{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Good Governance

1. Purpose

The purpose of this policy is to establish a framework for strong, effective governance within {{org_field_name}} to ensure the provision of high-quality, person-centred domiciliary care services.

Governance in domiciliary care is fundamental to achieving accountability, transparency, and continuous improvement. It ensures that our organisation meets the legal and regulatory requirements set by the Regulation and Inspection of Social Care (Wales) Act 2016and adheres to best practices in care provision, risk management, and workforce development.

This policy aims to:

• Promote ethical leadership and accountability at all levels of the organisation.
• Establish clear lines of responsibility for the Responsible Individual (RI), Registered Manager, and all staff.
• Ensure a culture of openness, honesty, and continuous learning.
• Maintain compliance with CIW and all relevant statutory frameworks.
• Implement robust quality assurance and risk management systems.

Effective governance ultimately protects and promotes the well-being of individuals using our services, their families, and our workforce.

2. Scope

This policy applies to all individuals and groups involved in the governance and operation of {{org_field_name}}, including:

2.1 Responsible Individual (RI)

• Holds ultimate accountability for governance, compliance, and quality of care.
• Ensures the organisation operates within CIW regulations and meets standards of safety, quality, and transparency.

2.2 Registered Manager

• Oversees day-to-day operations, staff management, and service delivery.
• Implements policies and procedures to ensure compliance with CIW inspection requirements.

2.3 Care and Support Staff

• Adhere to policies, procedures, and ethical guidelines while delivering care.
• Receive ongoing training and supervision to uphold high standards of practice.

2.4 External Stakeholders

• Includes local authorities, commissioners, regulators, healthcare professionals, and the families of service users.
• Participate in collaborative decision-making to ensure continuous service improvement.

3. Governance Framework

3.1 Leadership and Accountability

Good governance starts with strong leadership and clear accountability. At {{org_field_name}}, we:

• Maintain a hierarchical but collaborative leadership structure, ensuring responsibilities are clearly defined.
• Ensure that the Responsible Individual (RI) and Registered Manager work together to uphold legal and ethical care standards.
• Have defined reporting procedures to ensure that all decisions are documented and communicated effectively.
• Promote a culture of integrity, respect, and openness, ensuring all staff can raise concerns without fear of reprisal.

To uphold accountability:

• The RI holds monthly governance meetings with senior staff to review operational, financial, and compliance matters.
• The Registered Manager submits reports on service performance, incidents, and quality improvement measures.
• Staff engage in reflective practice, with regular supervisions, appraisals, and team meetings to assess care quality and professional development.

3.2 Compliance with Regulations

To ensure full compliance with CIW regulations and national standards, we:

• Register and maintain compliance with The Regulated Services (Registration) (Wales) Regulations 2017.
• Conduct quarterly audits in key areas such as safeguarding, medication management, and service user experience.
• Follow CIW’s Securing Improvement and Enforcement Policy, taking immediate action to rectify concerns or non-compliance issues.

4. Quality Assurance and Continuous Improvement

4.1 Internal Audits and Monitoring

A robust internal auditing system is in place to evaluate the quality and safety of our services.

• Monthly audits assess care records, incident reports, training records, and medication logs.
• Findings are reviewed by senior management, with corrective actions implemented within 14 days.
• An Annual Quality of Care Review is conducted, following CIW’s Guidance on Completing the Quality of Care Review.

4.2 Responding to CIW Inspections

We fully comply with CIW inspection processes and:

• Welcome feedback and use findings to drive improvements.
• Respond formally to any concerns or recommendations raised during inspections.
• Develop an action plan within 10 working days if improvements are required.

4.3 Service User and Family Feedback

We actively involve service users, their families, and advocates in decision-making.

• Regular satisfaction surveys are conducted.
• The Short Observational Framework for Inspection (SOFI2) is used to assess the well-being of service users who may have difficulty communicating.
• A formal complaints and feedback procedure ensures that concerns are addressed transparently and effectively.

5. Risk Management and Safeguarding

5.1 Identifying and Managing Risks

A comprehensive risk management framework is in place to:

• Identify, assess, and mitigate risks in all aspects of service delivery.
• Maintain a Risk Register, updated quarterly by the senior leadership team.
• Ensure staff report incidents and near-misses promptly, with thorough investigation and resolution.

5.2 Safeguarding Responsibilities

• All staff undergo mandatory safeguarding training as per CIW’s Safeguarding Policy.
• Clear reporting procedures are in place for suspected abuse, neglect, or harm.
• Staff are trained in whistleblowing procedures, ensuring concerns are reported without fear of retaliation.

6. Staff Competency and Professional Conduct

6.1 Staff Training and Development

• All new staff complete an induction programme, including governance, compliance, and safeguarding training.
• Ongoing professional development includes annual refresher courses in compliance, dignity in care, and communication skills.
• A performance management system ensures staff meet and exceed regulatory and professional standards.

6.2 Code of Conduct and Ethical Standards

• Staff must act with honesty, respect, and professionalism at all times.
• A zero-tolerance policy exists for discrimination, bullying, or unethical behaviour.
• All employees are expected to uphold CIW’s Core Values: Caring, Fairness, Respect, Integrity, and Professionalism.

7. Transparency and Public Accountability

7.1 Open Communication with CIW and Other Regulators

• Annual reports are submitted in accordance with The Regulated Services (Annual Returns and Registration) (Wales) Regulations 2019.
• We provide full cooperation with CIW, local authorities, and commissioners, ensuring transparency in service delivery.

7.2 Commitment to Human Rights and Equality

• Our services comply with The Human Rights Act 1998 and The Equality Act 2010.
• We actively promote diversity, inclusion, and person-centred care in all aspects of our service.

8. Policy Review

This policy will be reviewed annually or earlier if there are:

• Changes in legislation.
• Updates to CIW requirements.
• Identified gaps or improvements needed.

This ensures continuous alignment with best practices and high standards of governance in domiciliary care services.

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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.