{{org_field_logo}}

{{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 set out the governance arrangements used by {{org_field_name}} to support safe, lawful, effective and professional temporary staffing services to care homes, nursing homes, healthcare providers and other client organisations.

{{org_field_name}} operates as an employment business supplying temporary workers to client organisations. It does not itself provide regulated care activities and is not registered with the Care Quality Commission. Responsibility for the delivery, direction, supervision and regulation of care rests with the client organisation, where applicable.

{{org_field_name}} is responsible for ensuring that workers supplied to clients are appropriately recruited, vetted, checked, trained, competent and suitable for the assignments offered, and that concerns about conduct, competence, safeguarding, health and safety, professional registration, incidents or complaints are managed promptly and appropriately.

This policy supports compliance with relevant legislation and guidance, including the Employment Agencies Act 1973, the Conduct of Employment Agencies and Employment Businesses Regulations 2003, the Agency Workers Regulations 2010, the Employment Rights Act 1996, the Employment Rights Act 2025, the Working Time Regulations 1998, the National Minimum Wage Act 1998, the National Minimum Wage Regulations 2015, the Equality Act 2010, the Immigration, Asylum and Nationality Act 2006, the Safeguarding Vulnerable Groups Act 2006, the Police Act 1997, the Rehabilitation of Offenders Act 1974 and Exceptions Order 1975, the UK GDPR, the Data Protection Act 2018, the Health and Safety at Work etc. Act 1974 and the Modern Slavery Act 2015 where applicable.

2. Scope

This policy applies to:

• All registered nurses, healthcare assistants, and other temporary workers employed or engaged by {{org_field_name}} under zero-hours or flexible contracts
• Directors, supervisors, and administrative staff involved in recruitment, placement, quality assurance, and operational management
• The supply of temporary workers to client organisations, including care homes, nursing homes, healthcare providers and other regulated or non-regulated settings, where the client organisation remains responsible for the delivery, direction and supervision of care or services.
• Client organisations, insofar as they are required to provide relevant assignment information, health and safety information, role requirements, supervision arrangements, feedback, incident information and safeguarding information to {{org_field_name}}.

3. Related Policies

• Supervision and Appraisal Policy
• Professional Registration and Revalidation Support Policy
• Incident and Accident Reporting Policy
• Safeguarding Adults and Children Policy
• Complaints Policy
• Training and Development Policy
• Whistleblowing Policy
• Code of Conduct
• Health and Safety Policy
• Recruitment, Vetting and Selection Policy
• Right to Work Policy
• Agency Worker Terms and Key Information Document Procedure
• Agency Workers Regulations Policy
• Working Time and Holiday Pay Policy
• National Minimum Wage Compliance Policy
• Equality, Diversity and Inclusion Policy
• Data Protection, Confidentiality and Records Retention Policy
• DBS and Criminal Record Information Handling Policy
• Modern Slavery and Labour Exploitation Policy
• Client Terms of Business Procedure
• Fitness to Practise and Professional Registration Policy
• Health and Safety Assignment Risk Information Procedure

4. Legal and Regulatory Framework

{{org_field_name}} will maintain governance arrangements that reflect its role as an employment business supplying temporary workers. The agency will comply with applicable legal and regulatory requirements, including:

