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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Clinical Governance Policy

1. Purpose

The purpose of this policy is to define the framework for clinical governance at {{org_field_name}} and to ensure that care and support is provided with sufficient care, competence and skill, safely, effectively and in accordance with the service’s Statement of Purpose.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the statutory guidance issued by the Welsh Ministers under section 29 of the Regulation and Inspection of Social Care (Wales) Act 2016, and the principles and duties arising from the Social Services and Well-being (Wales) Act 2014.

Clinical governance is the framework through which {{org_field_name}} monitors, reviews and improves the quality and safety of care and support. It includes effective leadership and accountability, assessment and personal planning, clinical effectiveness, risk management, safeguarding, medicines management, infection prevention and control, staff competence, accurate record keeping, incident reporting, audit, learning from concerns and complaints, and continuous quality improvement.

{{org_field_name}} will ensure that governance arrangements support person-centred, evidence-based and rights-based care, protect and promote individuals’ safety and well-being, support individuals to achieve their personal outcomes, and enable risks or shortfalls in the quality or safety of the service to be identified and addressed without delay.

2. Scope

This policy applies to all staff delivering care or supporting clinical processes at {{org_field_name}}, including nursing staff, care workers, medication leads, managers, agency staff, and visiting professionals. It also informs the roles of the Responsible Individual, the Registered Manager, and any external contractors delivering clinical or allied health services. Clinical governance principles apply to all aspects of direct care, including assessment, medication, infection control, wound care, nutrition, safeguarding, and end-of-life care.

3. Related Policies

This policy should be read in conjunction with:
CHW11 – Safe Care and Treatment Policy
CHW21 – Medication Management and Administration Policy
CHW17 – Infection Prevention and Control Policy
CHW18 – Risk Management and Assessment Policy
CHW24 – Management of Accidents, Incidents and Near Misses Policy
CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
CHW27 – Staff Supervision, Training and Development Policy
CHW04 – Good Governance

4. Policy Details

4.1 Clinical Governance Framework

At {{org_field_name}}, our clinical governance framework is built upon the six key pillars of clinical governance:

1. Clinical Effectiveness
2. Risk Management
3. Patient and Public Involvement
4. Staff Management and Education
5. Audit and Performance Monitoring
6. Information and Communication

Each pillar is supported by clear policies, procedures, leadership responsibilities, staff training, and audit systems to ensure consistent delivery of high-quality care.

4.2 Clinical Effectiveness

Care and support provided by {{org_field_name}} will be based on the individual’s assessed needs, personal outcomes, views, wishes and feelings, relevant health assessments, evidence-based practice, current national guidance and, where appropriate, guidance issued by NICE and relevant Welsh health bodies.

Clinical interventions, including wound care, catheter care, pressure area management, nutrition and hydration support, medicines support and end-of-life care, will only be undertaken in accordance with the individual’s assessed needs, Personal Plan, relevant clinical instructions and the competence and scope of practice of the member of staff undertaking the intervention.

Each individual will have a Personal Plan which sets out how their care and support needs will be met on a day-to-day basis, how they will be supported to achieve their personal outcomes, how identified risks will be mitigated, and how positive risk-taking and independence will be supported where appropriate.

Where an individual commences the service, the provider assessment required by Regulation 18 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, will be completed within seven days of commencement of care and support. The Personal Plan will be reviewed and revised as necessary following that assessment.

Personal Plans will be kept under review and will be formally reviewed whenever required and at least every three months. Reviews will consider whether the individual’s assessed needs have changed and the extent to which the individual has been able to achieve their personal outcomes. The individual, the placing authority where applicable, and any representative will be involved in accordance with the Regulations.

Where a clinical or other significant change is identified, the relevant assessment, risk assessment and Personal Plan will be reviewed without waiting for the next scheduled three-monthly review. Appropriate health or other professional advice will be sought where necessary.

