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Clinical Governance in Care Homes with Nursing (Wales) Policy

Policy Aims and Scope

This policy applies to care homes with nursing to show how {{org_field_name}} maintains high standards of clinical excellence in respect of its healthcare provision and nursing care at all levels of its management and organisation.

Policy Statement

{{org_field_name}} considers that its clinical and nursing functions should be exercised in line with the requirements of the Regulated Services (Service Providers and Responsible Individuals) Regulations 2017 and the standards for clinical governance that are recommended for all health services by NHS Wales. By clinical governance is meant the combined means by which high standards of healthcare of people in care homes are maintained and improved through, for example:

• comprehensive person-centred care
• effective leadership and teamwork and management oversight of the standards of clinical practice by {{org_field_name}}
• clinical practices that fully follow NICE guidelines and quality standards
• employment of high calibre nursing staff who continue to meet NMC registration and revalidation requirements and its code of conduct
• ensuring nurse management posts are filled by competent and suitably qualified people
• continuous quality monitoring, assurance and improvement of all clinical and health-related practices as part of the home’s overall quality assurance methods
• continuous staff development and learning in all relevant aspects of clinical and nursing practice and related healthcare activities; with access to information that keeps people’s learning up to date
• regular supervision and support of registered nurses as clinical leads of non-nurse qualified healthcare workers
• high standards of recording and record-keeping in line with the home’s policies, with, where applicable, use of electronic records that can be integrated with NHS Wales recording systems and in line with NHS information governance policies
• comprehensive and continuous assessment and management of all risks to people’s health and wellbeing, including those from infectious outbreaks such as Covid-19
• comprehensive recording and reviewing of all incidents that do or might impair safe care and treatment with a view to learning from them
• compliance with all notification requirements of the Care Inspectorate Wales and other healthcare bodies
• the exercising, where applicable, of a Duty of Candour.

Related Policies and Procedures

There is a raft of policies to which the activities of clinical governance relate which can be cross-referenced with the following examples and should be referred to in support of the provider’s clinical governance. (The list is not comprehensive.)

Clinical Governance Feature	Relevant Policies
Person-centred care	Personal Care and SupportPromoting the Welfare of People Who Use Services: Personal and Nursing CareEnd of Life Care
Leadership, management and teamwork	Good Governance: Effective Leadership and ManagementDay to Day ManagementTeam-building
Clinical practices	Healthcare and Clinical ProceduresHealth Promotion (See also policies on specific nursing and healthcare procedures.)
Nurse Recruitment and Employment, including Nurse Management	Staff Recruitment and SelectionStaffing Levels and Rotas
Quality monitoring, assurance and improvement	Quality Assurance and Management
Staff development and learning	Staff Development and Training
Recording and Information Governance	Record KeepingInformation Governance and the GDPR
Risk assessment and management	Health and Safety: Risk Assessment and ControlRisk Assessment and Management for People Receiving CareSafeguarding (Various)Infection Control (Various)Medication Administration (Various)
Critical Incidents, including emergencies, errors, near misses, etc.	Various policies on managing emergencies, accidents, critical incidents and medication errors.
Notifications	Notifications of Incidents to the Care Inspectorate Wales
Duty of Candour	Duty of Candour

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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}}

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