• Employment Agencies Act 1973 and Conduct of Employment Agencies and Employment Businesses Regulations 2003: requirements relating to employment businesses, work-seeker terms, hirer terms, suitability checks, information sharing, restrictions on fees to workers, transfer fee arrangements, records and restrictions on withholding pay.
• Agency Workers Regulations 2010: day-one rights for agency workers in relation to access to collective facilities and information about vacancies, and equal treatment rights after the qualifying period in relation to basic working and employment conditions.
• Employment Rights Act 1996 and Employment Rights Act 2025: applicable worker and employee protections, including protections relating to pay, deductions, statutory rights and developing rights relating to zero-hours and similar arrangements, guaranteed hours and shift notice provisions as they are commenced.
• Working Time Regulations 1998: working time limits, rest breaks, rest periods, night work protections and paid annual leave.
• National Minimum Wage Act 1998 and National Minimum Wage Regulations 2015: payment of at least the applicable minimum wage or national living wage, including annual rate changes.
• Equality Act 2010: fair and non-discriminatory recruitment, selection, assignment, reasonable adjustment and employment service arrangements.
• Immigration, Asylum and Nationality Act 2006: right to work checks and prevention of illegal working.
• Safeguarding Vulnerable Groups Act 2006, Police Act 1997 and Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975: appropriate DBS, barred list and criminal record checks for eligible roles.
• UK GDPR and Data Protection Act 2018: lawful, fair, secure and proportionate processing of candidate, worker, client, health, safeguarding, DBS and employment records.
• Health and Safety at Work etc. Act 1974: co-operation with clients to protect the health, safety and welfare of workers and others affected by work activities.
• Modern Slavery Act 2015: prevention of labour exploitation and modern slavery, including transparency requirements where the agency is in scope and contractual compliance where required by clients.

5. Safe Recruitment, Vetting and Suitability

{{org_field_name}} will not supply a worker to a client unless it has taken reasonable steps to confirm that the worker is suitable for the role and meets the requirements notified by the client.

Before a worker is supplied, {{org_field_name}} will, as applicable to the role:

• verify the worker’s identity;
• complete a right to work check before work starts;
• check qualifications, training, skills and experience;
• obtain and verify professional registration, including any conditions, restrictions, warnings, suspensions or fitness to practise concerns where applicable;
• obtain references and employment history appropriate to the role;
• assess gaps in employment history where relevant to safeguarding or suitability;
• complete DBS checks only where the role is eligible;
• complete barred list checks only where the worker will be carrying out regulated activity;
• confirm mandatory training and role-specific training;
• assess health, competence or adjustment needs relevant to safe working; and
• record the outcome of checks before the worker is made available for assignment.

Where {{org_field_name}} receives information indicating that a worker may be unsuitable for an assignment, the agency will consider the information promptly and will inform the client where required, withdraw or suspend the worker where appropriate, and make referrals to relevant bodies where legally required.

6. Right to Work

{{org_field_name}} will complete right to work checks before a worker starts work and will retain evidence of the check in accordance with Home Office requirements. Checks will be completed consistently for all workers to avoid unlawful discrimination.

Where a worker has a time-limited right to work, {{org_field_name}} will record the expiry date and complete follow-up checks before the statutory excuse expires. Where required, the agency will use the Home Office online right to work checking service or Employer Checking Service.

Workers must immediately notify {{org_field_name}} of any change to their immigration or right to work status. A worker will not be supplied, or will be removed from assignments, where the agency cannot establish or maintain a lawful right to work.

7. Worker Terms, Key Information Document and Assignment Information

Before agreeing terms with an agency worker, {{org_field_name}} will provide the worker with clear written information required by law, including the agency’s terms and, where applicable, a Key Information Document.

The Key Information Document will clearly summarise key pay-related information, including the type of contract, minimum expected rate of pay, how the worker will be paid, deductions, fees, holiday pay arrangements and an example statement showing how gross pay may be affected by deductions.

Before each assignment, {{org_field_name}} will provide the worker with relevant assignment information, including:

• the client’s identity and location;
• the start date and expected duration of the assignment;
• the type of work and duties;
• required experience, training, qualifications and professional registration;
• expected hours, breaks, shift pattern and any night work;
• pay rate and payment arrangements;
• health and safety risks and control measures notified by the client;
• supervision and reporting arrangements; and
• any special requirements notified by the client.

8. Agency Worker Rights and Equal Treatment

{{org_field_name}} will support compliance with the Agency Workers Regulations 2010. Agency workers are entitled to day-one rights in relation to access to collective facilities and amenities and information about relevant vacancies at the client organisation.

After the qualifying period, agency workers are entitled to equal treatment in relation to relevant basic working and employment conditions, including pay, duration of working time, night work, rest periods, rest breaks and annual leave, as if they had been recruited directly by the client to do the same role.

{{org_field_name}} will request relevant comparator and assignment information from clients and will act on information received to support lawful pay and working condition arrangements. Workers should raise any concern about equal treatment, facilities, vacancy access, pay, working time, rest breaks or annual leave with {{org_field_name}} promptly.

