that protecting an individual's confidentiality and ensuring compliance with data protection laws are fundamental to ethical and legal care practices, especially when handling personal and sensitive health data.
7.2. See our Confidentiality and Data Protection (UK GDPR) Policy and Procedure for full details on how personal and health data must be obtained, stored, shared, and processed in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018.
7.3. When Data Can Be Shared Without Consent
7.3.1. In some situations, data protection laws allow information to be shared without consent if it is necessary for:-
- a. Safeguarding: If there is a serious risk of harm to a service user or others, staff have a duty to share information with appropriate agencies (e.g., local authority safeguarding teams).
- aa. Local Authority: Staffordshire County Council
- i. Email: [protected:aSSASPB.admin][protected:astaffordshire.gov.uk]
- ii. Online: Staffordshire & Stoke-on-Trent Adults Safeguarding Partnership Board
- iii. Telephone (working hours): 0345 604 2719
- iv. Telephone (out of hours): 0345 604 2886
- aa. Local Authority: Staffordshire County Council
- b. Medical emergencies: If a person is unconscious or unable to provide consent, relevant medical information may be shared with healthcare professionals to provide urgent care.
- c. Legal requirements: If ordered by a court or required by law (e.g., under the Mental Capacity Act 2005, Deprivation of Liberty Safeguards).
7.3.2. In all cases where consent is overridden, the decision must be justified, recorded, and reported to senior management.
8. Definitions
8.1. Capability: An employee’s ability to perform the duties of their role to the required standard, taking into account their skills, knowledge, competence, aptitude and health.
8.2. Capability Issue: A concern that an employee is not meeting the required standards of performance or competence for their role, which may arise from lack of skills, knowledge, experience, training, support or health-related factors, rather than from deliberate misconduct.
8.3. Performance: The way in which an employee carries out their duties and responsibilities, including the quality, accuracy, timeliness and safety of their work.
8.4. Misconduct: Deliberate or negligent behaviour that breaches organisational rules, policies or standards of conduct. Misconduct is normally managed under the Disciplinary Policy rather than this Capability Policy.
8.5. Informal Capability Support: Early-stage, supportive measures such as supervision, coaching, mentoring, additional training or temporary adjustments to duties, aimed at helping an employee to reach the required standard without using the formal stages of this policy.
8.6. Formal Capability Procedure: A structured process involving written notification of concerns, formal meetings, agreed improvement plans, review periods and potential outcomes, including redeployment or dismissal where appropriate.
9. General Principles
9.1. Capability concerns will be dealt with promptly, fairly and consistently, with a focus on support, improvement and learning.
9.2. Where capability concerns may impact the safety or quality of care, immediate steps will be taken to assess and manage risk, which may include increased supervision, temporary adjustments to duties or, in serious cases, temporary suspension on full pay while concerns are investigated.
9.3. At all formal stages of this procedure, employees have the right to be accompanied by a trade union representative or a work colleague.
9.4. Reasonable adjustments will be considered for employees with disabilities or health conditions.
9.5. We will ensure that staff involved in capability processes are able to understand and participate fully in those processes, including by providing information in accessible formats and communication support where required, so that employees with disabilities, impairments or sensory loss are not disadvantaged.
10. Identification of Capability Concerns
10.1. Capability concerns may be identified through supervision, appraisal, direct observation, audits, complaints, incidents, feedback from people using the service or colleagues, or failure to meet agreed objectives or standards.
10.2. The manager will gather relevant information and evidence before deciding how to proceed.
11. Informal Capability Support
11.1. Where concerns are minor or at an early stage, the line manager will normally discuss them informally with the employee, explaining the standards required and agreeing supportive actions.
11.2. An informal improvement plan may be agreed, setting out the support to be provided (e.g. training, mentoring, shadowing, supervision), the improvements required and the timescale for review.
11.3. Informal discussions and agreed actions will be recorded in supervision notes or similar records.
11.4. If informal measures do not lead to sufficient improvement, or if concerns are serious, the formal capability procedure may be initiated.
