An HIS requirement is an enforceable legal duty with a timescale, and a recommendation sets out what a service should do to meet the relevant standards. Return the factual accuracy form within 5 working days of the draft report, send an improvement action plan with an owner and date for each item, and keep evidence of each fix, because a requirement stays outstanding until HIS sees it.
What each one means
A requirement sets out what an independent healthcare provider must do to comply with the National Health Service (Scotland) Act 1978, regulations or a condition of registration. Where there is a breach, HIS must make one, and requirements are enforceable. A recommendation sets out what a service should do to align with relevant standards and guidance.1 HIS's enforcement policy adds that failing to act on a recommendation will not directly result in enforcement action, and that recommendations are based on the Health and Social Care Standards and best practice guidance.2
| Requirement | Recommendation | |
|---|---|---|
| Wording in the report | The provider must | The service should |
| Basis | The 1978 Act, the 2011 regulations or a condition of registration, cited by regulation number | The Health and Social Care Standards and other guidance, cited by statement |
| Timescale | Set by HIS, for example immediate, or by a named date | None set |
| If not met | Stays outstanding, can lead to a follow-up inspection and formal enforcement | Repeated in the next report |
The timeline after a report
HIS aims to send the draft report about 5 weeks after the inspection. The factual accuracy form and the improvement action plan go back by about week 6, and if the form is not returned within 5 working days HIS may finalise the report. The final report and the action plan are published at 8 weeks, and the plan is removed at 16 weeks. HIS may ask for an updated plan at 16 weeks, especially where a key focus area was graded Unsatisfactory, or carry out a follow-up inspection to confirm requirements are met.1
- Read each item against its source. Look up the regulation behind each requirement and the standard behind each recommendation, so the fix answers the law and not only the wording.
- Check the facts within 5 working days. Use the factual accuracy form for errors of fact, with evidence. Disagreement with a judgement is a separate conversation with the inspector.
- Give every item an owner and a date. One named person each, and a date no later than HIS's timescale. Immediate means now.
- Fix the system that produced the gap. If one record was incomplete, audit all of them and change how records are made. A single corrected record will not satisfy a requirement on record keeping.
- Keep the evidence as you go. Minutes, audit results, updated policies with version dates, staff training records. HIS closes a requirement on evidence it can see.
- Publish what has to be public. Several common requirements are about publication, an annual duty of candour report, a complaints procedure on the website, the vision shared with patients.
- Review progress at governance. Put the action plan on every governance agenda until each item is closed, and minute it.
- Requirement or recommendation, number and wording ______
- Regulation or standard cited ______
- HIS timescale ______
- What we will change ______
- Owner ______ Due ______
- Evidence it is done, and where it is kept ______
- Reviewed at governance on ______
One follow-up, item by item
A Glasgow clinic inspected in November 2025 received 10 requirements and 9 recommendations, plus two requirements and one recommendation from a complaint investigation the same day. At its announced follow-up on 1 June 2026 HIS found every requirement met and action taken on every recommendation.3 The items are a useful list of what HIS checks.
- A standard operating procedure for notifications, naming who notifies HIS.
- An annual duty of candour report, produced and published.
- Every complaint investigated under the policy, with the complaints log fully completed.
- Risk registers reviewed by senior staff who did not compile them.
- An annual return submitted when HIS asks.
- Patient care records fully completed, signed and dated, and audited.
- Two references, Disclosure Scotland checks and PVG membership before anyone starts work.
- Induction, mandatory training, and appraisals recorded in staff files.
Its grades after the follow-up were Satisfactory in all three key focus areas, the highest a follow-up can award.3 The guide to HIS grades explains that limit.
Complaints, a frequent requirement
Regulation 15 of the 2011 regulations requires a complaints procedure, a full investigation of every complaint, and a reply telling the complainant what action will be taken within 20 working days. The written procedure must be given to every patient and must include HIS's name and address.4
If a requirement is not met
HIS's enforcement policy is graduated. It first raises concerns with the provider. It may then serve a condition notice under section 10U, then an improvement notice under section 10R, which sets out its intention to cancel registration unless significant improvement is shown in a set time, and finally a cancellation notice under section 10S. Emergency procedures exist where there is serious risk to life, health or wellbeing.2 Details of enforcement action are published on HIS's website, and providers must tell their patients about it.5
Questions
Is a recommendation optional?
Not acting on one will not directly lead to enforcement, but HIS repeats unmet recommendations in the next report and they affect how your service is graded.
What if I disagree with a finding?
Errors of fact go on the factual accuracy form within 5 working days of receiving the draft report, with evidence. HIS finalises the report once the form is back and any amendments are made.
Is my action plan made public?
Yes. HIS publishes it with the final report about 8 weeks after the inspection, and removes it from its website at 16 weeks.
Sources
- 1Healthcare Improvement Scotland, 2024Independent healthcare regulation, inspection methodology, July 2024Read source
- 2Healthcare Improvement Scotland, 2020Independent healthcare regulation, enforcement policyRead source
- 3Healthcare Improvement Scotland, 2026Announced follow-up inspection report, an independent clinic in Glasgow, July 2026Read source
- 4legislation.gov.uk, 2011The Healthcare Improvement Scotland (Requirements as to Independent Health Care Services) Regulations 2011, regulation 15Read source
- 5Healthcare Improvement Scotland, 2024Independent healthcare regulation, provider handbook, July 2024Read source
Written by the wai team from Healthcare Improvement Scotland guidance, checked on 15 October 2026. This is guidance, not legal advice. HIS does not endorse wai or any software.