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CH185-Clinical Governance Policy

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Registration Number: {{org_field_registration_no}}

Clinical Governance Policy

1. Purpose

The purpose of this policy is to outline how {{org_field_name}} implements, maintains and continually improves a robust Clinical Governance Framework within the care home. Clinical governance ensures that residents receive safe, effective, compassionate, person-centred and high-quality care through clear leadership, accountability, risk management, evidence-based practice, effective record keeping, audit, learning and continuous improvement.

This policy supports compliance with the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Quality Commission (Registration) Regulations 2009, CQC Fundamental Standards, and CQC’s current assessment framework. The policy applies to all regulated activities carried out by the service, including the provision of accommodation for persons who require nursing or personal care, and any nursing, personal care, treatment, support, medicines management, nutrition, hydration, safeguarding, infection prevention and clinical oversight provided within the home.

2. Scope

This policy applies to all employees, registered nurses, care staff, senior care staff, managers, ancillary staff, agency workers, volunteers, contractors, visiting professionals and any person or organisation working on behalf of {{org_field_name}} within the care home.

It applies to all aspects of clinical governance in the care home, including assessment, care planning, risk management, medicines management, infection prevention and control, nutrition and hydration, safeguarding, clinical incidents, accidents, falls, wounds, pressure care, deterioration, end-of-life care, mental capacity and consent, deprivation of liberty safeguards, staffing, staff competency, equipment, premises, visiting arrangements, complaints, notifications, audits, quality assurance, record keeping, learning and service improvement.

The policy applies to all residents living at the home, including people receiving residential care, nursing care, respite care, intermediate care, reablement, dementia care, end-of-life care or any other regulated care and support provided by the service.

3. Related Policies

4. Policy Statement and Commitment

{{org_field_name}} is committed to ensuring that all care, treatment and support provided within the care home is planned, delivered, monitored and improved through a structured Clinical Governance Framework. The framework enables the provider, Registered Manager, Nominated Individual, senior leaders and staff to maintain oversight of quality, safety, risk, resident experience, staffing, safeguarding, incidents, complaints, audits, outcomes and regulatory compliance.

Clinical governance at {{org_field_name}} is designed to ensure that residents are protected from avoidable harm, treated with dignity and respect, involved in decisions about their care, supported to maintain relationships and independence, and enabled to achieve the best possible quality of life.

The service promotes an open, transparent and learning culture. We use feedback, audits, incidents, complaints, safeguarding learning, staff input, resident and family views, professional guidance, CQC guidance and recognised best practice to drive continuous improvement. This supports CQC’s expectation that well-led services have effective governance and management systems and use information about risks, performance and outcomes to improve care.

5. Key Elements of Clinical Governance

Leadership and Accountability

The Registered Provider has overall responsibility for ensuring that effective governance systems are established, operated and reviewed. The Nominated Individual provides provider-level oversight and ensures that the Registered Manager has the resources, support and authority required to deliver safe and effective care.

The Registered Manager is responsible for the day-to-day operation of the Clinical Governance Framework within the care home. This includes oversight of clinical risk, care planning, audits, medicines, infection prevention and control, staffing, safeguarding, incidents, complaints, resident experience, regulatory notifications and continuous improvement.

Where the service provides nursing care, the clinical lead, nurse in charge or other designated competent clinical person is responsible for supporting clinical oversight, escalation, clinical decision-making, staff competency and liaison with external healthcare professionals.

All staff are accountable for working within their role, competence, training and professional responsibilities. Staff must report concerns, incidents, near misses, safeguarding concerns, poor practice, changes in residents’ needs, clinical deterioration or risks without delay.

Governance responsibilities are reviewed through management meetings, clinical governance meetings, audits, supervision, handovers, staff meetings, quality assurance visits and provider oversight. Records of governance discussions, actions, learning and completed improvements must be maintained.

