QC24-Good Governance Policy and Procedure

QC24 - Good Governance Policy and Procedure
Quality Assurance - Administration Quality Assurance
Tailored Care Services Ltd

Office S11, Flexspace, Monckton Road , Wakefield, West Yorkshire, WF2 7AS
Review Sheet
Last Reviewed Last Amended Next Planned Review in 12 months, or

03 Aug '20 03 Aug '20 sooner as required.
Minimal action required circulate information amongst relevant

Business impact
parties.
LOW IMPACT
Reason for this review Scheduled review
Were changes made? Yes
This policy details the good governance approach of the service and the roles and
Summary: responsibilities that can be undertaken. It has been reviewed with no imminent changes in
practice and references updated to ensure they remain current.
• The Health and Social Care Act 2008

• Health and Safety at Work etc. Act 1974
Relevant legislation: • Medicines Act 1968
• Data Protection Act 2018
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
• Author: Royal College of Nursing, (2016), Clinical governance. [Online] Available from:
https://www.rcn.org.uk/clinical-topics/clinical-governance [Accessed: 3/8/2020]
• Author: Scally, G and Donaldson, L, (1998), Clinical governance and the drive for
quality improvement in the new NHS in England. [Online] Available from:
Underpinning https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113460/ [Accessed: 3/8/2020]
knowledge - What have • Author: Care Quality Commission, (2019), Health and Social Care Act 2008 (Regulated
we used to ensure that Activities) Regulations 2014: Regulation 17. [Online] Available from:
the policy is current: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good
-governance#guidance [Accessed: 3/8/2020]
• Author: SCIE, (2013), Social care governance: A practice workbook for Northern
Ireland (2nd edition). [Online] Available from:
https://www.scie.org.uk/publications/misc/governance.asp [Accessed: 3/8/2020]
Suggested action: • Encourage sharing the policy through the use of the QCS App
QCS have undertaken an equality analysis during the review of this policy. This statement is
Equality Impact a written record that demonstrates that we have shown due regard to the need to eliminate
Assessment: unlawful discrimination, advance equality of opportunity and foster good relations with
respect to the characteristics protected by equality law.
This policy is Copyright © Quality Compliance Systems Ltd. 2018 (Last updated 2020) and is only licensed for use with a current
Licence Certificate. If you have a current Licence Certificate, it can be accessed in your online account. Page 1/7
Use without a current Licence Certificate is strictly prohibited.

1. Purpose
1.1 To describe what good governance means to Tailored Care Services Ltd and that the term 'good
governance' links to a quality management framework within Tailored Care Services Ltd. The Quality and
Quality Assurance Policy and Procedure must therefore be read with this policy.
1.2 To specify who has accountability and what action Tailored Care Services Ltd takes to continuously
improve services.
1.3 To support Tailored Care Services Ltd in meeting the following Key Lines of Enquiry:
Key Question Key Lines of Enquiry
E1: Are people’s needs and choices assessed and care, treatment and
EFFECTIVE support delivered in line with current legislation, standards and evidence-
based guidance to achieve effective outcomes?
R2: How are people’s concerns and complaints listened and responded to
RESPONSIVE
and used to improve the quality of care?
S2: How are risks to people assessed and their safety monitored and
SAFE managed so they are supported to stay safe and their freedom is
respected?
W2: Does the governance framework ensure that responsibilities are clear
WELL-LED and that quality performance, risks and regulatory requirements are
understood and managed?
1.4 To meet the legal requirements of the regulated activities that Tailored Care Services Ltd is registered
to provide:
The Health and Social Care Act 2008
Health and Safety at Work etc. Act 1974
Medicines Act 1968
Data Protection Act 2018
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
2. Scope
2.1 The following roles may be affected by this policy:

All staff
Registered Manager
2.2 The following Service Users may be affected by this policy:

Service Users
2.3 The following stakeholders may be affected by this policy:

Commissioners
External health professionals
Local Authority
NHS
3. Objectives
3.1 To demonstrate that the auditing, identification and management of governance at Tailored Care
Services Ltd is effective and clear. With procedures for reviewing and learning from incidents, near misses,
accidents, complaints, whistleblowing and adult support and protection concerns.
3.2 To ensure that evidenced-based care is used to continuously improve quality through a culture of
openness and transparency.

