Registration Number: {{org_field_registration_no}}

Good Governance: Organisational Structure Policy – Children & Young-Adult Services

1. Purpose and Scope

This policy explains how {{org_field_name}} governs and manages its domiciliary care service for children and young adults. It applies to all aspects of our personal care delivery in people’s homes and the community. The aim of the policy is to ensure that we operate a well‑led, safe and high‑quality service that meets the needs of children, young people and their families in line with the Care Quality Commission (CQC) Regulation 17 on good governance. It also reflects statutory guidance such as Working together to safeguard children and the Children Acts 1989 and 2004, which emphasise a child‑centred, whole‑family approach to safeguarding, as well as the wellbeing principle set out in the Care Act 2014. By setting out our governance arrangements in writing, we provide clarity for staff, children, young people, parents and regulators about how decisions are made, how risks are managed and how quality is assured.

2. Governance Framework

Definition of governance. Governance refers to the system of rules, practices and processes that {{org_field_name}} uses to manage its operations effectively. It provides a structured approach to decision‑making, risk management, compliance and quality assurance. A robust governance framework ensures that our domiciliary care service is well‑led, safe and continually improving, and that we comply with legal, ethical and regulatory obligations, including those set by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

2.1 Strategic leadership

Our leadership team sets the tone for the whole organisation. We operate with a clear mission to deliver compassionate, person‑centred care that enables children and young adults to live at home or within their community with dignity, safety and opportunities for development. The vision and values of {{org_field_name}} are aligned with best practice standards and CQC requirements. Senior leaders:

Set clear objectives for service delivery and organisational development. For example, we commit to outcomes‑focused care plans that incorporate children’s wishes and feelings, and we define measurable quality targets such as response times, satisfaction levels and safeguarding performance.
Develop and review policies to maintain compliance with relevant legislation and guidance. Policies are updated regularly to reflect changes in law or emerging best practice. This includes child protection procedures, lone‑worker safety protocols, clinical governance for delegated health tasks, and data protection arrangements.
Ensure financial sustainability through effective budgeting and resource allocation. Maintaining adequate staffing levels, equipment and training budgets is essential to keep children safe and maintain continuity of care.
Monitor external changes in law, regulation and research to ensure the organisation remains compliant and forward‑looking. For example, updates to the Working together to safeguard children guidance (last revised in June 2025) emphasise stronger multi‑agency cooperation and a whole‑family approach.
Provide leadership and support to staff to foster a culture of quality care and continuous improvement. We believe that a supportive management environment encourages staff to speak up about concerns and contributes to better outcomes for children and young people.

2.2 Oversight and monitoring of service quality, safety and compliance

Our governance system includes robust monitoring mechanisms to oversee the quality, safety and compliance of the services we provide. We operate quality assurance systems that evaluate the standard of care delivered and identify areas for improvement. These systems include:

Regular audits and inspections. We undertake scheduled and unannounced audits covering care quality, safeguarding, medication management, health and safety, infection prevention and control, and staff training. Audit findings are reviewed by senior management and any required actions are tracked to completion. CQC’s guidance on good governance requires providers to assess, monitor and improve the quality and safety of services, including the experience of service users.
Performance monitoring. We collect and analyse data on response times, missed visits, staff continuity, incident reporting and service user satisfaction. Data‑driven decision‑making allows us to identify trends and take prompt corrective action.
Incident reporting and learning. We operate a mandatory incident reporting system that covers medication errors, falls, safeguarding concerns, complaints and near misses. Significant incidents are investigated using root cause analysis to identify contributing factors and lessons learned. Findings are shared with staff to promote a learning culture and prevent recurrence.
Compliance reviews. We conduct regular self‑assessments against CQC fundamental standards and relevant legislation. These reviews examine whether our systems meet Regulation 17 requirements, such as secure record‑keeping, feedback mechanisms and risk management. We also prepare for and respond to external inspections by CQC and local authority commissioners.

2.3 Engagement with stakeholders

The voices of children, young people, their families, our workforce and external partners are central to good governance. Effective engagement helps us to understand what matters to those we serve and to co‑design improvements.