Clinical outcomes and the effectiveness of care will be monitored through Personal Plan reviews, clinical observations, incident and safeguarding information, feedback, multidisciplinary or professional input where appropriate, and clinical and quality audits.

4.3 Risk Management and Safety

{{org_field_name}} will maintain effective arrangements to identify, assess, manage, monitor and review risks to the health, safety and well-being of individuals receiving care and support and, where relevant, risks to other individuals, staff and visitors.

Risk assessments will be proportionate to the individual’s assessed needs and circumstances and will be reflected in the individual’s Personal Plan where relevant. Risk assessments will be reviewed whenever there is a significant change in the individual’s needs, circumstances or condition, following an incident where the existing assessment may no longer be adequate, and at other intervals identified by the service’s risk management arrangements.

Clinical risks including, where applicable, falls, choking, malnutrition or dehydration, medicines-related risks, infection, pressure damage, deterioration in health and risks associated with specialist clinical interventions will be identified and managed promptly. Positive risk-taking and independence will be supported where appropriate while ensuring that identified risks of harm are appropriately mitigated.

Staff undertaking clinical or care activities must have the appropriate knowledge, skills, competence, training and, where applicable, professional registration required for their role. Where a member of staff identifies deterioration, an unexpected clinical finding or another immediate risk to an individual, appropriate clinical or emergency assistance must be sought without delay.

All accidents, incidents, near misses, safeguarding matters and clinical concerns will be recorded, escalated, investigated and reviewed in accordance with the relevant organisational policies. Learning and recurring themes will be incorporated into risk management, Personal Plans, staff training and the service’s quality assurance arrangements.

The service provider will ensure that events specified in Schedule 3 to the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, are notified to Care Inspectorate Wales and, where applicable, any other body specified in the Regulations. Notifications required under Regulation 60 will include the required details and will be made without delay and in writing, unless a different timescale is expressly specified by the Regulations, using the manner and form required by Care Inspectorate Wales.

The Registered Manager will ensure that potential notifiable events are identified and escalated promptly through the service’s notification arrangements. The Responsible Individual will maintain oversight of the systems for recording incidents, complaints and matters requiring statutory notification.

4.4 Involvement of People and Representatives

We are committed to involving residents, families, and representatives in clinical decisions. Individuals are supported to understand their care and make informed decisions about treatment, refusal of care, or advance care planning. Consent is sought for all clinical interventions as outlined in CHW09. Where capacity is in question, decisions are made under CHW39 in line with the Mental Capacity Act 2005. We ensure people feel heard and respected through keyworker reviews, health discussions, and regular feedback forums.

4.5 Education, Training and Clinical Competence

Clinical governance depends on a confident and competent workforce. All staff receive appropriate training for their roles including moving and handling, pressure care, nutrition, infection control, medication administration, first aid, and clinical record keeping. Nurses and senior care staff are required to maintain their professional registration and undergo clinical competency checks. Clinical supervision, reflective practice, and spot-checks are carried out regularly. New or high-risk procedures (e.g. catheter care or PEG feeding) require specialist training and competency sign-off before staff can undertake them unsupervised. Staff development is tracked through CHW27 and reviewed in formal supervision.

4.6 Clinical Audit and Quality Assurance

{{org_field_name}} will maintain effective systems for monitoring, reviewing and improving the quality and safety of care and support. Clinical and governance audits will be undertaken at frequencies proportionate to the nature and risks of the service.

Audits will include, where relevant to the service, medicines management, medicines errors, Personal Plans and risk assessments, wound and pressure-area care, nutrition and hydration, weight monitoring, infection prevention and control, accidents and incidents, safeguarding, clinical documentation and the accuracy and completeness of records.

Audit findings will be analysed by persons with the appropriate knowledge, skills and competence. Identified shortfalls will result in proportionate improvement actions with identified responsibilities and timescales. Progress against improvement actions will be monitored, and immediate action will be taken where the quality or safety of care is or may be compromised.

