{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Clinical Governance Policy

{{org_field_name}}

1. Purpose

The purpose of this policy is to define the commitment of {{org_field_name}} to maintaining a robust and effective clinical governance framework that promotes the delivery of safe, high-quality, and person-centred care by all temporary workers placed in care homes, nursing homes, and healthcare settings. Clinical governance is the system by which healthcare organisations are held accountable for continuously improving the quality of their services and safeguarding high standards of care through the creation of an environment in which clinical excellence will flourish. As a nursing agency supplying registered nurses and healthcare assistants on a temporary basis, {{org_field_name}} has a duty to ensure that all agency workers operate within a framework of professional accountability, continuous improvement, and safe practice. This policy has been developed in accordance with The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Quality Commission (CQC) Fundamental Standards, and professional codes of conduct such as the NMC Code and the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England.

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 provision of care across all client organisations, including care homes, nursing homes, and other regulated settings

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

4. Policy Statement

{{org_field_name}} is fully committed to embedding clinical governance in all aspects of its operations to ensure that all agency staff consistently deliver safe, effective, and person-centred care. Our approach to clinical governance is structured around six core pillars:

1. Clinical Effectiveness
2. Risk Management
3. Patient and Service User Experience
4. Audit and Quality Improvement
5. Education, Training, and Continuous Professional Development
6. Staff and Leadership Engagement

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.

5. Responsibilities

Director
In the absence of a registered manager, the Director will be the accountable officer for clinical governance. 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

All Agency Staff
All agency staff are responsible for:

• Delivering care in line with the NMC Code (if applicable), the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers, and the standards 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

6. The Six Pillars of Clinical Governance

6.1 Clinical Effectiveness
{{org_field_name}} ensures that the care provided by agency workers is evidence-based, effective, and meets recognised professional and regulatory standards. This is achieved by:

• Ensuring all agency workers are suitably qualified, experienced, and competent
• Providing mandatory training and promoting continuous professional development (CPD)
• Ensuring staff have access to guidance on best practices, including NMC, NICE, and CQC standards
• Supporting reflective practice through supervision, appraisal, and debriefing
• Encouraging staff to evaluate the effectiveness of the care they provide and to seek continuous improvement

6.2 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

6.3 Patient and Service User Experience
Person-centred care is at the core of all services provided by {{org_field_name}}. 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

6.4 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

6.5 Education, Training, and Continuous Professional Development
{{org_field_name}} will:

• Ensure that all staff complete mandatory training prior to placement, including safeguarding, health and safety, infection prevention and control, and basic life support
• 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

6.6 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

7. 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

8. Governance Structures

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

• A Clinical Governance Register maintained by the Director, recording incidents, complaints, safeguarding concerns, training compliance, and supervision records
• Quarterly governance reviews undertaken by the Director
• Annual audits of clinical governance processes and data
• Regular policy reviews and updates

9. 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

10. 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

11. Director’s Oversight

The Director will:

• Lead on all clinical governance functions within {{org_field_name}}
• 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

12. Policy Review

This policy will be reviewed annually by the Director of {{org_field_name}} or sooner if required due to changes in legislation, guidance, or operational requirements.

---

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.