{{org_field_logo}}

{{org_field_name}}

---

Good Governance: Organisational Structure (England) Policy

Purpose

This policy shows (with the relevant service information included) how this care service is organised and managed in line with the requirements of Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation requires service providers to have methods to:

1. assess, monitor and improve the quality and safety of the services provided including the quality of people’s experience in receiving the services
2. to assess, monitor and mitigate risks to the health, safety and welfare of people receiving care and others involved, which includes risks to staff
3. keep securely accurate records of the care and treatment provided to each person receiving care and of decisions taken about their care and treatment
4. keep securely other records on staff and those required for the management of the service
5. seek and act on feedback from people receiving care and others in order to be assessing and improving the services
6. ensure that {{org_field_name}}’s methods of governance and management remain effective.

The regulation also requires care providers to reply to CQC requests for information (for example, in response to concerns or queries about the service or to complete a Provider Information Return) 28 days from receiving the request.

{{org_field_name}} is also mindful of the Quality Statements under Well-led, which with other domains form the CQC single assessment framework, and seeks to answer in its governance practices all questions relating to:

• shared direction and culture
• capable, compassionate and inclusive leaders
• freedom to speak up
• workforce diversity, equality and inclusion
• governance, management and sustainability
• partnerships and communities
• learning, improvement and innovation
• environmental sustainability — sustainable development.

Description of Service

{{org_field_name}} is registered with the Care Quality Commission to deliver the following regulated activities
• Personal care.
• Accommodation for person who require nursing or personal care.
• Treatment of disease, disorder or injury.
{{org_field_name}} is registered to have the legal entity as:
• Organisation with the:
a) Nominated Individual as: {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}}
b) Registered Manager as: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
{{org_field_name}} operates as a care home with/without nursing the groups of people stated in the Statement of Purpose.

Organisation and Management Overview

{{org_field_name}} operates within the following structure:

Nominated individual: {{org_field_nominated_individual_first_name}} {{org_field_nominated_individual_last_name}}
Role within {{org_field_name}} structure: Director
Registered manager: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Deputy manager: {{org_field_deputy_manager_first_name}} {{org_field_deputy_manager_last_name}}

Other management/leadership functions/roles (specify, eg care co-ordinator clinical leads, staff training, etc)

1. Care co-ordination (not yet appointed)
2. Staff supervision and management (Registered and Deputy Manager)
3. Staff development and training (Registered and Deputy Manager)
4. Quality assurance and compliance (Registered and Deputy Manager)
5. Safeguarding – (Registered and Deputy Manager)
6. Infection prevention and control (including Covid-19 measures) – (Registered and Deputy Manager)
7. Health and safety (Registered and Deputy Manager)
8. Clinical leads (not yet appointed)

Ancillary support/HR/administration and financial management.

How The Service Provides “Good Governance”

{{org_field_name}} has a suite of polices that show in detail its compliance with Regulation 17 and the relevant Quality Statements as follows:

1. Promotion of an open, transparent, person-centred culture

Governance, Leadership and Management

Statement of purpose

Information for people receiving care

Website (where applicable)

2. Nominated individual’s oversight of governance arrangements (where NI is other than registered manager) [see (f) above]

Fit and Proper Person Requirement for Directors (where applicable)

Nominated individual management and supervision checklist

Area management monitoring forms (where applicable)

Regular provider visits form (where applicable)

3. Assessing quality, safety, and promoting continuous development and improvement [see (a) & (e) above]

Quality Assurance and Management

Responding to the Experiences of People Receiving Care

Complaints and Compliments

Making Unannounced Calls or “Spot Checks” (Domiciliary Care)

Audit planning forms

Audit tools (related to areas for audit)

Self-audit tools

Questionnaires and survey forms

Complaints forms

Business planning tools

4. Assessing and controlling risks to welfare and safety [see (b) above]

Safeguarding People Receiving Care from Abuse and Harm

Mental Capacity, Human Rights and Deprivation of Liberty

Clinical Governance (where applicable)

Health and Safety

Infection Prevention and Control (including for Covid-19)

Medication Administration and Management (and additional policies)

Risk Assessment and Management for People Receiving Care

Risk assessment and management forms (related to different risk areas to be Assessed)

Critical incident reporting and reviewing forms

Medication audit forms

5. Keeping records and record keeping systems [see (c) & (d) above]

Records and Record Keeping

People Who Use Services’ Access to Records

Records Kept in People Who Use Services’ Homes (Domiciliary Care)

Information Governance Under the GDPR

Care records auditing forms

6. Responding to CQC’s requests for information

Statutory Notifications

Completion of PIRs on request

Completion of forms issued by CQC

7. Partnership working including commissioners, safeguarding, health services and CQC

Working with Other Providers and Agencies

Stakeholder feedback form and questionnaire

Monitoring and auditing (adjust as applicable)

An appropriate person will carry out continuous and at least weekly checks on:

• care practices and recording
• catering arrangements
• administration of medicines
• use of equipment and devices used in the delivery of care
• checking of location premises for health, safety and security, including fire safety
• checking of infection control and hygiene measures (including for Covid-19)
• current safeguarding and complaints’ issues, including any alerts to the local safeguarding authority
• checks on staffing availability and performance
• continuity of care: travel and care time.

There is a rolling schedule of audits on a 1–3 month basis to carry out full checks on the above areas together with:

• risk assessments and control measures, including mental capacity issues
• staffing complements, staff supervision and training
• all health and safety issues
• infection prevention and control issues.

There is at least an annual self-evaluation of the service’s performance against each of the five Key Questions and Quality Statements using suitable professional tools, which include obtaining systematised feedback from people who use services and stakeholders.

---

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 ©2024 {{org_field_name}}. All rights reserved