Quality Assurance, Audit and Provider Oversight

{{org_field_name}} operates a structured quality assurance and audit programme to assess, monitor and improve the quality and safety of care provided within the care home. Audits include, but are not limited to, care plans, risk assessments, medicines, controlled drugs where applicable, infection prevention and control, hand hygiene, wounds, pressure care, falls, nutrition and hydration, weight monitoring, accidents and incidents, safeguarding, complaints, staffing, supervision, training, mental capacity and consent, DoLS, health and safety, fire safety, premises, equipment, records and resident experience.

Audit findings are recorded, analysed and used to identify themes, trends, risks, omissions, good practice and areas for improvement. Each audit must include clear actions, a named responsible person, timescales for completion, evidence of completion and management sign-off.

The Registered Manager is responsible for ensuring that audit outcomes are discussed at governance meetings and that overdue or repeated actions are escalated to the Nominated Individual or provider. The provider will maintain oversight of quality and safety through regular reports, quality visits, review of key performance indicators and scrutiny of improvement plans.

Where audits identify shortfalls that may affect resident safety, dignity, rights or regulatory compliance, immediate action must be taken to reduce risk. Lessons learned must be shared with staff through handovers, supervision, meetings, briefings, training and updated procedures.

The service will maintain evidence that governance systems are effective, including completed audits, action plans, meeting minutes, quality reports, resident and family feedback, staff feedback, incident analysis, complaints learning and evidence of sustained improvement.

CQC Assessment Framework and Quality Statements

The Clinical Governance Framework is aligned with CQC’s current assessment framework, including the five key questions: Safe, Effective, Caring, Responsive and Well-led. The service uses CQC quality statements, evidence categories and relevant “we statements” to evaluate performance, identify improvement priorities and prepare evidence of compliance.

Governance reviews will consider how the service demonstrates safe systems, learning culture, safeguarding, involving people, person-centred care, equity, consent, workforce competence, medicines optimisation, infection prevention and control, leadership, freedom to speak up, partnership working, sustainability and continuous improvement.

The Registered Manager will ensure that evidence of good governance is organised and available, including policies, audits, action plans, resident outcomes, feedback, staff training records, supervision records, meeting minutes, incident learning, safeguarding records, complaints analysis and quality improvement evidence.

Risk Management

All potential and actual risks to residents’ health, safety, welfare, dignity, rights and wellbeing are identified, assessed, recorded, reviewed and managed. Risk assessments are personalised and must balance safety with residents’ rights, choices, independence, preferences and quality of life.

Risk assessments must be completed by staff with the appropriate knowledge, skills and competence. They must be reviewed regularly and whenever there is a change in need, following an incident, hospital admission or discharge, safeguarding concern, complaint, change in medication, deterioration, infection, fall, wound, pressure damage, weight loss, choking risk, mobility change, mental capacity concern or other relevant event.

Risk management includes, but is not limited to, falls, moving and handling, pressure ulcers, choking, nutrition and hydration, medicines, diabetes, epilepsy, catheter care, continence, skin integrity, infection prevention and control, distressed behaviour, self-neglect, smoking, fire safety, bed rails, equipment, environmental risks, absconding, community access, visiting, mental capacity, DoLS and end-of-life care.

Staff must follow risk management plans and escalate concerns promptly. Where risks cannot be managed safely within the home, the Registered Manager or clinical lead must seek advice from relevant healthcare professionals, commissioners, safeguarding teams, the GP, community nursing teams, specialist nurses or emergency services as appropriate.

Incidents, accidents and near misses must be reviewed to identify immediate action, root causes, patterns, learning and prevention measures. Learning must be shared with staff and used to update care plans, risk assessments, training and practice.

Accidents, Incidents, Near Misses and CQC Notifications

All accidents, incidents, near misses and significant events must be reported, recorded, reviewed and investigated in accordance with the Accident and Incident Reporting Policy and CQC Notifications Policy.

The Registered Manager must ensure that incidents are assessed to determine whether they require notification to CQC, the local authority safeguarding team, commissioners, the police, the Health and Safety Executive, the resident’s GP, relatives or representatives, or other relevant agencies.