9. Pay, National Minimum Wage, Holiday Pay and Timesheets

{{org_field_name}} will ensure that workers are paid lawfully and at least at the applicable National Minimum Wage or National Living Wage rate. Pay rates will be reviewed when statutory rates change.

From 1 April 2026, the National Living Wage applies to workers aged 21 and over at the statutory rate in force at that time. The agency will ensure that rates, deductions and working time calculations do not reduce pay below the applicable legal minimum.

Workers are entitled to statutory paid annual leave in accordance with the Working Time Regulations 1998. Holiday entitlement and holiday pay will be calculated in accordance with current law and guidance, including rules applicable to irregular hours and part-year workers where relevant.

Workers must submit accurate timesheets or other evidence of hours worked in accordance with agency procedures. {{org_field_name}} will not withhold payment for work properly undertaken solely because a client has not signed or returned a timesheet, where there is other satisfactory evidence that the work was carried out. Any disputed hours will be investigated promptly with the worker and client.

10. Working Time, Rest Breaks and Fatigue

{{org_field_name}} will monitor working patterns where reasonably practicable to support compliance with working time, rest break, rest period and night work requirements. Workers must provide accurate availability and working time information, including work undertaken for other employers where this may affect safe working or legal limits.

Workers must not accept assignments where they are unfit to work due to fatigue, illness, medication, impairment or any other reason that may affect safe practice. Concerns about excessive hours, missed breaks, unsafe staffing levels or fatigue must be reported to {{org_field_name}} and the client organisation as soon as possible.

11. Health and Safety Responsibilities

{{org_field_name}} will co-operate with client organisations to support the health, safety and welfare of agency workers and others affected by their work. Before supplying a worker, the agency will seek relevant health and safety information from the client, including known risks, control measures, personal protective equipment requirements, induction requirements, manual handling risks, infection prevention and control arrangements and incident reporting procedures.

The client organisation is responsible for day-to-day control of the workplace, local risk assessments, premises, equipment, systems of work and direct supervision. {{org_field_name}} will not knowingly supply a worker to an assignment where it is aware that the work cannot be carried out safely.

Workers must follow client health and safety procedures, use equipment and PPE as instructed, report hazards promptly, and take reasonable care of their own health and safety and that of others.

12. Policy Statement

{{org_field_name}} is committed to maintaining a robust governance framework for the safe and lawful supply of temporary workers. The agency’s governance arrangements are designed to ensure that workers are recruited safely, vetted appropriately, supplied only to suitable assignments, supported to maintain professional standards, and subject to effective monitoring, feedback and escalation arrangements.

Where workers are assigned to regulated health or social care settings, {{org_field_name}} will support client organisations by supplying workers who meet the agreed role requirements. The client organisation remains responsible for care planning, direct supervision, local clinical procedures, risk assessments, medicines systems, delegation decisions and regulatory compliance for the regulated activity.

Our governance framework is structured around the following core areas:

1. Safe recruitment, vetting and suitability
2. Professional registration, competence and training
3. Assignment information, client requirements and worker deployment
4. Risk management, safeguarding and incident escalation
5. Worker rights, pay, working time and fair treatment
6. Feedback, audit, quality improvement and learning
7. Data protection, confidentiality and records management
8. Leadership, accountability and continuous improvement

All staff, whether directly employed or supplied temporarily to client organisations, are responsible for supporting and participating in the clinical governance arrangements of both {{org_field_name}} and the client organisations they are assigned to.

13. Responsibilities

Director

The Director is accountable for the governance of {{org_field_name}} as a temporary staffing agency. Where a Clinical Lead or Governance Lead is appointed, they will support the Director with professional, clinical and quality assurance matters. The Director remains responsible for ensuring that the agency has effective systems for recruitment, vetting, worker suitability, assignment checks, worker rights, safeguarding escalation, incident management, complaints, training, supervision, records, data protection and continuous improvement.

