CHW185-Clinical Governance Policy
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{{org_field_name}}
Registration Number: {{org_field_registration_no}}
Clinical Governance Policy
1. Purpose
The purpose of this policy is to define the framework for clinical governance at {{org_field_name}}, ensuring that we maintain high standards of clinical care, safety, accountability, and continuous improvement in line with the Regulation and Inspection of Social Care (Wales) Act 2016, CIW’s quality standards, and the principles of the Social Services and Well-being (Wales) Act 2014. Clinical governance is a systematic approach to maintaining and improving the quality of care and safeguarding high standards through a culture of openness, learning, and responsibility. This policy ensures that our care is evidence-based, person-centred, well-led, and safe. It guides staff in how to deliver care that is legally compliant, ethically sound, and continuously reviewed for effectiveness.
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:
- Clinical Effectiveness
- Risk Management
- Patient and Public Involvement
- Staff Management and Education
- Audit and Performance Monitoring
- 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 are based on the best available evidence, NICE guidance, national clinical pathways, and person-centred assessments. All clinical interventions, including wound care, catheterisation, pressure area management, and end-of-life care are delivered following up-to-date clinical protocols. Each individual has a Personal Plan that outlines assessed needs, desired outcomes, and the clinical procedures required. Staff follow these plans and review them regularly in multidisciplinary meetings. Clinical outcomes are monitored through routine care reviews, feedback, and audits.
4.3 Risk Management and Safety
We have a robust risk management system to identify, assess, mitigate, and monitor clinical risks. Risk assessments are completed for every individual receiving care and are reviewed monthly or following a significant change. Clinical risks such as falls, choking, medication errors, infections, or pressure ulcers are documented and managed proactively. All staff are trained in safe care practices, manual handling, medication handling, and first aid. The Registered Manager ensures oversight of clinical incidents and leads on investigating and responding to adverse events. All incidents are reviewed under CHW24 and serious incidents are reported to CIW in accordance with Regulation 60.
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
Regular audits are carried out to assess the quality, safety, and effectiveness of clinical care. This includes audits on medication errors, wound care, weight management, infection control, accident reports, and care documentation. Audit results are analysed and presented at management meetings and used to inform improvement actions. The Quality of Care Review is conducted every six months in line with CIW guidance, drawing on clinical data, feedback, and incident analysis. Learning from audits is shared with the team and embedded into daily practice through updates, training, and changes to policies.
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 a duty to safeguard individuals from harm. Staff are trained to recognise clinical indicators of abuse or neglect such as unexplained injuries, poor wound care, or refusal of treatment. Concerns are reported in line with CHW13 to the Safeguarding Lead: {{org_field_safeguarding_lead_name}}, {{org_field_safeguarding_lead_role}}, and referred to {{org_field_local_authority_authority_name}} where necessary. Clinical restraint or deprivation must only be used as a last resort and authorised appropriately under CHW39.
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 Registered Manager is responsible for the overall clinical governance within the service and ensures that systems are in place to support safe care. The Responsible Individual oversees compliance and quality assurance and ensures resources are allocated to support governance. Every member of staff is accountable for the quality of care they provide. Concerns about clinical practice or safety can be raised through supervision, team meetings, or the Whistleblowing Policy (CHW29). A culture of openness and learning is promoted.
5. Policy Review
This policy will be reviewed annually or sooner in response to changes in legislation, CIW regulatory expectations, audit findings, or clinical incidents. It forms part of {{org_field_name}}’s commitment to excellence in clinical care, service improvement, and the safety and dignity of the people we support.
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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