2.3.1 Service users and families

We are committed to a child‑centred approach within a whole‑family focus. The Working together guidance states that “a child‑centred approach is fundamental to safeguarding and promoting the welfare of every child” and that practitioners should see and speak to the child, listen to what they say and take their views seriously. Children and young people have said they value vigilance, understanding, stability, respect, information, explanation, support, advocacy and protection. We reflect these principles by:

Listening to children and young people. Care staff involve children and young people in decisions about their care wherever appropriate. We speak directly with them, use age‑appropriate communication, offer advocacy and respect their choices. Where a child is unable to express their views, staff work with parents, guardians and professionals to understand the child’s needs and wishes.
Working with families. We recognise that children are usually best looked after within their families. Families are engaged in care planning and reviews, and we encourage parents or guardians to provide feedback through surveys, telephone calls, review meetings and a simple “How did we do?” card. We also keep families informed of audit results, incidents and improvements.
Consent and capacity. We follow the law on consent for children and young people. Young people aged 16–17 are presumed to have capacity to consent to their own treatment unless there is evidence to the contrary. Children under 16 can consent if they have sufficient understanding, intelligence and competence (Gillick competence); otherwise, someone with parental responsibility must give consent. Our staff receive training on assessing competence and on the Fraser guidelines for sexual health matters. Where a child lacks capacity or refuses treatment, we act in their best interests and seek court involvement if necessary.

2.3.2 Staff and workforce

We value our workforce and recognise that governance depends on competent and motivated staff. Staff receive initial and ongoing training that covers child protection, safeguarding, mental capacity, delegated healthcare tasks, medication administration, record‑keeping, equality and diversity, and lone‑worker safety. We maintain regular supervision and performance reviews to support professional growth and address any practice issues. Whistleblowing policies and an open‑door management culture encourage staff to report concerns without fear of reprisal.

2.3.3 Regulatory and external bodies

{{org_field_name}} works closely with regulatory and external bodies to uphold quality and safety. We liaise with the CQC, local authorities, Integrated Care Boards (ICBs), safeguarding partnerships and health professionals. Multi‑agency working is essential: the 2023 update to Working together emphasises strengthening multi‑agency working across the whole system and embedding consistent child protection practice. We share relevant information with other agencies – subject to confidentiality laws – to protect children and young adults, and we participate in multidisciplinary meetings, child protection conferences and case reviews.

3. Organisational Structure

Our organisational structure provides a clear framework for decision‑making, accountability and effective governance. Each role contributes to safe and high‑quality care for children and young adults. A structure chart illustrating reporting lines is available in the service office and is reviewed whenever roles change.

3.1 Board of Directors

The Board of Directors sets the overall strategic direction, corporate governance and financial oversight of {{org_field_name}}. Directors ensure that the organisation meets statutory obligations and adheres to CQC regulations and children’s legislation. They scrutinise the performance of the Registered Provider and senior management, approve budgets and major policies, and support the organisation’s mission. The Board receives regular reports on quality, safety, safeguarding, complaints and service user feedback, enabling it to hold managers accountable and direct improvements.

3.2 Registered Provider

The Registered Provider is the legal entity responsible for the overall management, regulation and compliance of the domiciliary care service. Responsibilities include ensuring that all legal, regulatory and ethical requirements are met; overseeing financial, strategic and operational governance; maintaining compliance with CQC regulations, the Health and Social Care Act 2008, the Children Acts and the Care Act 2014; ensuring effective policies, procedures and governance structures are in place; and responding to inspections and audits.

3.3 Nominated Individual

The Nominated Individual acts on behalf of the Registered Provider and is accountable for supervising the management of regulated activities. This role serves as the main point of contact with the CQC and other agencies. The Nominated Individual ensures that the service is well‑led and adheres to fundamental standards. They supervise the Registered Manager and senior leaders, ensuring that action plans for improvement are implemented promptly and that safeguarding concerns are escalated appropriately.

3.4 Registered Manager

The Registered Manager has day‑to‑day responsibility for delivering safe, high‑quality care to children and young adults. Key duties include managing care operations, staff and compliance; overseeing recruitment, induction, training and performance management; ensuring safe care and treatment in line with Regulation 12; implementing and reviewing care policies, risk assessments and audits; handling complaints, incidents and safeguarding matters; liaising with families and external agencies; and ensuring accurate record‑keeping. The Registered Manager promotes a culture where the welfare of children and young adults is paramount and where staff feel supported to deliver excellence.

3.5 Deputy Manager

The Deputy Manager supports the Registered Manager in operational leadership and deputises in their absence. They coordinate rotas, oversee staff supervision and appraisal, monitor care delivery, and address operational challenges such as staff shortages or complex care packages. The Deputy Manager also contributes to quality audits, safeguarding investigations and training. Having a deputy ensures continuity of leadership and resilience in service delivery.

3.6 Care Coordinators

Care Coordinators organise and manage service delivery. They match care workers to children and young adults based on skills, experience and compatibility; create and adjust rotas; maintain communication with service users and families; ensure care plans are current and tailored to individual needs; monitor operational issues; and assist with incident reporting, safeguarding and regulatory compliance. Coordinators work closely with health professionals, schools and social workers to ensure an integrated approach to care.

