{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Good Governance Policy

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 2016​and 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​.

3.3 Financial Sustainability and Business Continuity Oversight

The service provider and Responsible Individual maintain oversight of financial arrangements and investment to ensure the service remains financially sustainable and people are protected from the risk of unplanned withdrawal or disruption of care. This includes regular review of business continuity risks (workforce availability, commissioning changes, supplier failure, and emergency planning), and escalation arrangements where financial or operational pressures could impact safe delivery of care.

3.4 Duty of Candour (Openness and Transparency when things go wrong)

We act in an open and transparent way with individuals receiving care and support and, where appropriate, their representatives. We promote a culture of candour by ensuring that when things go wrong we: explain what is known at the time, share the outcome of any investigation as appropriate, and offer an apology where appropriate. We take action to prevent and address any bullying, victimisation, harassment, or obstruction of staff exercising candour. Where a social care professional registered with Social Care Wales may have breached their professional duty of candour (including obstruction), we have systems to identify this and take appropriate action, including referral to the relevant professional regulator where required.

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.
• Quality of Care Review (Responsible Individual)

The Responsible Individual (RI) ensures there is a robust system for monitoring, reviewing and improving the quality of care and support. A Quality of Care Review is completed as often as required but at least every six months, and on completion the RI prepares a written report for the service provider which includes: (a) an assessment of the standard of care and support provided and (b) recommendations for improvement. Each review includes, as a minimum, analysis of aggregated data and themes from incidents (including notifiable incidents), safeguarding matters, whistleblowing, concerns and complaints; review of action taken in response to complaints; and consideration of audits of the accuracy and completeness of records. The outcomes and learning are communicated to staff and used to drive the service improvement plan, and inform the statement of compliance for the provider’s annual return.

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 Statement of Compliance and CIW Annual Return

The Responsible Individual ensures the provider completes the CIW Annual Return as required and that the information provided is accurate and complete. The RI prepares the statement of compliance included in the annual return, drawing on the findings and recommendations from the most recent Quality of Care Review(s), CIW inspection outcomes, and evidence of how feedback and learning have improved outcomes for people using the service. The Registered Manager supports collation of evidence (audits, training compliance, complaints analysis, safeguarding data, feedback), and the RI maintains oversight of the final submission through CIW Online.

The Responsible Individual ensures suitable arrangements are in place to notify CIW of events requiring notification, in the manner and timescales required, and to keep clear records of notifications made and actions taken.

7.3 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

The Responsible Individual ensures suitable arrangements are in place to keep policies and procedures up to date having regard to the statement of purpose, and to ensure staff and volunteers have access to and understand the policies and procedures necessary to achieve the best possible outcomes for individuals.

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.