The Responsible Individual will put suitable arrangements in place to establish and maintain a system for monitoring, reviewing and improving the quality of care and support provided by the service. The quality of care and support will be reviewed as often as required and at least every six months in accordance with Regulation 80 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

As part of each Quality of Care Review, the Responsible Individual will ensure consideration is given to:

• feedback and views obtained from individuals, representatives, service commissioners and staff in accordance with the Regulations;
• aggregated information relating to incidents and notifiable incidents;
• safeguarding matters;
• whistleblowing concerns;
• concerns and complaints, including actions taken in response to complaints;
• findings from audits of the accuracy and completeness of records;
• relevant inspection findings and regulatory information;
• findings arising from Responsible Individual visits; and
• patterns, trends, lessons learned and other information relevant to the quality and safety of the service.

Following completion of each Quality of Care Review, the Responsible Individual will prepare a report to the service provider which includes an assessment of the standard of care and support provided and recommendations for improvement.

Findings from clinical audits and Quality of Care Reviews will be translated into measurable improvement actions where required. Learning will be communicated to relevant staff and reflected, as appropriate, in Personal Plans, risk assessments, staff training, supervision, procedures and service development.

4.7 Information and Record Keeping

Accurate and timely clinical documentation is critical to safe care. All clinical records are completed contemporaneously and stored securely in accordance with CHW34 – Confidentiality and Data Protection Policy. Records include assessments, observations, MAR charts, risk assessments, and communication with health professionals. Staff must only record what they have seen, done, or verified. All documentation is regularly audited, and training is provided where gaps are identified. Electronic and paper records are subject to access controls and confidentiality agreements.

4.8 Safeguarding in Clinical Practice

Clinical governance includes protecting individuals from abuse, neglect and improper treatment. {{org_field_name}} will provide the service in a way which ensures that individuals are safe and are protected from abuse, neglect and improper treatment in accordance with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

Staff will be trained to recognise and respond to safeguarding indicators arising in clinical practice. These may include, but are not limited to, unexplained injuries, unexplained or avoidable deterioration, signs of neglect, inappropriate medicines administration, poor wound or pressure-area care, malnutrition or dehydration, unsafe or unlawful restraint, inappropriate deprivation of liberty, acts of omission, or failure to seek appropriate healthcare.

Any allegation, evidence or reasonable concern of abuse, neglect or improper treatment must be acted upon immediately in accordance with CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy and the Wales Safeguarding Procedures. Immediate action will be taken to protect individuals from harm and appropriate referrals will be made to the relevant safeguarding authority and other agencies as required.

Safeguarding concerns will be reported to the Safeguarding Lead: {{org_field_safeguarding_lead_name}}, {{org_field_safeguarding_lead_role}}, and referred to {{org_field_local_authority_authority_name}} where required. Statutory notifications to Care Inspectorate Wales and any other bodies will be made where the circumstances meet the notification requirements of the Regulations.

Control or restraint must only be used where it is necessary to prevent a risk of harm to the individual or another individual and where the intervention is a proportionate response to that risk. Control or restraint must only be carried out by staff who are trained in the method used and in accordance with the organisation’s policy on the use of control, restraint and restrictive practices. A record of every incident in which control or restraint is used must be made within 24 hours.

Where an individual may lack mental capacity to consent to arrangements for their care and support, staff will act in accordance with the Mental Capacity Act 2005 and applicable statutory safeguards. No individual will be deprived of their liberty for the purpose of receiving care and support without lawful authority. Any actual or potential deprivation of liberty will be identified, escalated and managed through the appropriate lawful process.

4.9 Escalation and Partnership Working

We maintain strong working relationships with GPs, community nurses, pharmacists, and specialist teams. Where a clinical need exceeds our scope of practice, staff are expected to escalate concerns promptly to external professionals. Clinical deterioration, medication reactions, or new symptoms are referred without delay. Communication is documented, and we follow up to ensure the individual receives the necessary care. Hospital discharge summaries and specialist reports are reviewed and incorporated into personal plans.

