Welcome to episode 18 of Continuous Quality Compliance. Today I am talking about Regulation 17 Governance
CQC’s intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service.
The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others.
Providers must continually evaluate and seek to improve their governance and auditing practice.
They are also looking for providers to securely maintain accurate, complete and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity.
Governance is your overall strategy for the business which encompasses the Quality Assurance element.
Your Quality Assurance system will be part of this , the audits you do to look at the evidence you gather and ensure that they are meeting your standards and CQC standards. Remember the CQC standards are the minimum you have to meet.
Providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. If you don’t see patients if you are a provider that only does diagnostics reporting, you must still ask for feedback from those that you are providing your service to and those who you employ or those who you contract to do the work for you.
CQC are looking for providers should actively seek the views of a wide range of stakeholders, including people who use the service, staff, visiting professionals, professional bodies, commissioners, local groups, members of the public and other bodies, about their experience of, and the quality of care and treatment delivered by the service. Providers must be able to show how they have:
· analysed and responded to the information gathered, including taking action to address issues where they are raised, and
· used the information to make improvements and demonstrate that they have been made
CQC can prosecute for a breach of part of this regulation (17(3)) if a provider fails to submit such a report when requested. CQC may consider that this failure could prevent the provider from taking appropriate, timely action. CQC could therefore move directly to prosecution for a breach of this part of the regulation without first serving a Warning Notice.
Continuous improvement is important, learning form audits and the analysis lessons learnt are important. Looking at how you can disseminate the findings to others within the organisation. CQC are also looking for how you are going to improve processes for your clients, they want to know what plans you have in place.
Providers must monitor progress against plans to improve the quality and safety of services, and take appropriate action without delay where progress is not achieved as expected.
Where providers have to meet relevant nationally recognised guidance these should be looked at on a regular basis for updates. Providers should be aware that quality and safety standards change over time when new practices are introduced, or because of technological development or other factors.
You should have a good risk management system in place . It needs to be appropriate for the size of your company and what you do.
Managing risk is bout looking at all the things that could go wrong and looking at the probability if it is high then you should probably put controls in place. State what controls are in place so you can see if they are indeed working.
Good record keeping and management comes under Governance.
There are always things to improve in an organisation. It may be something small or it could be a larger project.