{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Good Governance Policy

1. Purpose

This policy establishes the governance framework for {{org_field_name}} to ensure accountability, transparency, and compliance with all regulatory, legal, and ethical responsibilities. Good governance is critical to maintaining a high-quality, safe, and effective care service that meets the needs of residents and complies with the Regulation and Inspection of Social Care (Wales) Act 2016.

2. Scope

This policy applies to:

• The Board of Directors and Responsible Individual (RI).
• The Registered Manager and senior management team.
• All staff members, including care and non-care staff.
• External partners, commissioners, and regulators, ensuring aligned governance practices.

3. Legal and Regulatory Framework

This policy aligns with:

• Regulation and Inspection of Social Care (Wales) Act 2016
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017
• The Regulated Services (Registration) (Wales) Regulations 2017
• The Regulated Services (Annual Returns and Registration) (Wales) Regulations 2019
• CIW’s Securing Improvement and Enforcement Policy (2024)
• Criminal Enforcement Policy (CIW, 2023)
• Commitment to Human Rights and Safeguarding Policies

4. Governance Principles

At {{org_field_name}}, our governance framework is built on six key principles:

4.1 Leadership and Accountability

• The Board of Directors and Responsible Individual (RI) provide clear leadership, ensuring the home meets regulatory and ethical obligations.
• The Registered Manager ensures daily operations align with legal, safety, and quality standards.
• Staff roles and responsibilities are clearly defined, with a hierarchical structure to ensure accountability.
• CIW and external stakeholders have direct access to senior leadership to discuss concerns.

Efficiency Measure:

• Regular governance meetings ensure all management levels stay informed of regulatory updates and operational performance.
• Accountability mechanisms ensure any governance failures are identified and addressed promptly.

4.2 Compliance with CIW Regulations and Legislation

• CIW regulations are embedded into the organisation’s governance framework.
• The Responsible Individual (RI) ensures all policies meet CIW standards, and regular audits confirm compliance.
• The organisation submits Annual Quality of Care Reports in line with CIW requirements.

Efficiency Measure:

• Internal compliance audits every three months to identify risks before they become regulatory issues.
• Annual external audits for independent oversight of governance structures.

4.3 Quality Assurance and Continuous Improvement

• Quality of care reviews are carried out regularly using CIW’s Quality of Life Methodology (SOFI2).
• Resident and family feedback is collected and analysed to improve service delivery.
• The organisation acts on CIW inspection feedback to drive continuous improvement.

Efficiency Measure:

• Quarterly staff training updates to address CIW inspection findings.
• Digital tracking system to monitor compliance gaps and action plans.

4.4 Risk Management and Safeguarding

• A robust risk management framework ensures early identification of risks, including financial, operational, health, and safety risks.
• A dedicated Safeguarding Lead ensures all staff are trained in safeguarding protocol.
• Incident reporting mechanisms ensure swift action on complaints, safeguarding concerns, and health risks.

Efficiency Measure:

• Real-time digital risk register tracks all identified risks and mitigation plans.
• Mandatory safeguarding training for all staff, reviewed annually.

4.5 Transparency and Ethical Decision-Making

• All financial and operational decisions are made in a transparent, ethical manner, with record-keeping of all governance decisions.
• Conflicts of interest must be declared by directors and staff.
• The organisation follows CIW’s duty of candour principles, ensuring openness when things go wrong.

Efficiency Measure:

• Open-door policy for staff and residents to report concerns without fear of reprisal.
• Independent whistleblowing process (CHW29 – Whistleblowing Policy) for anonymous reporting of governance failures.

4.6 Staff Development and Organisational Culture

• Good governance starts with well-trained staff. All employees receive continuous professional development aligned with CIW standards.
• Performance appraisals ensure staff align with organisational values and compliance expectations.
• A culture of learning, innovation, and respect is fostered throughout the care home.

Efficiency Measure:

• Annual competency assessments for staff, ensuring regulatory knowledge is up to date.
• Recognition and reward schemes to encourage ethical behaviour and compliance.

5. Governance Structures and Reporting Mechanisms

5.1 Board Oversight and Meetings

• The Board of Directors meets quarterly to review governance performance.
• CIW’s regulatory reports and compliance ratings are discussed at every meeting.

5.2 Reporting to CIW

• The Responsible Individual (RI) ensures timely submission of:
  • Annual Quality of Care Review Reports.
  • Incident and Safeguarding Notifications.
  • Inspection Response Reports.

5.3 Whistleblowing and Complaints Management

• Staff and residents have clear channels to report governance concerns.
• A formal complaints process ensures all complaints are addressed within 28 days.

6. Managing Non-Compliance and Governance Failures

If governance failures are identified:

• Stage 1: Internal Review – The Board and RI investigate the issue within seven days.
• Stage 2: Corrective Action Plan – Compliance issues are addressed with clear action steps.
• Stage 3: External Reporting – If required, CIW, local authorities, or enforcement bodies are informed.
• Stage 4: Staff Disciplinary Action – If governance failures are linked to staff misconduct, disciplinary procedures are enacted.

7. Related Policies

• Fit and Proper Persons: Directors Policy (CHW01)
• Fit and Proper Persons: Employed Staff Policy (CHW02)
• Safeguarding Policy (CHW13)
• Whistleblowing Policy (CHW29)
• Duty of Candour Policy (CHW35)

8. Policy Review

This policy is reviewed annually or when legislative or regulatory changes occur. Updates will be communicated to CIW, staff, and residents.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.