3.7 Care Workers

Care Workers are the frontline staff delivering direct care and support in children’s homes and community settings. They provide personal care, medication assistance, delegated healthcare tasks, support with mobility and nutrition, and companionship. Care Workers follow individualised care plans and respect the preferences and cultural background of each child or young adult. They adhere to safeguarding policies, report concerns promptly, document their work contemporaneously and participate in mandatory and ongoing training. Because they often work alone in people’s homes, care workers follow lone‑worker safety procedures and maintain regular contact with supervisors.

3.8 Designated Safeguarding Lead

For services involving children and young adults, we appoint a Designated Safeguarding Lead (DSL) who is a senior member of staff trained to a high level in child protection. The DSL oversees safeguarding policies and practices, advises care workers on concerns, liaises with local authority safeguarding partners, and ensures that safeguarding referrals are made without delay. The DSL also coordinates safeguarding training and maintains a record of safeguarding incidents and actions taken.

3.9 Additional support roles

Other functions underpin the effectiveness of our service:

Finance and administration staff handle payroll, budgeting, invoicing and financial reporting to ensure resources are available for safe care.
IT and data protection staff maintain secure record‑keeping systems, manage encryption and access controls, and ensure compliance with the Data Protection Act 2018 and GDPR. They conduct data security audits and provide guidance on information handling.
Clinical governance advisors (where delegated healthcare is undertaken) liaise with NHS teams to ensure that any healthcare tasks delegated to our staff are within their competence and supported by appropriate training and supervision.

4. Governance Responsibilities

Our governance responsibilities are broad and inter‑related. They encompass leadership, monitoring, quality assurance, continuous improvement, information governance and legal compliance.

4.1 Managing and governing the organisation

We maintain robust governance by implementing structured leadership, oversight mechanisms and accountability frameworks. Key practices include:

Regular management meetings. Senior managers meet monthly to review key performance indicators, staffing levels, financial sustainability, safeguarding reports, complaints, incidents and service user feedback. Quarterly strategy sessions allow us to address challenges, update risk registers and agree improvement plans.
Annual business planning. Each year, the Board and senior management set objectives, consider upcoming legislative changes and allocate resources. This planning ensures that the organisation remains sustainable and responsive to the needs of children, young adults and their families.
CQC compliance. We continually review our services against the Regulation 17 requirement to establish and operate effective systems for governance. We also monitor compliance with Regulation 12 (safe care and treatment) and Regulation 13 (safeguarding). We prepare and update our Provider Information Return when requested by CQC and implement corrective action plans following inspections.
Policy management. Policies and procedures are aligned with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Children Acts 1989/2004, the Care Act 2014, the Mental Capacity Act 2005, and other relevant legislation. Policies are reviewed at least annually and whenever regulations change. Staff are trained on policy adherence to ensure consistent practice.

4.2 Continuous assessment and improvement

We use a range of quality assurance systems and processes to monitor and improve the quality of our service. These include:

Internal audits. Quarterly audits cover care quality, safeguarding, medication management, staff training, infection prevention and control, delegated healthcare tasks and lone‑worker safety. Unannounced spot‑checks assess care delivery in children’s homes. Audit reports are discussed in management meetings and action plans are created to address any non‑compliance.
Action plans for improvement. Corrective and preventive actions are implemented for any issues identified through audits or incidents. Progress is tracked to ensure that improvements are sustained.
Staff training and development. We provide mandatory and ongoing professional development for all staff, including safeguarding, child development, communication, medication, equality, diversity and inclusion. Supervisions and appraisals occur every six months, and workforce planning identifies skills gaps. We encourage staff to undertake nationally recognised qualifications and training standards promoted by Skills for Care.
Quality improvement initiatives. We foster a culture of learning and innovation. Staff are encouraged to propose improvements, and we use feedback and data to develop initiatives such as new communication tools for non‑verbal children, collaborative care planning with schools, or technology to enhance lone‑worker safety.

4.3 Seeking and acting on feedback

Listening to feedback and acting upon it is a fundamental requirement of good governance. We seek feedback through post‑visit spot‑checks, telephone surveys, review meetings and anonymous reporting tools. Feedback is recorded, analysed and used to inform service improvements. We share summaries of feedback with staff, children and families, showing what has changed as a result. Trends from compliments, complaints and incident reviews are reported monthly to the Registered Manager and Nominated Individual and are used to set training and audit priorities.

Complaints are handled transparently in line with Regulation 16. Complaints can be made by children, parents, advocates or any other person. We acknowledge complaints promptly, investigate them fairly and independently, provide a written response and implement any identified improvements. We also ensure that children and young people are informed of the outcome and reasons when their views have not led to a particular course of action.