CQC must be notified without delay of notifiable incidents as required under the Care Quality Commission (Registration) Regulations 2009, including serious injuries, abuse or allegations of abuse, police involvement and events that prevent or threaten to prevent the service from operating safely.

Incident reviews must identify immediate actions, duty of candour requirements, safeguarding actions, changes to care plans or risk assessments, staff support, training needs, environmental changes and service-wide learning. Themes and trends must be reviewed through the clinical governance process.

Evidence-Based Care and Clinical Effectiveness

Care, treatment and support must be based on current legislation, CQC guidance, NICE guidance, professional standards, national safety alerts, local authority guidance, NHS guidance, safeguarding guidance and recognised best practice.

Clinical decisions must be person-centred, proportionate, clearly recorded and based on assessment of the resident’s needs, risks, wishes, mental capacity, consent, equality needs, communication needs, protected characteristics, cultural needs and desired outcomes.

Where the service provides nursing care, nursing interventions must be delivered by registered nurses or competent delegated staff in accordance with professional standards, local procedures and the resident’s care plan. Registered nurses must work within the Nursing and Midwifery Council Code and escalate concerns where care needs exceed the competence or resources of the service.

The effectiveness of care must be reviewed through resident reviews, clinical observations, outcome monitoring, feedback, audits, incident analysis, professional input and changes in the resident’s condition. Where care is not achieving the intended outcome, the care plan and risk assessments must be reviewed and appropriate professional advice sought.

Person-Centred, Respectful and Rights-Based Care

Care within the home must be person-centred and tailored to each resident’s needs, preferences, history, routines, communication needs, cultural background, religious beliefs, protected characteristics, relationships, abilities, risks and desired outcomes.

Residents must be treated with dignity, respect, compassion and kindness. Staff must promote privacy, independence, choice, control, inclusion and equality. Residents must be supported to make decisions about their daily lives, care, treatment, visitors, routines, meals, activities, personal care, medicines, healthcare appointments and end-of-life wishes wherever they have capacity to do so.

Where a resident may lack capacity to make a specific decision, staff must follow the Mental Capacity Act 2005, complete decision-specific capacity assessments where required, involve relevant representatives, make best interests decisions and record the rationale clearly. Any restriction must be lawful, necessary, proportionate and the least restrictive option.

Residents and, where appropriate, their relatives, advocates or representatives must be involved in care planning, risk assessment, reviews and decisions about care and treatment. The service will make reasonable adjustments to support involvement and communication.

Visiting, Accompanying and Maintaining Relationships

The service recognises that visiting, contact with family and friends, community connections and accompaniment to appointments are essential to residents’ wellbeing, rights and quality of life.

Residents must be supported to receive visits from people they wish to see, to take visits outside the care home, and to maintain relationships and community links unless there are exceptional circumstances that justify a restriction. The starting assumption must be that in-person visiting is possible.

Any precautions or restrictions must be based on an individual risk assessment, be necessary and proportionate, be the least restrictive option, and be reviewed regularly. Blanket restrictions or long-term restrictions must not be applied. Decisions must involve the resident and, where appropriate, relatives, friends, advocates or representatives.

Any restriction must be clearly recorded, including the resident’s wishes, the risks identified, options considered, people involved, the legal basis, the human rights considerations, the least restrictive measures used and the review date. Residents receiving end-of-life care must always be supported to receive in-person visits.

Learning, Workforce Development and Competency

{{org_field_name}} ensures that staff are recruited, inducted, trained, supervised, appraised and assessed as competent to carry out their roles safely and effectively. Staffing levels and skill mix must be sufficient to meet residents’ assessed needs at all times, including during sickness, annual leave, emergencies, outbreaks, increased dependency and end-of-life care.

Staff must receive role-specific training, supervision, competency assessment and continuing professional development. Training will include, where relevant to the role, safeguarding, moving and handling, medicines, infection prevention and control, food hygiene, nutrition and hydration, falls prevention, pressure care, dementia, mental capacity and DoLS, equality and diversity, fire safety, health and safety, first aid, end-of-life care, record keeping, complaints, duty of candour, incident reporting, whistleblowing and data protection.