4. Policy
4.1 Tailored Care Services Ltd commits to providing safe, high-quality care. The systems and processes
at Tailored Care Services Ltd meet legal responsibilities, comply with best practice and the views of our
staff and Service Users.
Tailored Care Services Ltd will;
Take a human rights-based approach that protects and upholds a Service User’s right to privacy,
dignity, choice, respect and control
Encourage, listen and respond to the views of Service Users, staff and people who have an interest in
Promote a culture of openness, honesty and transparency, fulfilling our Duty of Candour
responsibilities. Our staff will be knowledgeable and confident to challenge and report risks and
concerns
Have clearly defined roles and responsibilities to ensure accountability
Identify risks in all areas of Tailored Care Services Ltd and will act to remove or reduce these risks
Analyse governance processes to identify themes and trends and take corrective action where
required
Review all governance processes to ensure that we work innovatively and are effective
Tailored Care Services Ltd follows this policy and procedure to create an environment in which excellence
in care will flourish.
4.2 Accountabilities - Tailored Care Services Ltd will
Have responsibility for scrutinising governance systems and processes at Tailored Care Services Ltd
Ensure continuous improvement
Have an organisational structure in place that defines leadership and accountability
4.3 Responsibilities - Registered Manager
Be responsible for overall management of Tailored Care Services Ltd
Seek and respond to the views of Service Users, staff, health professionals, advocates and other
interested parties
Delegate responsibility and hold staff to account for agreed actions
Have governance systems that are effective and fit for purpose and achieve continuous improvement
Report statutory notifications and escalate concerns to Raymond Gwasera
Take a values-based approach to recruitment and promoting staff retention
Promote an open, transparent culture and learning environment
Ensure that there is ongoing compliance with regulatory and contractual requirements
Ensure compliance with policies and procedures
Ensure that there are enough staff with suitable skills, experience and knowledge
Review and learn from accidents, incidents (including safeguarding), complaints and share this
learning with staff
Act on results of audits and reviews of the service
Collate, report and use data to inform stakeholders of the quality of the service
Seek expert advice by working with other health professionals
Work within Codes of Conduct and act as a role model at all times
4.4 Responsibilities - Care Worker

Work within their job description and code of conduct
Provide the Care as planned
Raise concerns and suggestions in a timely manner
Identify personal learning needs
Follow the policy and procedure

Work within Codes of Conduct and act as a role model at all times
5. Procedure
5.1 Accountability
Within Tailored Care Services Ltd there is a clear, structured approach to governance with all staff
having a line manager and defined accountabilities documented in job descriptions
Where there is accountability for informing external stakeholders or the involvement of other
organisations about any aspect of Tailored Care Services Ltd, accountability will be documented
All staff will ensure that they work within their own professional codes of conduct at all times
All staff at Tailored Care Services Ltd have accountability for ensuring that they work within Tailored
Care Services Ltd and Wakefield Council safeguarding procedures, and any poor practice or failure to
follow the procedures will result in disciplinary action
5.2 Audit
Tailored Care Services Ltd will undertake reviews and monitor systems and processes to identify where
quality or safety issues are being compromised and will respond appropriately and without delay. Tailored
Care Services Ltd will do this by:
Undertaking audits in areas such as health and safety, medication management, infection control, Care
Planning, safeguarding, environmental etc.
Using best practice such as NICE guidelines to benchmark standards and performance
Involving people who use the services where possible
Put in place an audit cycle and will review themes, trends and risks from audit at board level as well as
operational management level
5.3 Effectiveness
Effectiveness is about making sure the right people get the right care at the right place in an effective way,
Tailored Care Services Ltd will achieve this by ensuring:
Care Plan and Service User reviews are undertaken, care practice is undertaken to ensure adherence
to procedures and to identify when any changes or further developments to practice are required
Nutrition, skin, medication and falls are included in this process
That effectiveness is monitored, and additional resources and support identified where appropriate e.g.
district nurses, GP or other community health support
That when a Care issue is beyond the knowledge, skills and experience of the staff involved, then
additional support is identified to ensure that the issues are shared and the outcomes for the Service
User improved
5.4 Continuing Professional Development
Staff skills will be regularly reviewed and where additional training is required, this will be identified and
provided
Opportunities will be provided to widen skills, understanding and knowledge
This will increase the ability of the staff and ultimately, Tailored Care Services Ltd, to provide effective,
timely and responsive support
Where incidents arise, a root cause analysis will assess whether training needs to be reviewed
5.5 Involvement of Service Users
In order to ensure that governance is effective and holistic, Service Users will be involved in
determining the quality, timeliness and level of support provided and inform the results of any
governance processes
Tailored Care Services Ltd will listen to Service Users and Tailored Care Services Ltd will adapt the
service as a result
Systems, such as surveys, will be used to gain Service User views
Any changes made will be fed back to the Service User and recognition given to their views