12. Formal Capability Procedure – Stage 1
12.1. The employee will receive written notification of the capability concerns, the evidence to be considered, and the date, time and location of a formal capability meeting. They will be informed of their right to be accompanied.
12.2. At the Stage 1 meeting, the manager will explain the concerns, review the evidence, consider any explanation or mitigating factors, and explore what support may help the employee to improve.
12.3. Following the meeting, the manager may decide to:
- a. Take no further action; or
- b. Agree a formal Capability Improvement Plan (CIP) setting out clear performance standards, support measures, and a review period; and/ or
- c. Issue a written warning that failure to achieve and sustain the required standard may lead to progression to Stage 2 and could ultimately result in dismissal.
12.4. The outcome of the meeting, including any warning and the CIP, will be confirmed in writing to the employee.
12.5. Review of Progress
12.5.1. During the review period, the manager will meet regularly with the employee to monitor progress, provide feedback and adjust support as needed.
12.5.2. At the end of the review period, a further meeting will be held to assess whether the required standard has been met and sustained.
13. Formal Capability Procedure – Stage 2
13.1. If, after Stage 1 and the review period, the employee has not made sufficient improvement, or if there are further serious concerns, a Stage 2 capability meeting will be convened. The employee will be notified in writing and may be accompanied.
13.2. At the Stage 2 meeting, the manager (normally the Registered Manager or a more senior manager) will review the history of the case, the support provided, and the employee’s response.
13.3. Possible outcomes of Stage 2 include:
- a. Extension or revision of the Capability Improvement Plan and review period.
- b. Issuing a final written warning, stating that failure to achieve and sustain the required standard may result in dismissal.
- c. Consideration of redeployment to a suitable alternative role, where available and appropriate.
13.4. The outcome will be confirmed in writing.
14. Formal Capability Procedure – Stage 3 (Dismissal or Alternative Action)
14.1. If, after Stage 2 and any further review period, the employee still fails to meet the required standard, or if there are very serious capability concerns that pose a significant risk to people using the service, a Stage 3 capability hearing may be convened to consider dismissal or other action.
14.2. The employee will be given written notice of the hearing, the concerns to be considered, the possible outcomes (including dismissal), and their right to be accompanied.
14.3. The hearing will normally be chaired by the Registered Manager or another senior manager with authority to dismiss.
14.4. Possible outcomes include:
- a. No further action.
- b. Further support and an extended review period.
- c. Redeployment to a suitable alternative role (if available).
- d. Dismissal with notice (or payment in lieu of notice) on grounds of capability.
14.5. Where dismissal or redeployment is related to concerns that may affect the safety of people using services, consideration will be given to whether a referral to the Disclosure and Barring Service (DBS) or other relevant bodies is required.
14.6. The decision and reasons will be confirmed in writing, including information about the right of appeal.
15. Appeals
15.1. Employees have the right to appeal against formal capability warnings or dismissal decisions. Appeals must be submitted in writing within 7 working days of receiving the decision, stating the grounds for appeal.
15.2. Appeals will be heard, where possible, by a manager not previously involved in the case.
15.3. The outcome of the appeal will be confirmed in writing and will be final within the organisation’s procedures.
16. Interaction with Other Policies
16.1. Where it is unclear whether concerns relate to capability or misconduct, advice should be sought from HR (where available) or the Registered Manager. In some cases, it may be appropriate to pause this procedure while a disciplinary or safeguarding investigation is carried out.
16.2. This policy should be read alongside our Staff Supervision, Training, and Development Policy and Procedure, Disciplinary Policy and Procedure, Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure, and Equality, Diversity and Human Rights Policy and Procedure.
16.3. Where capability concerns are linked to incidents that may require statutory notification to the Care Quality Commission or other bodies, this policy must be applied alongside our Duty of Candour Policy and Procedure to ensure all regulatory notification and openness requirements are met.
