Delegated healthcare activities and CQC compliance: where providers can get caught out

CQC has highlighted cases where staff were carrying out DHTs without any clearly identified delegating healthcare professional. It has also noted confusion about the role of enteral feeding companies, which may offer support but are not the delegating healthcare professional.

It is an offence to carry out a regulated activity without the appropriate registration. Therefore, it is important that providers ensure their delivery arrangements comply with CQC guidance.

What is delegation?

The Nursing and Midwifery Council defines delegation as "the transfer to a competent individual, of the authority to perform a specific task in a specified situation.”

CQC guidance defines delegation as the process by which a healthcare professional, employed by a provider registered for TDDI, assigns a specific procedure or task to a care worker or nursing associate employed by a different provider, that is not registered for TDDI.

In practice, the relevant healthcare professionals who may delegate such tasks are those listed in Schedule 1, paragraph 4(4) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including doctors, nurses, and other allied health and social care professionals.

What are DHTs?

There is no fixed statutory list of DHTs. That is deliberate. The guiding principles recognise that delegation decisions are fact-specific and depend on the individual, the task, the setting, the competence of the worker and the governance arrangements in place.

In practice, DHTs are usually clinical activities that would ordinarily be performed by a regulated healthcare professional, but which may safely be carried out by a suitably trained and supported care worker when robust safeguards are in place.

What are the four DHT guiding principles?

The Department of Health and Social Care's 2024 guiding principles on DHTs, group safe delegation into four areas:

1. Person-centred care planning and assessment;
2. Governance, regulation and accountability;
3. Learning and development, skills and competency; and
4. Monitoring and review.

In broad terms, they require the person’s needs and wishes to remain central, roles and responsibilities to be clearly documented, staff to be trained and competent before undertaking the activity, and the arrangement to be kept under review.

Principle 2 is particularly important because it explains where accountability, roles and responsibilities lie when DHTs are carried out across organisational boundaries.

Where do the main risks and areas of confusion arise?

The main area of confusion, and therefore legal and regulatory risk, arises where providers confuse delegation with supervision, or assume that because a task has been delegated, responsibility has moved with it. It has not.

CQC’s guidance makes clear that a healthcare professional employed by a provider registered for TDDI may delegate a procedure to a care worker or nursing associate employed by a second provider, such as a care home without nursing or a domiciliary care agency. Notably, the second provider is not treated as carrying on the regulated activity of TDDI merely because its staff perform the delegated task. The regulated activity, and responsibility for it, remains with the first provider, as the employer of the healthcare professionals who are delegating those tasks.

The delegating healthcare professional also retains overall responsibility for the person’s relevant healthcare needs, the clinical decision to delegate (including whether the task is appropriate for delegation, whether it is suitable for the individual concerned) and the outcome of the delegated task. That does not mean the second provider is free from responsibility. The second provider remains responsible for its own workers and must still comply with the regulations. It must not permit staff to accept delegated tasks unless they have the support, supervision, training and competence to carry them out safely.

This is where the principal compliance risk often arises for social care providers. Even where a provider is not itself registered for TDDI, it may still face CQC scrutiny if DHTs are being delivered without clear governance, defined accountability or proper oversight. This can result in adverse inspection findings, requirements to submit notifications to the CQC where care has not been delivered in accordance with the regulations and meets the threshold for reporting an incident, and in some cases a breach of a regulation. All of this can lead to enforcement action being taken against both the provider that delegated the tasks and the provider to whom the tasks were delegated.

Principle 2 therefore reinforces that DHTs involve shared but distinct responsibilities. The healthcare professional remains accountable for the decision to delegate and the clinical oversight associated with that decision. Their employer therefore continues to be responsible for delivering the TDDI. The second provider remains accountable for the conduct, competence and supervision of its own staff, and for meeting the relevant CQC requirements in relation to safe care and good governance.

How do DHTs fit within the CQC framework?

Whilst DHT arrangements can sometimes feel vague or hard to pin down, they do serve an important practical purpose. They allow care to be delivered in a flexible range of ways that better match the needs of people using services and the capacity of the providers involved.

For providers, the practical message is straightforward:

1. Clearly identify the named delegating healthcare professional who is delegating the task;
2. Clearly identify and define the specific task being delegated;
3. Ensure there are appropriate arrangements in place for clinical oversight and monitoring of the task;
4. Ensure the worker receiving the delegated task is authorised, trained, and competent to carry it out;
5. Set out a clear process for escalation and review if concerns arise.

For regulated healthcare professionals, the key point is to remember that delegation transfers the task, not overall accountability for the clinical decision to delegate. Those delegating tasks remain responsible for assuring themselves that the person receiving the task is competent to carry it out. The rationale for delegation and ongoing oversight should be clearly documented within the care record.

For both sides, the safest approach is to treat delegation as a live governance issue, not simply a workforce workaround.

Helpful resources:

• Delegated healthcare activities
• Treatment of disease, disorder or injury - Care Quality Commission
• NHS England » Delegation of healthcare tasks to personal assistants

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If you are a CQC‑registered provider and have questions about DHTs or any other aspect of your regulatory obligations, please contact Jen Davie or Andrew Andrews in our Regulatory Compliance team.