4.4 Assessing, monitoring and improving quality and safety

Ensuring high standards of care, safety and compliance is at the heart of our governance framework. We take a proactive approach to risk management and health and safety:

Risk assessments. We conduct regular risk assessments in service users’ homes and the wider community to identify and mitigate hazards. Assessments cover moving and handling, medication management, infection control, environmental risks, online safety and safeguarding. Risk controls are embedded in care plans and monitored regularly. Emerging risks are escalated at operations meetings and reported to the Nominated Individual. We maintain an organisational risk register that assigns owners, controls and review dates for each risk.
Lone‑worker safety. Care workers often work alone in people’s homes. We have lone‑worker policies, provide personal safety devices, maintain regular check‑in systems and conduct risk assessments for each environment. Emergency response procedures are in place to protect staff.
Incident reporting and learning culture. A mandatory incident reporting system records medication errors, falls, safeguarding concerns and complaints. Each significant incident is investigated using root cause analysis and the learning is shared. Quarterly incident review meetings enable staff to reflect on themes and agree improvements. We promote a ‘no blame’ culture where staff feel comfortable reporting mistakes.
Safeguarding compliance. We adhere to the duty to protect children and young adults from abuse and neglect. Staff are trained to recognise signs of abuse and exploitation and to report concerns immediately. The DSL ensures that safeguarding referrals are made in accordance with local safeguarding partnership procedures. We cooperate fully with children’s social care, the police and other agencies in investigations. Annual refresher training ensures that staff remain competent.

4.5 Record keeping and data protection

CQC Regulation 17 requires providers to maintain accurate, complete and contemporaneous records in respect of each service user and staff member. We ensure that:

Service user records include detailed care plans, risk assessments, medical histories, consent forms and information about the child’s views and wishes. Records are legible, indelible and up to date. Decisions taken in relation to care and treatment are recorded along with discussions with children, young people and those acting on their behalf.
Staff records include background checks, employment contracts, training logs and performance reviews. We comply with Regulation 19 (fit and proper persons) and keep these records secure and confidential.
Secure systems are used for storing digital records. Access is restricted to authorised personnel, and we use encryption and passwords to protect data integrity. Paper records are stored in locked cabinets. We comply with the Data Protection Act 2018 and GDPR. Staff receive regular training on data protection, and quarterly data security audits identify risks and ensure compliance.
Risk registers are maintained at organisational and individual levels. High or emerging risks are escalated and tracked. We record actions taken and review dates, ensuring that risks are not overlooked.

4.6 Compliance with statutory requirements

We are committed to full compliance with all legal, ethical and professional regulations governing care for children and young adults. This includes:

CQC registration and compliance. We adhere to CQC’s fundamental standards, including Regulation 17 on good governance and Regulation 12 on safe care and treatment. We submit reports when requested and implement improvement plans.
Children Acts 1989 and 2004. The welfare of the child is paramount. We involve children, young people and families in decisions, respect their rights and cooperate with local authorities in child protection matters.
Working together to safeguard children. We follow the 2023 statutory guidance, which emphasises strengthening multi‑agency working, a child‑centred and whole‑family approach, and new national child protection standards. Practitioners see and speak to children, observe their behaviour and take their views seriously.
Care Act 2014. We uphold the wellbeing principle, which includes personal dignity, physical and mental health, protection from abuse and neglect, and control over day‑to‑day life. This principle guides our support for young adults and for parents caring for children with disabilities. We also ensure that services remain appropriate as young people transition to adulthood, as highlighted in the statutory guidance on transitions.
Mental Capacity Act 2005. For young people aged 16 and above who may lack capacity, we follow the Mental Capacity Act and its Code of Practice. We assess capacity for each decision, consult with those close to the person and act in their best interests.
Gillick competence and Fraser guidelines. For children under 16, we assess their ability to consent to treatment. A child is considered Gillick competent if they can understand the nature, purpose and consequences of the proposed intervention. Where a child is not competent, someone with parental responsibility must provide consent.
Equality Act 2010. We have due regard to eliminate discrimination and promote equality. Safeguarding partners must put measures in place to support all children and families to access services and overcome barriers related to protected characteristics. Our policies emphasise inclusive practice and reasonable adjustments.
Domestic Abuse Act 2021 and UN Convention on the Rights of the Child. We recognise that children are victims of domestic abuse in their own right and ensure that services respond appropriately. We respect children’s rights to expression, information and protection.
Duty of Candour (Regulation 20). We communicate openly with service users, families and regulators about significant incidents. Staff are trained to offer apologies, provide explanations and implement learning when things go wrong.

5. Policy Review

This policy will be reviewed at least annually and sooner if there are changes to legislation, statutory guidance or CQC requirements. Reviews will involve consultation with staff, children, young people and families to ensure that the policy remains relevant and effective. Updates will be approved by the Board of Directors and shared with all staff.

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.

DC188-Good Governance Organisational Structure Policy Children