How do you respond to an HIW improvement plan or immediate concern?

Answer each finding with a specific, measurable, timed action, name who is responsible, and send HIW the evidence within three months of the inspection. Immediate concerns about patient safety come first, through an immediate improvement plan, and serious concerns left unresolved at the end of an inspection can lead to a non-compliance notice.¹²

The three appendices in an HIW report

Each plan is a table. Improvement needed, the standard or regulation it relates to, the service action, the responsible officer and the timescale. A representative with overall responsibility for making sure the plan is carried out signs it.² The term immediate assurance is used in HIW's NHS work. For independent services, HIW describes immediate improvement plans and non-compliance notices.¹

What HIW expects in the plan

• A clear statement of how each finding will be addressed.
• Actions that are specific, measurable, achievable, realistic and timed.
• Enough detail to give HIW and the public assurance that the finding will be addressed.
• Evidence against each action sent to HIW within three months of the inspection.
• A check that the finding is not repeated elsewhere in your organisation.

Once agreed, the improvement plan is published on HIW's website with the report.² Write it knowing patients will read it. Each finding names a standard, and the guide to the National Minimum Standards in Wales lists all 25.

1. Deal with immediate concerns the same day. If HIW raises an immediate concern during the inspection, act before the team leaves where you can. Concerns resolved on the day are recorded in Appendix A.
2. Map each finding to its standard. Read the finding against the National Minimum Standard or regulation HIW names, so the action fixes the requirement rather than the symptom.
3. Write one action per finding. Specific, measurable and timed. Change a process, a check or a default, and say how you will know it worked.
4. Name one responsible officer. A person with the authority to make the change, not a team.
5. Collect the evidence as you go. Audit results, revised policies, training records or record samples, dated, ready to send within three months.
6. Check across the organisation. If you run more than one service, confirm the same finding does not apply elsewhere, and say so.

1. Finding ______
2. Improvement needed ______
3. Standard or regulation ______
4. Service action ______
5. Responsible officer ______ Timescale ______
6. Evidence sent to HIW on ______

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When HIW takes further action

Where significant and immediate concerns about safety are not suitably addressed by the end of the inspection, HIW issues an immediate non-compliance notice, the first step in a process that may lead to civil or criminal proceedings. It may also impose, vary or remove conditions, suspend registration or apply for urgent cancellation. After receiving a plan, HIW may ask for updates, carry out a focused inspection to test specific actions, or carry out a full re-inspection.¹

Questions

How long do I have to send HIW the evidence?

HIW's reports ask for the evidence against each stated action within three months of the inspection.

Is the improvement plan published?

Yes. Once agreed, the improvement plan is published on HIW's website alongside the report.

What is a non-compliance notice?

A notice HIW issues where significant and immediate concerns about patient safety have not been suitably addressed by the end of the inspection. It is the first step in a process that may lead to civil or criminal proceedings.

Sources

1. 1HIW, 2025How does HIW inspect independent services?Read source
2. 2HIW, 2026Independent Healthcare Inspection Report (Announced), Clinig Byw'n Iach, The Lifestyle Clinic, 21 April 2026Read source

Written by the wai team from Healthcare Inspectorate Wales guidance, checked on 15 October 2026. This is guidance, not legal advice. HIW does not endorse wai or any software.