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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Good Governance Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} operates in a manner that is compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 17 – Good Governance and the associated requirements in Regulations 4–20A. Through effective governance systems, this policy provides a framework for accountability, transparency and continual improvement within our care home, ensuring that all activities are managed safely and effectively to deliver high-quality, person-centred care and to prevent avoidable harm.

2. Scope

This policy applies to:

• All staff, including managers, care workers, administrative personnel, and external contractors.
• The Registered Manager, Nominated Individual, and senior leadership team, who have key responsibilities in ensuring regulatory compliance.
• The people we support, their families, and representatives who rely on our service for high standards of care.

3. Key Governance Principles

Good governance at {{org_field_name}} is based on the following principles:

3.1 Compliance with Legal and Regulatory Frameworks

To maintain regulatory compliance, we:

• Adhere to all CQC Fundamental Standards and ensure compliance with Regulation 17 – Good Governance, which requires effective systems and processes to:
  • Assess, monitor, and improve service quality.
  • Identify and mitigate risks.
  • Maintain accurate records relating to care provision and management.
  • Ensure learning and development from incidents and complaints.
• Regularly update our policies in line with CQC guidance, the Care Act 2014, Mental Capacity Act 2005, and Equality Act 2010.

We recognise that good governance under Regulation 17 underpins compliance with other key regulations, including Regulation 12 (safe care and treatment), Regulation 18 (staffing), Regulation 19 (fit and proper persons: employed), Regulation 20 (duty of candour) and Regulation 20A (requirement as to display of performance assessments). Our governance systems include robust assurance and auditing processes to assess, monitor and drive improvement in the quality and safety of the services we provide, including people’s experience of care, and to identify, assess and mitigate risks to the health, safety and welfare of people using the service, in line with current CQC guidance.

3.2 Leadership and Accountability

• The Registered Manager and Nominated Individual ensure robust governance structures and report to CQC and other relevant bodies.
• A clear organisational structure is in place, defining roles, responsibilities, and accountability at all levels.
• Regular board meetings and leadership reviews take place to assess governance effectiveness.

3.3 Risk Management and Continuous Improvement

• A Risk Management Framework is in place, covering health and safety, safeguarding, and compliance risks.
• All incidents, complaints, and feedback are analysed, and action plans are implemented to mitigate risks.
• Regular audits and quality assurance reviews are conducted to identify areas of improvement.

3.4 Person-Centred and Inclusive Care Delivery

• Care is tailored to each individual, ensuring personal preferences, autonomy, and dignity are respected.
• We support diversity and inclusion, ensuring compliance with the Equality Act 2010.
• People we support, families, and advocates are actively involved in care planning and decision-making.

3.5 Effective Record Keeping and Data Protection

• All records, including care plans, risk assessments, and incident reports, are accurate, up-to-date, and stored securely.
• We comply with the UK General Data Protection Regulation (UK GDPR), the Data Protection Act 2018 and our Confidentiality and Information Governance Policies to ensure the secure, lawful and transparent handling of personal information, including digital records, in line with CQC guidance on processing information.

3.6 Staff Training, Supervision, and Support

• Staff undergo mandatory training in key governance areas, including duty of candour, safeguarding, and compliance.
• Regular supervisions, appraisals, and competency assessments are conducted to ensure high standards.
• A whistleblowing policy is in place to encourage staff to report concerns without fear of retribution.

In accordance with the Health and Social Care Act 2008 as amended by the Health and Care Act 2022, {{org_field_name}} ensures that each person working for the purposes of our regulated activities receives training on learning disability and autism that is appropriate to their role. This includes using training that is aligned with the Oliver McGowan Code of Practice on Mandatory Training on Learning Disability and Autism, or equivalent training that meets the same learning outcomes.

We maintain clear records of all learning disability and autism training completed by staff, including the level, date and refresher requirements, and we review this as part of our regular supervision, appraisal and competency processes.

3.7 Financial Transparency and Ethical Management

• The organisation follows Regulation 13 – Financial Position to ensure financial stability and ethical resource allocation.
• Clear financial policies are in place for managing service user finances, payroll, and operational costs.

3.8 Incident Reporting, Learning, and Continuous Improvement

• All incidents, complaints, and safeguarding concerns are reported, investigated, and addressed.
• Lessons learned from audits, feedback, and inspections drive continuous improvement plans.

3.9 Displaying CQC Ratings and Compliance Information

• Our CQC rating and performance assessments are displayed in accordance with Regulation 20A – Display of Performance Assessments.
• Our Statement of Purpose is reviewed regularly and kept up to date.

Ratings are displayed conspicuously and legibly at each location where services are delivered and on our website, in the format required by Regulation 20A and current CQC guidance.

3.10 Alignment with CQC’s Assessment Framework

{{org_field_name}} structures its governance arrangements to align with the Care Quality Commission’s current single assessment framework, including the 5 key questions (safe, effective, caring, responsive and well-led) and the associated quality statements. In particular, our governance systems are designed to evidence that the service is “well-led” by demonstrating effective leadership, a positive and open culture, clear accountability, and robust assurance and risk-management processes that drive continuous improvement.

4. Related Policies

This policy should be read in conjunction with the following policies:

• CH01 – Fit and Proper Persons: Directors Policy
• CH02 – Fit and Proper Persons: Employed Staff Policy
• CH03 – Requirements for Registered Managers Policy
• CH07 – Person-Centred Care Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH14 – Receiving and Acting on Complaints Policy
• CH18 – Risk Management and Assessment Policy
• CH35 – Duty of Candour Policy

5. Monitoring and Compliance

To ensure that this policy is effectively implemented:

• Quarterly governance audits are carried out.
• Annual governance reports are produced and shared with CQC, trustees, and stakeholders.
• Compliance with governance standards is reviewed during CQC inspections.
• Staff training logs and competency assessments are regularly checked.

Governance audits and annual reports are structured to reflect CQC’s current single assessment framework and Well-led quality statements. Evidence gathered through audits, feedback, incident reviews and staff engagement is mapped to the relevant regulations and quality statements so that we can demonstrate sustained compliance and continuous improvement at any point in time.

6. Policy Review

This policy will be reviewed annually or sooner if:

• There are changes in legislation or CQC regulations.
• Governance audits highlight areas requiring policy improvement.
• There are significant incidents or concerns requiring an update in governance practices.
• New or updated statutory codes of practice or CQC guidance are issued that affect governance requirements, including (but not limited to) codes and guidance on infection prevention and control, the display of ratings, and mandatory training on learning disability and autism.

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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}}
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