Staff must receive learning disability and autism training that is appropriate to their role and aligned with the Oliver McGowan Code of Practice. The service will complete regular skills assessments to determine the level of training required for each staff member and will maintain evidence of completion, refresher training and impact on practice.

Staff must not undertake tasks unless they have been trained, assessed as competent and authorised to do so. Competency must be reviewed regularly and following incidents, concerns, changes in role, new equipment, new procedures or changes in residents’ needs.

The Registered Manager will monitor training compliance, supervision, appraisal, competency, agency staff induction and professional registration where applicable. Any gaps that may affect resident safety must be escalated and addressed through the governance process.

Complaints, Concerns, Feedback and Continuous Improvement

Complaints, concerns, compliments and feedback are welcomed as opportunities to learn and improve. Residents, relatives, representatives, advocates, visitors, staff and professionals must be supported to raise concerns without fear of discrimination, disadvantage or reprisal.

All complaints must be acknowledged, recorded, investigated and responded to in accordance with the Complaints Policy and Regulation 16. Responses must be open, respectful, evidence-based and include the outcome, actions taken, learning identified and escalation routes where the complainant remains dissatisfied.

Complaint themes and trends must be reviewed through clinical governance meetings and provider oversight. Learning from complaints must be used to improve care plans, risk assessments, staff practice, training, communication, staffing, management systems and policies.

The service will actively seek feedback from residents, relatives, advocates, staff and external professionals through reviews, meetings, surveys, resident meetings, relatives’ meetings, quality assurance visits and day-to-day engagement. Feedback must be analysed and acted upon to improve the quality and safety of care.

Open, Honest and Learning Culture, Including Duty of Candour

{{org_field_name}} promotes a culture of openness, honesty, transparency, accountability and learning. Staff are expected to speak up about risks, mistakes, poor practice, unsafe care, closed cultures, safeguarding concerns, staffing concerns and any matter that may affect residents’ safety, dignity, rights or wellbeing.

The service will comply with the statutory Duty of Candour. Where a notifiable safety incident occurs, the Registered Manager or delegated competent person must ensure that the relevant person is informed as soon as reasonably practicable, receives a truthful explanation of what happened, is given a sincere apology, is informed of the actions being taken, and receives appropriate written follow-up.

Saying sorry is not an admission of liability. The purpose of the apology is to acknowledge harm, maintain trust, support the person affected and promote learning.

Duty of candour records must include the incident, harm, people involved, verbal notification, apology, written notification, investigation outcome, actions taken, family or representative involvement and learning shared with staff.

Learning from incidents and duty of candour events must be reviewed through clinical governance and used to improve care and prevent recurrence.

Safeguarding and Protection from Harm

{{org_field_name}} has systems and processes to prevent, identify, report and respond to abuse, neglect, discrimination, exploitation, avoidable harm, improper treatment, organisational abuse and closed cultures.

Staff must be trained to recognise and report safeguarding concerns, including physical abuse, emotional abuse, sexual abuse, financial abuse, neglect, self-neglect, domestic abuse, discriminatory abuse, modern slavery, organisational abuse, misuse of restraint, inappropriate restrictions, medication misuse, pressure damage, unexplained injuries, poor moving and handling, poor nutrition or hydration, and neglect of healthcare needs.

Safeguarding concerns must be reported immediately to the Registered Manager, Safeguarding Lead or senior person on duty. The service must take immediate action to protect residents from harm and must refer concerns to the local authority safeguarding team, CQC, police, commissioners or other relevant agencies as required.

The Registered Manager must ensure that safeguarding records are accurate, contemporaneous and include the concern, immediate action, referrals, notifications, investigation, outcomes, learning and actions taken to reduce future risk.

Safeguarding themes and trends must be reviewed through the clinical governance process and used to improve staffing, training, supervision, care planning, risk management, culture and oversight.

Use of Technology, Digital Records and Information Governance

{{org_field_name}} uses digital systems, where appropriate, to support safe care delivery, care planning, medicines management, auditing, monitoring, communication, reporting, governance and quality improvement.