The Director will:

• Provide leadership and oversight of the clinical governance framework
• Review this policy annually or sooner if required
• Ensure robust systems are in place for monitoring quality, managing risk, and facilitating staff development
• Review and act upon trends from incident reports, complaints, audits, and staff feedback
• Ensure that learning is shared across the organisation
• Ensure that governance information is incorporated into staff training, induction, and supervision
• Ensure the agency complies with the Employment Agencies Act 1973 and the Conduct of Employment Agencies and Employment Businesses Regulations 2003.
• Ensure workers receive required written terms and, where applicable, a Key Information Document before agreeing terms with the agency.
• Ensure suitable checks are completed before a worker is supplied, including identity, right to work, qualifications, employment history, references, professional registration where applicable, DBS eligibility and barred list checks where legally permitted or required.
• Ensure client assignment details are obtained and communicated to workers before assignments, including role requirements, location, expected hours, pay, health and safety risks, supervision arrangements and any special requirements.
• Ensure workers are paid lawfully for work undertaken and that pay is not withheld solely because a client has not signed or returned a timesheet where there is other evidence that the work was carried out.
• Ensure safeguarding, conduct, competence and fitness to practise concerns are escalated to the client, relevant regulator, DBS, local authority or other appropriate body where required.
• Ensure records are retained securely and only for as long as necessary, in accordance with UK GDPR, the Data Protection Act 2018 and applicable recruitment agency record-keeping requirements.

Recruitment and Compliance Staff

Recruitment and compliance staff are responsible for:

• Completing and recording pre-assignment checks before a worker is supplied.
• Confirming the worker’s identity, right to work, qualifications, training, experience, professional registration and suitability for the assignment.
• Obtaining references and employment history appropriate to the role, particularly where the worker may work with children or vulnerable adults.
• Ensuring DBS checks are requested only where the role is eligible and that barred list checks are requested only where the role falls within regulated activity.
• Checking any restrictions, cautions, conditions of practice, suspensions or lapsed registrations for regulated professionals before placement and at appropriate intervals thereafter.
• Obtaining relevant assignment details from clients and ensuring the worker receives the information needed to perform the assignment safely.
• Escalating concerns about suitability, safeguarding, conduct, competence, health, professional registration, right to work or worker welfare without delay.

All Agency Staff

All agency staff are responsible for:

• Carrying out assignments in accordance with their role, competence, training, professional registration where applicable, the NMC Code or other relevant professional code where applicable, the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England where applicable, and the policies and procedures of the client organisation.
• Participating fully in supervision, appraisal, and training
• Reporting incidents, near misses, and concerns promptly
• Cooperating with investigations and audits
• Seeking guidance when unsure of procedures or if concerns arise
• Upholding the values of professionalism, dignity, respect, and accountability
• Only accepting assignments for which they have the necessary competence, experience, training and lawful authority.
• Providing accurate and up-to-date information about qualifications, training, professional registration, right to work, health, availability and any matter that may affect their suitability for work.
• Informing {{org_field_name}} immediately of any change to right to work status, DBS status, professional registration, fitness to practise, health condition affecting work, criminal investigation, caution, conviction, safeguarding concern or restriction relevant to their role.
• Complying with client site induction, local procedures, infection prevention and control requirements, medicines policies, record-keeping procedures, confidentiality requirements and health and safety arrangements.
• Accurately recording hours worked and promptly raising any pay, working time, rest break or assignment concern.

14. The Six Pillars of Clinical Governance

14.1 Professional Effectiveness, Competence and Safe Practice

{{org_field_name}} will support professional effectiveness and safe practice by ensuring that workers are supplied only to roles for which they appear suitably qualified, trained, experienced and competent.

This will be achieved by:

• checking qualifications, training, experience and professional registration where applicable;
• confirming that workers understand the limits of their competence and must not work outside those limits;
• requiring nurses and other regulated professionals to maintain registration and comply with their professional codes;
• requiring healthcare support workers and care staff to follow applicable codes of conduct and client procedures;
• promoting reflective practice, supervision, appraisal and learning from feedback;
• acting promptly where concerns are raised about competence, conduct, performance, professional registration or fitness to practise; and
• sharing relevant concerns with the client and, where required, the relevant regulator, DBS or safeguarding authority.

