CPOL50 Clinical Governance Policy by Provide Community

Clinical Governance Policy

Version: V5

Ratified By:

Quality Reference Group

Date ratified: 03/06/2024

Job Title of author: Deputy Director of Nursing and Quality

Reviewed by Committee or Expert Group Quality Reference Group

Equality Impact Assessed by: Deputy Director of Nursing and Quality

1. Introduction

What is Clinical Governance?

‘Clinical Governance’ describes the structures, processes and culture needed to ensure that healthcare organisations, and all individuals within them, can assure the quality of the care they provide and are continuously seeking to improve all aspects of quality.

Healthcare organisations have a duty to the communities they serve to maintain the quality and safety of care they deliver. Whatever structures, systems and processes an organisation puts in place, they must be able to show evidence that these standards are upheld.

The clinical governance framework seeks to improve the quality and safety of all service users and provide a positive patient experience during every contact within Provide. By maintaining a well-structured comprehensive clinical governance system, we can assure the quality-of-service delivery on every occasion through the right care at the right time delivered by competent staff members

Across Provide our governance systems form the foundations on which we practice and are integrated, to ensure that all services are monitored. Robust governance across all areas of the Group enables clinical governance, financial governance, information governance, corporate governance, governance around risk, research and patients/residents/service users experience to be monitored and data triangulated, to ensure individuals are held at the centre of all decisions

2. Purpose & Scope

The purpose of this policy is to develop and sustain a culture of best practice in clinical governance. This policy applies to all Provide services, staff, temporary workers, subcontractors, NHS shared contracts, and volunteers

3. Roles & Responsibilities

Provide Board is committed to ensuring its patients, residents, and service users receive high quality services. The Board is responsible for ensuring the safety and quality of service delivery across the Group through the practice of high clinical standards, identification of risks and adherence to relevant legislative and regulatory requirements.

The Board of Provide assigns responsibility to the Chief Executive (CE) for: -

• Ensuring that a well-developed risk management process is in place to prevent, minimise and manage risk issues.

• Develop systems to ensure staff understand and enact their responsibilities and enable clinical governance principles and processes to be applied throughout the service via appropriate structures, policies, processes, and resources.

• Ensuring all clinical staff are suitably qualified to undertake their role through: -

• Comprehensive recruitment practices.

• A credentialing process that meets statutory requirements

• Appropriate supervisory processes.

• A professional development process consistent with Group and clinicians needs.

• Providing mechanisms that monitor, improve, and respond to safety and quality of care issues that, in turn, informs the development and evaluation of the quality plan including: -

• A clinical audit program.

• Identification and monitoring of adverse events.

• A robust complaints, claims, and compliment process.

• A programme of support and monitoring through visits across all service areas

• Robust incident reporting and investigation, with easy access to all staff members, utilising a Just Culture approach.

• Appropriate training and a robust mandatory training process

• Robust management and monitoring of all risks, through analysis from team to Board level

• A robust ratification process for all policies and procedural documents which are fit for purpose and developed with quality and safety at their core.

• Ensuring reporting structures are in place whereby accurate data and information is provided to all relevant bodies internally and externally and enables systematic monitoring and review.

• Establishing mechanisms for the effective and appropriate involvement of service users, and the community, in quality related activities.

• Providing appropriate infrastructure and support systems, including appropriate information and governance systems, to deliver safe and quality services to our service users.

4. Sub-contractors, Volunteers and NHS Shared Contracts

All sub-contractors and volunteers will, as per their terms and conditions, have a contract that stipulates roles and responsibilities regarding clinical governance assurance. Where a sub-contractor or volunteer follows their own governance processes they must ensure they comply with the requirements set by Provide as part of the contractual arrangement. Provide may apply additional Key Performance Indicators (KPIs) to these contracts to ensure that clinical assurance is maintained.

NHS shared contracts may operate under a shared governance framework; however, arrangements should be in place to ensure that these meet each contracts requirements, and that staff working within these services are clear around their reporting routes, roles, and responsibilities contractually.

The Provide Board maintains oversight of compliance with the clinical governance assurance process. Clinical assurance is reported through the Groups Quality and Safety Committee (QSC) meetings by way of verbal updates, presentations, reports, dashboards, scorecards, and risk registers. There is a clear escalation route to the Board as required

5. References

Clinical Governance Guidance (2011) Department of Health, Available from: http://www.dh.gov.uk/health/2011/09/clinical-governance/

Clinical Governance (accessed Oct 2019) Royal College of Nursing https://www.rcn.org.uk/clinical-topics/clinical-governance

Regulation 17: Good Governance (May 2019) Care Quality Commission https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-goodgovernance

EQUALITY

IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Clinical Governance Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Informs all Provide employees, volunteers, sub-contractors and NHS Shared Contracts on the clinical governance assurance processes within Provide and reporting accountability.

Project/Policy Manager: Deputy Director of Nursing and Quality Date: March 2024

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this –e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan. Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that datagathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.efa.org.uk – Employers forum on age © MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’