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Good Governance: Leadership and Management (England) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care provider’s approach to promoting an open, transparent ethos and culture in line with Regulation 17: Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Quality Statements developed by the CQC to assess a care service’s governance arrangements.

The Quality Statements for “Well-led” reflect what is expected of a “good service”, which is always the minimum aim of this care service.

  1. Shared direction and culture
  2. We have a shared vision, strategy and culture. This is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and our communities in order to meet these.
  3. Capable, compassionate and inclusive leaders
  4. We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty.
  5. Freedom to speak up
  6. We foster a positive culture where people feel that they can speak up and that their voice will be heard.
  7. Workforce equality, diversity and inclusion
  8. We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.
  9. Governance, management and sustainability
  10. We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.
  11. Partnerships and communities
  12. We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.
  13. Learning, improvement and innovation
  14. We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.
  15. Environmental sustainability — sustainable development
  16. We understand any negative impact of our activities on the environment and we strive to make a positive contribution in reducing it and support people to do the same.

{{org_field_name}} has established systems and processes for monitoring and auditing all aspects of its governance to ensure it achieves the standards described in these quality statements.

Developing Good Governance

{{org_field_name}} uses as its definition of good governance a commitment to and accountability for continuously improving the quality of its services, including where nursing is provided high standards of clinical oversight, so that it achieves excellence in all aspects of personal, health, and social care.

To achieve this, {{org_field_name}} recognises the importance of positive leadership and management to develop the service in line with person-centred values, people’s human rights and standards of care that reflect these in all respects of its service delivery.

{{org_field_name}} will always ensure that it treats people receiving care with respect, dignity and compassion by having a well-trained, highly motivated and professionally led staff group aware of its legal, ethical and moral duties working under the leadership of a qualified and committed management team.

{{org_field_name}} ensures that all directors and management team members meet all the “fit person” requirements for their respective roles and responsibilities, in line with the relevant Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This enables {{org_field_name}} to provide the highest quality service possible for all people receiving care in all areas of service delivery.

See also Fit and Proper Person Requirement for Directors (England) Policy and Clinical Governance (Care Homes with Nursing, England) Policy.

Managing Values and Principles

Directors and managers should always support the philosophy of care at the service in the following ways as examples of an overall commitment to person-centred care.

The Provider’s Expectations of its Directors and Managers

This provider considers that that its directors (where appointed), chief executive (where applicable) senior, middle and front-line managers all play crucial leadership roles in ensuring that the service complies with all standards of “good governance” and that the approach taken by all managers, in particular their leadership styles, is likely to have a great bearing on the performance of staff and quality of care.

Directors and managers should always support the philosophy of care at the service in the following ways.

The service thus expects its managers and management teams to:

  1. Be qualified, competent and experienced to run the service and meet its stated purpose, aims and objectives, and meet all registration requirements.
  2. Have adequate senior management experience individually and collectively.
  3. Ensure they provide positive direction and leadership and communicate the service aims and standards clearly to staff; ensure due diligence in all aspects of their work
  4. Have relevant qualifications in health and care for the different posts occupied by the management team, including where relevant suitable nursing qualifications, which individually and collective meet all registration requirements.
  5. Use opportunities to maintain and improve their professional knowledge and competences.
  6. Be committed to upholding human rights, equal opportunities, equality laws and non-discriminatory policies and practice.
  7. Be committed to and finding ways of supporting environmental sustainability.
  8. Have all the necessary management systems and policies and procedures in place to meet high quality standards in all aspects of the running of the service.
  9. Maintain robust staff recruitment policies to ensure adequate staffing of the service in line with regulatory requirements.
  10. Know how to assess and address the needs of the users of the service in order to achieve their personal outcomes
  11. Always promote and safeguard the wellbeing and interest of the people receiving care.
  12. Meet high standards of personal conduct in line with the applicable professional codes of practice, including ensuring confidentiality of information, financial probity, privacy and concern for the safekeeping and wellbeing of people receiving care and staff.
  13. Achieve high standards of clinical governance in addressing healthcare needs of people receiving care.
  14. Be thoroughly familiar with the barriers (including illnesses and conditions and social barriers) facing people receiving care in achieving their personal outcomes and can develop strategies and policies to help them overcome these.
  15. Have a strong sense of individual and collective responsibility offering mutual respect and support.
  16. Ensure there are clear lines of accountability so everyone knows to whom to refer and report issues arising from their respective work roles.
  17. Meet all professional registration requirements where they apply and ensure that where registered nurses are employed, they carry out their roles and responsibilities to the highest standards of clinical excellence and governance.
  18. Lead by example and uphold the highest standards at all times, and being supportive of the staff who work under their leadership.
  19. Encourage innovation, creativity and staff development and learning at all levels.
  20. Make full use of external support, advice and guidance and ensure compliance with all statutory requirements
  21. Ensure that the management approach creates an open, positive and approachable atmosphere, promoting inclusion and equality, where staff and people receiving care feel that they have a say in how things are done and feel that they contribute to the running of the service.
  22. Openly acknowledge any limitations of the service provision, particularly in relation to the number of staff employed, and their competence and skills, and strive to make the improvements needed.


{{org_field_name}} ensures that people appointed as directors, management and leadership roles are suitably qualified and are supported in their continuing professional development.

The registered person and management team of the service believe that to provide a quality service, the service requires high-quality staff who are suitably trained, supervised and supported.

All new care staff receive a comprehensive induction training based on the service’s principles and values. They must achieve the Care Certificate within the first 12 weeks of taking up their appointment. They then continue their professional development in line with the recommendations made by Skills for Care and, where relevant, other professional bodies and the CQC.

Each member of staff has a personal development plan in which their training needs are identified and a plan made as to how such needs will be met.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Copyright ©2024 {{org_field_name}}. All rights reserved

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