Digital systems must be used safely, lawfully and securely. Access must be restricted to authorised users, passwords must not be shared, and staff must receive training on the correct use of systems before access is granted.

Electronic care records must be accurate, complete, contemporaneous, person-centred and sufficiently detailed to evidence care provided, decisions made, risks identified, consent, capacity, professional advice, family involvement, outcomes and reviews.

Any digital failure, cyber incident, data breach, system outage or risk to continuity of care must be escalated immediately and managed in accordance with the Business Continuity, Records Management and Data Protection policies.

The service will audit digital records to ensure quality, accuracy, confidentiality, accessibility and compliance with UK GDPR, the Data Protection Act 2018, CQC requirements and Regulation 17.

Nutrition and Hydration Governance

The service will ensure that residents’ nutrition and hydration needs are assessed, planned, met, monitored and reviewed. This includes assessment of dietary needs, preferences, allergies, cultural and religious requirements, swallowing risks, choking risks, weight loss, malnutrition, dehydration, diabetes, modified diets, supplements and support required to eat and drink.

Residents must receive suitable and nutritious food and hydration that is adequate to sustain life and good health. Where required, referrals must be made to the GP, dietitian, speech and language therapist, dentist, community nursing team or other relevant professional.

Weight monitoring, food and fluid records, MUST or other recognised nutritional screening tools, choking risk assessments and care plans must be reviewed according to the resident’s level of risk.

Nutrition and hydration audits, weight loss trends, choking incidents, dietary concerns, supplements, mealtime experience and resident feedback must be reviewed through the clinical governance process.

Medicines Governance

Medicines must be managed safely, effectively and in accordance with legislation, prescriber instructions, NICE guidance, professional standards and the Medicines Management Policy.

Medicines governance includes safe ordering, receipt, storage, administration, recording, disposal, covert administration, self-administration, homely remedies, controlled drugs where applicable, allergies, refusals, missed doses, PRN medicines, topical medicines, time-critical medicines, oxygen, medication reviews and management of medicines during admission, discharge or transfer.

Staff administering or managing medicines must be trained and assessed as competent. Competency must be reviewed regularly and following medicines errors, incidents, concerns or changes in procedure.

Medicines errors, omissions, stock discrepancies, adverse effects, refusals and near misses must be reported, investigated and reviewed. Learning must be shared and used to improve practice.

Medicines audits must be completed regularly and reviewed through the clinical governance process. Actions must be recorded, allocated, completed and checked for effectiveness.

Infection Prevention and Control

{{org_field_name}} will maintain effective systems to prevent, detect and control infection, including healthcare-associated infections. Infection prevention and control arrangements will follow current legislation, national guidance, local public health advice and the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.

Infection prevention governance includes hand hygiene, personal protective equipment, cleaning, laundry, waste management, sharps safety, outbreak management, vaccination awareness, antimicrobial stewardship, isolation precautions where required, staff training, audits and environmental cleanliness.

Infection risks must be assessed and managed in a proportionate and person-centred way. Restrictions used during outbreaks must be lawful, necessary, proportionate, regularly reviewed and the least restrictive option.

Infection outbreaks, themes, audit findings, lessons learned and improvement actions must be reviewed through the clinical governance process.

Premises, Equipment and Environmental Safety

The provider will ensure that premises and equipment used for regulated activities are safe, suitable, properly maintained and used correctly. This includes resident accommodation, communal areas, bathrooms, kitchens, clinical areas, sluice facilities, laundry, gardens, mobility equipment, hoists, slings, beds, mattresses, bed rails, wheelchairs, sensor equipment, call bells, fire safety systems, water systems, gas, electricity and other utilities.

Equipment must be available in sufficient quantities to meet residents’ needs and must be checked, serviced, cleaned, maintained and replaced when required. Staff must be trained and competent to use equipment safely.

Environmental risks must be assessed, recorded and reviewed. Where risks are identified, action must be taken promptly to protect residents, visitors and staff.

