CH185-Clinical Governance Policy

Registration Number: {{org_field_registration_no}}

Clinical Governance Policy

1. Purpose

The purpose of this policy is to outline how {{org_field_name}} implements and maintains a robust Clinical Governance Framework for individuals receiving care in their own homes. Clinical governance ensures that we deliver safe, effective, compassionate, and high-quality care through continuous monitoring, improvement, and accountability. This policy demonstrates our commitment to upholding the highest standards as required by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and CQC Fundamental Standards.

2. Scope

This policy applies to all employees, volunteers, contractors, and any individuals or agencies working on behalf of {{org_field_name}}. It covers all aspects of clinical governance related to domiciliary and community-based care, ensuring people we support receive personalised, safe, and outcome-focused care in their own homes.

3. Related Policies

CH04-Good Governance
CH07-Person-Centred Care Policy
CH11-Safe Care and Treatment Policy
CH13-Safeguarding Adults from Abuse and Improper Treatment Policy
CH14-Receiving and Acting on Complaints Policy
CH18-Risk Management and Assessment Policy
CH27-Staff Supervision, Training, and Development Policy
CH35-Duty of Candour Policy
CH36-Initial Assessment and Care Planning Policy

4. Policy Statement and Commitment

{{org_field_name}} is committed to ensuring all aspects of home care are planned, delivered, and monitored through a structured Clinical Governance Framework. This ensures we consistently meet regulatory requirements, listen and respond to feedback, support continuous improvement, and safeguard those we care for.

5. Key Elements of Clinical Governance

a. Leadership and Accountability
The Registered Manager, supported by the Nominated Individual, has overall accountability for clinical governance. The Clinical Governance Lead coordinates all governance processes including audits, policy reviews, learning from incidents, and continuous improvement. All staff are accountable for their practice and are expected to escalate concerns or risks without delay.

b. Quality Assurance and Audit
We carry out regular audits of care records, medication administration, infection control practices, incident reporting, and service delivery. Each audit is analysed, and actions are tracked until resolution. Trends and learning points are shared across the team. Feedback from people we support and their families is systematically collected through surveys and reviews to improve our service.

c. Risk Management
All potential and actual risks to safety and wellbeing are identified, assessed, and recorded. Risk assessments are personalised and regularly reviewed. All staff are trained to report incidents, near misses, and safeguarding concerns in line with our safeguarding and risk management policies. Learning from adverse events is embedded into practice.

d. Evidence-Based Care and Clinical Effectiveness
All care interventions are based on best practice and current clinical guidelines, including those from NICE. We ensure care is tailored to individual needs, reflecting their health conditions, lifestyle preferences, and outcomes they wish to achieve. Staff are trained to deliver care safely and effectively, and all care is regularly reviewed for its effectiveness and appropriateness.

e. Person-Centred and Respectful Care
Our home care is tailored to meet the needs, preferences, and aspirations of each person (Regulation 9). We respect the autonomy, dignity, and privacy of each individual (Regulation 10), support them in decision-making (Regulation 11), and ensure they are fully involved in their care planning and review.

f. Learning and Workforce Development
We provide comprehensive induction, ongoing supervision, competency assessments, and continuous professional development (Regulation 18). Staff receive training specific to their roles including manual handling, medication administration, safeguarding, infection control, dementia awareness, and first aid. Staff are supported to reflect on their practice and develop new skills.

g. Complaints and Continuous Improvement
All complaints are logged, acknowledged, investigated, and responded to within agreed timescales (Regulation 16). We use complaint data to identify service improvements and training needs. Feedback is welcomed as a tool for driving positive change and enhancing quality of care.

h. Open and Honest Culture
We promote a culture of openness, honesty, and transparency in line with the Duty of Candour (Regulation 20). Any notifiable safety incidents are promptly reported to the person affected or their representative with a full explanation and apology. Learning from incidents is shared in team meetings and used to enhance our service.

i. Safeguarding and Protection from Harm
We have robust systems and processes in place to prevent, identify, and respond to abuse or neglect (Regulation 13). Staff are trained to recognise signs of abuse and report concerns to the Safeguarding Lead and relevant authorities. We ensure safe recruitment (Regulation 19) and vetting procedures are strictly followed.

j. Use of Technology and Innovation
We embrace safe use of digital systems to improve care delivery, record-keeping, communication, and data security. All electronic care records are securely stored and accessed only by authorised staff, in line with GDPR and CH34-Confidentiality and Data Protection Policy.

6. Monitoring and Review

Clinical governance is monitored through monthly governance reviews, quarterly care quality audits, annual staff appraisals, and incident reviews. Key performance indicators are used to track progress and identify areas for improvement. Lessons learned are documented and shared with teams for service development.

7. Policy Review

This policy is reviewed annually or sooner in response to legislative updates, regulatory guidance, or organisational needs. Updates are communicated to all staff, and training is provided where necessary to support implementation.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.