This process is central to the concept of 'person-centred care' and continuous improvement
Tailored Care Services Ltd will work to the Accessible Information Standards to ensure equity for the
people who use its services
5.6 Remedying Underperformance
Any shortfalls in Care provision will be identified through the governance process
The reasons for the shortfall will be analysed and if the issue was the result of poor performance by
staff it will be addressed either through supervision, additional training, disciplinary procedures or
ultimately dismissal
If there are implications for staff teams it will be addressed through training, supervisions or team
meetings
Risk assessments, Care Plans and ways of working will be revisited and updated to reassess the
issues and develop more robust processes
External resources may be identified to assist with the delivery of training or to provide guidance on
improving practice
Tailored Care Services Ltd will ensure that its staff are aware of key policies and procedures such as
Whistleblowing, Safeguarding, Accident and Incident Reporting and that they adhere to these policies
included in the QCS Management System
All staff have a responsibility for staying up to date with Tailored Care Services Ltd policies and
procedures and checking the QCS online or mobile app for updates and documents
Rufaro Hakata has responsibility for ensuring that the policies and procedures within the QCS
Management System are customised and reflect all aspects of governance processes within Tailored
Care Services Ltd and that staff have read and understood the documents
5.7 Risk Management
Tailored Care Services Ltd understands that risk management is about minimising risks to Service Users
by:
Identifying what can and does go wrong during Care
Understanding the factors that influence this
Learning lessons from any adverse events
Ensuring that action is taken to prevent recurrence
Putting systems in place to reduce or eliminate risks
Within Tailored Care Services Ltd, we will manage risk by;
Reviewing complaints, accidents and incidents, near misses, safeguarding and
whistleblowing concerns
Actively learning from mistakes by reviewing every incident or near miss, when it arises, investigating
why it happened, how it happened, who was involved and create an action plan that we will follow to
stop it happening again. The review of all incidents will be analysed to identify themes or trends so that
this will also evidence whether Tailored Care Services Ltd is learning from incidents
5.8 Staff Management
Staff will be supervised in line with the Supervision Policy and Procedure and this will be recorded and
evidenced
The supervisions will contain relevant discussions about specific issues of concern, will inform the
governance process and identify best practice and areas that need to be redressed
Staff will be encouraged to share views and opinions and be involved in Care Planning and the
development of ways of working
Staff with accountability for particular areas of work will be informed of these responsibilities and
provided with tools and guidance to ensure that they deliver the identified oversight responsibility
Role-specific codes of conduct will be used as a means of monitoring performance and staff standards

6. Definitions
6.1 Governance
A framework through which organisations are accountable for continually improving the quality of their
services and safeguarding high standards of care by creating an environment in which excellence in
care will flourish
6.2 Root Cause Analysis
A method of problem-solving used for identifying the root causes of faults or problems. It is a useful tool
following safeguarding incidents, complaints, accidents, near misses or any other incidents that cause
concern
Key Facts - Professionals
Professionals providing this service should be aware of the following:

Staff will have regular supervisions and Tailored Care Services Ltd will have an appraisal process in
place so that staff understand what they are accountable for

Tailored Care Services Ltd has processes in place where Care practices are identified, reported and
monitored and actions are taken to improve practice