4.10 Leadership and Accountability

The service provider retains responsibility for ensuring that the regulated service is provided in accordance with the applicable legislation, regulations, the Statement of Purpose and the service’s policies and procedures.

The Registered Manager is responsible for the day-to-day management of clinical governance within the service. This includes ensuring that effective systems are operated for assessment and Personal Planning, risk management, medicines management, safeguarding, infection prevention and control, staffing and staff competence, clinical escalation, incident management, record keeping, audit and quality improvement.

The Registered Manager will ensure that identified concerns about the quality or safety of care are acted upon promptly, that appropriate professional advice is sought where required, and that significant incidents and matters which may require statutory notification are escalated without delay.

The Responsible Individual will provide effective oversight of the management, quality and compliance of the service in accordance with the duties placed upon the Responsible Individual by the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

For the care home service, the Responsible Individual will visit each place for which they are designated, meet with staff and individuals using the service and undertake such visits at a frequency determined with regard to the Statement of Purpose, but at least every three months. These visits will contribute to monitoring the performance of the service and to the Quality of Care Review.

The Responsible Individual will ensure that effective systems are in place for recording incidents, complaints and matters requiring statutory notification, for maintaining accurate and complete records, and for ensuring that the service provider’s policies and procedures are kept up to date.

The Responsible Individual will put suitable arrangements in place for monitoring, reviewing and improving the quality of care and support and will complete the Quality of Care Review as often as required and at least every six months, preparing the report required by Regulation 80 for the service provider.

Where applicable, the Responsible Individual will report to the service provider on the adequacy of resources available to provide the service on a quarterly basis and will raise any significant concern about the management, safety, quality or compliance of the service without delay.

All members of staff are accountable for working within their role, competence, training, applicable professional requirements, Personal Plans and organisational policies. Staff must raise concerns about unsafe or poor clinical practice promptly through management arrangements, safeguarding procedures, incident-reporting arrangements or CHW29 – Whistleblowing Policy as appropriate.

4.11 Duty of Candour

{{org_field_name}} will act in an open and transparent way with individuals receiving care and support and with their representatives, in accordance with Regulation 13 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. Where the service provides accommodation to a child, this duty will also apply in relation to the placing authority as required by the Regulations.

The Responsible Individual will act in an open and transparent way in accordance with the separate duty imposed by Regulation 83.

Where something goes wrong in the provision of care and support, {{org_field_name}} will ensure that appropriate arrangements are in place to:

• communicate openly and honestly with the individual and, where appropriate, their representative;
• provide appropriate information about what has occurred;
• provide appropriate information about the outcome of any investigation;
• offer an apology where it is appropriate to do so;
• ensure concerns are appropriately recorded, investigated and escalated;
• identify and implement learning or improvement actions; and
• ensure that staff are not subjected to bullying, victimisation or harassment for appropriately raising concerns or exercising a professional duty of candour.

Where a possible breach of the professional duty of candour by a professionally registered member of staff is identified, this will be considered and managed in accordance with the requirements of the relevant professional regulator, including referral where appropriate.

5. Policy Review

This policy will be formally reviewed at least annually and will be reviewed and updated sooner whenever necessary to ensure that it remains current, accurate and consistent with the service’s Statement of Purpose.

An earlier review will be undertaken where relevant changes occur to legislation, regulations, statutory guidance, Care Inspectorate Wales requirements, national clinical guidance or professional standards, or where changes to the service, audit findings, incidents, safeguarding matters, complaints, Quality of Care Reviews, inspection findings or identified learning indicate that amendment is required.

The Responsible Individual will ensure that suitable arrangements are in place for this policy and associated procedures to be kept up to date in accordance with the requirements applicable to the regulated service.

Where amendments affect staff practice, relevant staff will be informed of the changes and provided with any additional information, instruction, training or supervision required to implement them safely and effectively.

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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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