14.2 Risk Management

Effective risk management is essential to protect service users, staff, and members of the public. {{org_field_name}} will:

• Maintain a comprehensive Incident and Accident Reporting Policy
• Monitor incidents, near misses, complaints, and safeguarding concerns
• Take immediate action to manage and mitigate risks
• Support staff to understand their responsibilities for risk identification, reporting, and management
• Liaise with client organisations regarding risk management protocols, ensuring agency staff adhere to local risk management frameworks
• Conduct periodic reviews of risk-related data to identify trends and implement preventive actions
• obtain relevant information from clients about assignment risks, role requirements and health and safety controls before supplying workers;
• ensure workers receive relevant risk and assignment information before work starts;
• review concerns about worker suitability, competence, conduct, safeguarding, professional registration, right to work, health and safety or working time;
• suspend, withdraw or restrict workers from assignments where necessary to protect service users, clients, workers or the public;
• notify clients promptly where information arises indicating that a worker may be unsuitable for an assignment; and
• make safeguarding, DBS, professional regulator or other statutory referrals where required.

14.3 Patient and Service User Experience

Although {{org_field_name}} does not provide regulated care, the agency recognises that workers supplied to client organisations may have direct contact with patients, residents and service users. The agency will support positive patient and service user experience by supplying suitable workers, promoting professional conduct and acting promptly on feedback or concerns.

We will:

• Ensure that all staff understand and respect the rights, needs, and choices of service users
• Train staff to promote dignity, respect, independence, and confidentiality
• Encourage client organisations to share service user feedback regarding agency staff
• Review feedback to identify opportunities for learning and improvement
• Take immediate action if concerns arise regarding staff conduct or the quality of care provided
• make clear to workers that dignity, respect, consent, privacy, confidentiality, safeguarding and professional boundaries must be maintained at all times;
• require workers to follow the care plans, local procedures and lawful instructions of the client organisation;
• obtain and review feedback from clients about worker conduct, reliability, competence and professionalism;
• investigate concerns fairly and promptly; and
• take appropriate action, including retraining, supervision, suspension, removal from assignments or referral to external bodies where required.

14.4 Audit and Quality Improvement

Continuous quality improvement is vital to maintaining high standards of care. {{org_field_name}} will:

• Carry out regular audits of documentation, incident reports, complaints, training compliance, and supervision records
• Analyse audit findings to identify trends, themes, and opportunities for improvement
• Develop and implement action plans to address areas for improvement
• Share lessons learned across the agency
• Review quality assurance information as part of the Director’s routine governance meetings
• recruitment files, including identity, right to work, references, qualifications, training, professional registration and DBS checks;
• Key Information Documents and worker terms;
• client terms of business and assignment information records;
• Agency Workers Regulations compliance, including equal treatment information where applicable;
• pay, holiday pay, National Minimum Wage and working time compliance;
• complaints, incidents, safeguarding concerns and outcomes;
• professional registration checks and fitness to practise concerns;
• data protection, DBS information handling and records retention; and
• modern slavery and labour exploitation risk indicators.

14.5 Education, Training, and Continuous Professional Development

{{org_field_name}} will:

• Ensure that workers complete mandatory and role-specific training required by {{org_field_name}} and/or the client before placement, which may include safeguarding adults and children, health and safety, infection prevention and control, basic life support, moving and handling, medication awareness or administration where relevant, food hygiene, fire safety, equality and diversity, information governance, mental capacity, deprivation of liberty safeguards where relevant, and any client-specific induction required for the assignment.
• Provide opportunities for ongoing training and CPD
• Support nurses to meet the requirements of NMC revalidation
• Encourage reflective practice, supervision, and appraisal as tools for continuous improvement
• Respond promptly to identified training needs following incidents, audits, or changes in legislation or guidance
• verify training evidence and renewal dates before workers are supplied;
• ensure workers understand they must not undertake tasks, including medicines-related tasks, clinical observations or moving and handling, unless trained, competent and authorised by the client;
• support nurses to maintain NMC registration and revalidation; and
• update training requirements following changes in law, guidance, client requirements, incidents, complaints, audits or safeguarding concerns.