Premises and equipment audits, maintenance records, servicing certificates, safety checks, incidents and environmental risks must be reviewed through the governance process.

CQC Ratings and Performance Assessment Display

Where {{org_field_name}} has received a CQC rating or performance assessment, the provider will ensure that the most recent rating is displayed conspicuously and legibly at the care home and on any website maintained by or on behalf of the provider.

The display must show the rating clearly, identify the relevant location or regulated activity, include the date of the rating and provide details of where the full CQC assessment can be accessed.

The Registered Manager will check regularly that the displayed rating and website information remain accurate and up to date.

Freedom to Speak Up and Prevention of Closed Cultures

{{org_field_name}} promotes a culture where staff, residents, relatives, advocates and professionals can raise concerns openly and safely. Concerns about poor care, unsafe staffing, bullying, harassment, discrimination, abuse, neglect, poor leadership, closed cultures or failure to act on risks must be taken seriously and escalated promptly.

Staff must be informed of how to raise concerns internally and externally, including to the Registered Manager, Nominated Individual, provider, local authority safeguarding team, CQC and other relevant bodies.

The provider will monitor indicators of closed culture, including high staff turnover, high agency use, repeated complaints, safeguarding concerns, poor staff morale, restrictive practice, poor engagement, lack of transparency, institutional routines, poor record keeping and failure to learn from incidents.

Concerns raised through whistleblowing, supervision, meetings, surveys, complaints or safeguarding must be reviewed through governance arrangements and used to improve the service.

Equality, Human Rights and Health Inequalities

Clinical governance must promote equality, human rights, inclusion and non-discriminatory care. The service will identify and respond to residents’ protected characteristics, communication needs, cultural needs, religious needs, sexuality, gender identity, disability, sensory needs, mental health needs, learning disability, autism, dementia and any factors that may increase the risk of poorer outcomes or unequal access to care.

Care planning, risk assessment, activities, nutrition, communication, visiting, complaints, safeguarding, end-of-life care and healthcare access must be adjusted to meet individual needs.

The service will monitor feedback, incidents, complaints, safeguarding and outcomes to identify potential inequality, discrimination or barriers to care. Any identified concern must be acted upon and reviewed through the governance process.

6. Monitoring and Review

Clinical governance will be monitored through a structured programme of audits, quality assurance checks, clinical governance meetings, staff meetings, resident and relatives’ feedback, provider oversight visits, incident reviews, safeguarding reviews, complaints analysis, care plan reviews, medication audits, infection prevention audits, nutrition and hydration audits, falls analysis, pressure care monitoring, training compliance checks, supervision monitoring and review of regulatory notifications.

The Registered Manager will maintain a clinical governance action plan that records identified shortfalls, actions required, responsible persons, timescales, completion dates, evidence of completion and checks of effectiveness. Actions that are overdue, repeated or high risk must be escalated to the Nominated Individual or provider.

Key performance indicators will be reviewed regularly and may include falls, falls with injury, pressure ulcers, wounds, infections, hospital admissions, safeguarding concerns, complaints, compliments, incidents, medicines errors, missed medicines, weight loss, choking incidents, staffing levels, agency use, staff turnover, training compliance, supervision compliance, care plan review compliance, DoLS status, CQC notifications and audit completion.

Governance meetings must review quality, safety, resident experience, staffing, risks, regulatory compliance, lessons learned, improvements and evidence required for CQC assessment. Minutes must be kept and must show decisions made, actions agreed, responsible persons and follow-up.

The provider will review the effectiveness of the Clinical Governance Framework and ensure that systems remain suitable, effective and aligned with current legislation, CQC guidance, best practice and the needs of residents.

7. Policy Review

This policy will be reviewed at least annually or sooner where there are changes to legislation, CQC guidance, statutory guidance, best practice, the regulated activities provided, organisational structure, resident needs, safeguarding learning, serious incidents, complaints, audit findings, enforcement action or other significant events.

Policy updates will be approved by the Registered Manager and provider or Nominated Individual. Changes will be communicated to relevant staff, and additional training, supervision or competency assessment will be provided where required.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.

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