All staff have responsibility for following processes and procedures and using appropriate recording
methods, which is all part of robust governance procedures
Tailored Care Services Ltd consistently uses root cause analysis following any incidents, including
safeguarding incidents, to understand lessons learnt and prevent issues arising again
Key Facts - People affected by the service
People affected by this service should be aware of the following:

You will be involved, and your opinions sought regarding the care and support provided
Tailored Care Services Ltd has a complaints procedure that we will share with you in a way that makes
it easy for you to tell us when something is wrong
Further Reading
As well as the information in the 'underpinning knowledge' section of the review sheet we recommend that
you add to your understanding in this policy area by considering the following materials:
Skills for Care offers a suite of resources to support with roles and responsibilities alongside governance
care guides for social care:
https://www.skillsforcare.org.uk/Leadership-management/managing-a-service/roles-and-
responsibilities/Roles-and-responsibilities.aspx
Guide 34: Practice development: collaborative working in social care (SCIE, 2010) - SCIE has
identified collaborative methodology as one of many ways of implementing change based on evidence from
research and practice. The method presented here has been adapted for social care from the NHS model
and represents a simple approach to change management:
http://www.scie.org.uk/publications/guides/guide34/
Root Cause Analysis:
http://www.nrls.npsa.nhs.uk/resources/collections/root-cause-analysis/
SCIE: Guide 38 Social Care Governance (SCIE, 2011) - although not updated since 2011, this
workbook provides some clear governance practices for England:
https://www.scie.org.uk/publications/guides/guide38/
QCS Quality and Quality Assurance Policy
Note: SCIE Social Care Workbook for NI links directly to the RQIA standards in Northern Ireland. However,
the document has information that is very relevant in England and clarifies the concept of governance
within a social care setting.

Outstanding Practice
To be ‘ outstanding ’ in this policy area you could provide evidence that:

Accountability and responsibility for governance is widely known and people are actively seeking
responsibility
Service improvements can be directly attributed to the governance processes
Tailored Care Services Ltd has evidence of being exceptionally open and transparent in the area of
governance
External organisations are involved in governance structures at Tailored Care Services Ltd
Where mistakes or errors are identified through governance processes, they are addressed in a timely
manner and they do not reoccur
Tailored Care Services Ltd uses best practice resources to inform development and evidence that
governance drives improvement
Tailored Care Services Ltd consistently uses root cause analysis following any incidents, including
safeguarding incidents, to understand lessons learnt and prevent issues arising again
The wide understanding of the policy is enabled by proactive use of the QCS App
Forms
Currently there is no form attached to this policy.

QC24-Good Governance Policy and Procedure

Uploaded by

Copyright:

Available Formats

QC24-Good Governance Policy and Procedure

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

QC24-Good Governance Policy and Procedure

Uploaded by

Copyright:

Available Formats

QC24 - Good Governance Policy and Procedure

Quality Assurance - Administration Quality Assurance

Tailored Care Services Ltd

Last Reviewed Last Amended Next Planned Review in 12 months, or

Minimal action required circulate information amongst relevant

Reason for this review Scheduled review

Were changes made? Yes

• The Health and Social Care Act 2008

Tailored Care Services Ltd

 Health and Safety at Work etc. Act 1974

 Medicines Act 1968

 Data Protection Act 2018

 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

2.1 The following roles may be affected by this policy:

2.2 The following Service Users may be affected by this policy:

2.3 The following stakeholders may be affected by this policy:

 External health professionals

Tailored Care Services Ltd

4.4 Responsibilities - Care Worker

Tailored Care Services Ltd

Tailored Care Services Ltd

Tailored Care Services Ltd

Key Facts - Professionals

Professionals providing this service should be aware of the following:

place so that staff understand what they are accountable for

monitored and actions are taken to improve practice

Key Facts - People affected by the service

People affected by this service should be aware of the following:

Tailored Care Services Ltd

To be ‘ outstanding ’ in this policy area you could provide evidence that:

Currently there is no form attached to this policy.

You might also like

Health and Safety at Work etc. Act 1974

Medicines Act 1968

Data Protection Act 2018

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

External health professionals