14.6 Staff and Leadership Engagement

The success of the clinical governance framework depends on the engagement and involvement of all staff. {{org_field_name}} will:

• Encourage open and honest communication at all levels
• Ensure staff have opportunities to contribute to service improvement through feedback and consultation
• Engage staff in reflective discussions during supervision and appraisal
• Share key learning from audits, incidents, and complaints with staff through supervision, meetings, or written communications
• Promote a no-blame culture to encourage incident reporting and continuous improvement
• encourage workers to raise concerns about unsafe care, poor practice, discrimination, harassment, exploitation, excessive hours, missed breaks, underpayment, safeguarding or client conduct;
• ensure workers can raise concerns without victimisation;
• signpost workers to the agency’s Whistleblowing Policy, Safeguarding Policy, Complaints Policy and worker support arrangements; and
• review worker feedback to identify recurring client, assignment, pay, welfare or safety concerns.

15. Equality, Non-discrimination and Reasonable Adjustments

{{org_field_name}} will provide recruitment, work-finding and assignment services fairly and without unlawful discrimination, harassment or victimisation. Decisions about registration, selection, assignment, training, pay, suspension or removal from work will be based on lawful, objective and role-related criteria.

The agency will consider reasonable adjustments for disabled candidates and workers in recruitment, registration, training, communication and assignment processes. Where an adjustment relates to a client site or role, {{org_field_name}} will liaise with the client where appropriate and with the worker’s consent where required.

The agency will not accept discriminatory instructions from clients. Where a client request appears discriminatory, the matter must be escalated to the Director and the agency may refuse to act on the instruction.

16. Data Protection, Confidentiality and DBS Information

{{org_field_name}} will process personal data, special category data and criminal offence data lawfully, fairly, transparently and securely in accordance with UK GDPR and the Data Protection Act 2018. This includes candidate, worker, client, payroll, health, training, professional registration, safeguarding, DBS, complaint, incident and investigation records.

Personal data will be collected and used only where there is a lawful basis and where it is necessary for recruitment, work-finding services, employment administration, safeguarding, legal compliance, health and safety, payroll, quality assurance or the establishment, exercise or defence of legal claims.

DBS certificate information will be handled securely, accessed only by those who need it, used only for the purpose for which it was obtained, retained only for as long as necessary and disposed of securely. The agency will not request DBS or barred list checks unless the role is eligible.

Workers must maintain confidentiality at all times and must comply with the confidentiality, records and information governance requirements of both {{org_field_name}} and the client organisation.

17. Safeguarding and DBS Referrals

{{org_field_name}} will maintain procedures for identifying, reporting and escalating safeguarding concerns involving adults, children, workers, clients or members of the public. Workers must report safeguarding concerns immediately in accordance with client procedures and must also notify {{org_field_name}} as soon as possible.

Where a worker is removed from regulated activity, or would have been removed had they not left, because they have harmed, may have harmed, or pose a risk of harm to a child or vulnerable adult, {{org_field_name}} will consider whether a referral to DBS is required.

The agency will also consider whether referrals or notifications are required to the client organisation, local authority safeguarding team, police, professional regulator or other relevant body.

18. Modern Slavery and Labour Exploitation

{{org_field_name}} will take reasonable steps to prevent modern slavery, human trafficking, forced labour, debt bondage, labour exploitation and other forms of worker abuse within its operations and labour supply chain.

The agency will monitor for indicators of exploitation, including workers being controlled by another person, inability to provide personal documents, unusual payment arrangements, excessive working hours, fearfulness, signs of coercion, transport or accommodation control, substitution concerns, or unexplained third-party involvement.

Concerns about modern slavery or labour exploitation must be escalated to the Director immediately and referred to appropriate authorities where required. Where {{org_field_name}} meets the statutory turnover threshold, it will publish an annual slavery and human trafficking statement in accordance with section 54 of the Modern Slavery Act 2015.

