Good Governance Policy

Aim

The aim of Cavendish Homecare Professionals is to ensure that it has strong, robust and effective governance procedures in place which support continuous service improvement and the delivery of high-quality, safe care.

Policy

In this organisation:

The principles of good governance will be embedded at all levels of the organisation so that Cavendish Homecare Professionals can continuously monitor its performance and improve its standards of quality and safety.
A process of quality assurance will be developed and maintained so that the organisation can assess and monitor its performance and compliance with Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended). The process will include self-assessment and regular audit of performance, as well as regular management reports to the senior management team.
Audit tools will identify quality and safety performance with respect to the above regulations and enable the identification of areas of non-compliance and an assessment of risks. Where such problems are identified the management team will take immediate action to address the issues within a system of robust risk assessment and management.
Audit tools will be kept under regular review to ensure that they remain effective and fit for purpose.
Audit tools will be benchmarked against appropriate standards and audits will be repeated once remedial measures have been taken to ‘close the loop’ and ensure that measures are effective.
Effective oversight and governance will be supported by keeping accurate records relating to care and treatment and managing the service, with appropriate data collection and recording based on information governance best practice principles and the requirements of the Data Protection Act 1998. Information will be kept up-to-date with appropriate management actions to ensure its accuracy, integrity and security. Records will include policies and procedures, service and maintenance records, audits and reviews, purchasing records, risk assessments and action plans in response to risk and incidents.
When required, data/audit results should be escalated and appropriate action taken.
Cavendish Homecare Professionals will ensure that it has robust and transparent processes in place to ensure that incidents, mistakes and errors – including near misses – are identified, logged and investigated with appropriate learning and changes made which will inform the organisation’s quality assurance processes.
The organisation will ensure that it has honest and well-publicised and understood complaints processes in place to ensure that complaints are listened to, logged and investigated, with appropriate actions taken.
The organisation will ensure that it has effective client feedback processes in place to ensure that clients, their relatives and representatives are encouraged to express their opinions, views and feelings about the services provided. Such systems will be proactive and inclusive so that all clients who wish to say something are empowered to do so. The organisation will listen to all views and use the information to inform its quality assurance processes and to inform appropriate actions.
The organisation will ensure that it gathers the views of other stakeholders and external bodies, as appropriate, relating to their experience of services provided.
Reviews and monitoring results will be made available to clients and their families and representatives and, where appropriate, will be sent to external bodies.
Information from all sources will be appropriately analysed by the senior management team of the organisation and appropriate action taken to make improvements and ensure that learning is embedded within improved practice. Where necessary, professional advice or expert support will be engaged to perform such analysis and make improvements.
Subject to statutory consent and applicable confidentiality, data protection and information governance requirements, the organisation will share relevant information, such as information about incidents or risks, with other relevant individuals or bodies such as the CQC and safeguarding boards.
The organisation will take every opportunity to encourage and support innovation and improvement, encouraging staff to speak out and make suggestions through the implementation of an open and transparent management style.
The organisation will utilise the secure online CQC facility to keep a provider information return (PIR) form. The PIR data will be kept up-to-date so that the organisation can respond promptly to PIR requests from the CQC.

Management duties

Managers and supervisors in the organisation have a duty to:

regularly audit the use of this policy and the effectiveness of procedures to promote effective governance within the organisation
report and investigate any data breaches or incidents
monitor and record complaints and compliments, taking action as required and fully investigating any complaints
ensure that clients and their relatives and representatives have adequate processes in place to be able to register queries or complaints and have their voices and views heard with reference to the services they receive, and to have their thoughts listened to and acted upon
support staff training, appraisal and supervision and welcome new ideas and innovation.

Staff duties

Staff in this organisation have a duty to:

report any concerns or incidents, including errors, mistakes, complaints and ‘near misses’
always act in full compliance with the Data Protection Act 1998 and respect the confidentiality and privacy of service users’ information, records and data
comply fully at all times with organisational policies on recording and storing information
attend appropriate training on information governance

Training

In this organisation:

induction will include training and guidance on data protection and information governance
all staff will be expected to attend refresher training relevant to their role

Date: January 2024

Version: 8 (Review)

Source: Expert Care Manager