19. Communication

Effective communication is essential for the implementation of clinical governance. {{org_field_name}} will:

• Ensure staff understand this policy and its implications through induction and regular updates
• Promote clear communication between agency staff and client organisations
• Ensure all reports, concerns, and feedback are appropriately recorded and shared with the Director for action
• ensure workers receive clear written terms, Key Information Documents where applicable, and assignment information before work starts;
• ensure clients provide sufficient information about the role, duties, risks, required checks, supervision, working time, pay information and assignment requirements;
• ensure concerns about worker suitability, safeguarding, incidents, complaints, health and safety, pay, discrimination or working time are escalated promptly; and
• ensure communication with workers and clients is documented and retained appropriately.

20. Governance Structures

{{org_field_name}} will implement the following structures to ensure effective governance:

• A Governance and Compliance Register maintained by the Director or delegated Governance Lead, recording recruitment checks, right to work checks, DBS checks where applicable, professional registration checks, training compliance, assignment issues, incidents, complaints, safeguarding concerns, health and safety concerns, worker feedback, client feedback, supervision records, audits, pay or working time concerns, data breaches and actions taken.
• Quarterly governance reviews undertaken by the Director
• Annual audits of clinical governance processes and data
• Regular policy reviews and updates
• periodic recruitment file audits;
• periodic right to work and professional registration audits;
• periodic pay, holiday pay and working time compliance checks;
• periodic Agency Workers Regulations compliance checks;
• periodic DBS eligibility and records handling checks;
• trend analysis of client complaints, worker concerns, incidents and safeguarding matters; and
• documented action plans with named owners and completion dates.

21. Supporting Staff

{{org_field_name}} is committed to supporting staff involved in incidents, complaints, or investigations by:

• Providing debriefing opportunities
• Offering supervision and additional training if required
• Ensuring a fair and transparent investigation process
• Maintaining confidentiality throughout any investigative process
• signposting workers to relevant procedures where concerns relate to pay, working time, holiday pay, discrimination, harassment, health and safety, safeguarding or whistleblowing;
• ensuring workers are not subjected to detriment for raising genuine concerns;
• considering reasonable adjustments and welfare support where required; and
• ensuring workers are given an opportunity to respond to allegations before decisions are made, unless immediate action is required to protect service users, workers, clients or the public.

22. Continuous Improvement

Continuous improvement is embedded in all governance processes. The Director will:

• Review all governance data quarterly
• Identify areas for improvement
• Update training, policies, and procedures where needed
• Share lessons learnt with staff
• Ensure that feedback from client organisations, staff, and service users is considered in improvement planning
• monitor changes in employment agency legislation, agency worker rights, employment rights, right to work requirements, DBS guidance, data protection requirements, health and safety guidance, safeguarding duties and healthcare staffing expectations;
• update worker terms, Key Information Documents, client terms, recruitment processes and assignment procedures when legal requirements change;
• review implementation of the Employment Rights Act 2025 as provisions relating to zero-hours and similar arrangements, guaranteed hours, shift notice and cancelled shift payments are commenced; and
• record the outcome of each legal or policy review and any changes made.

23. Director’s Oversight

The Director will:

• Lead on governance and compliance functions within {{org_field_name}}, including safe recruitment, worker suitability, assignment compliance, worker rights, safeguarding escalation, professional standards, complaints, incidents, health and safety, data protection and continuous improvement.
• Conduct policy reviews and approve updates
• Chair governance reviews
• Report learning and actions to the Board (where applicable)
• Ensure learning is embedded into day-to-day practice through training, supervision, and staff engagement
• ensure compliance with employment agency and employment business requirements;
• ensure the agency’s non-CQC registered status is accurately reflected in policies, marketing, client contracts and worker communications;
• ensure there is clear separation between the agency’s responsibilities as a staffing supplier and the client’s responsibilities as the regulated care provider; and
• ensure legal changes are reviewed and implemented promptly.

24. Policy Review

This policy will be reviewed at least annually by the Director of {{org_field_name}} or sooner where required due to changes in legislation, statutory guidance, regulatory guidance, client requirements, safeguarding learning, incidents, complaints, audit findings, employment agency standards, DBS guidance, right to work requirements, data protection requirements or operational needs.

The Director will ensure that any changes are communicated to relevant staff and workers, and that associated procedures, templates, worker terms, client terms and training materials are updated where necessary.

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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.