Clinical Governance Policy

Reviewed and agreed 18/10/2018
1. Policy

1.1 Clinical governance is defined as:

A framework through which Guernsey Mind is accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in the services it provides will flourish.

1.2 There are three key attributes to clinical governance:

• Recognisably high standards of care.

• Transparent responsibility and accountability for those standards.

• An ethos of continuous improvement.

1.3 There are eight key elements to clinical governance. These are outlined below, along with the mechanisms used to deliver each of the elements, and the expectations that are placed on Board members and staff at Guernsey Mind.

2. Education and training

2.1 It is the duty of all staff to keep their knowledge and skills up to date, and they must therefore engage in regular continuing learning in their relevant field and in current mental health practices. Opportunities for CPD will be offered by Guernsey Mind and staff are encouraged to seek new training opportunities. This will be managed through our annual staff review process. In addition, all staff are expected and bound to attend the following training:

• Mental Health First Aid

• Decider Skills

• Mental Health Law

• Safeguarding Adults

• Safeguarding Children

• Professional Boundaries

• Equality and Diversity

• Data Protection

• Fire Marshall (designated members of staff)

• First Aid at Work (designated members of staff)

All staff are expected to document their learning for their individual learning portfolios.

2.2 Guernsey Mind supports the ongoing development of staff, both financially and by allowing time out of the office for CPD. All training should be signed off by the Executive Director, and the Executive Director is responsible for ensuring the continuing development of staff. 2.3 Following any external CPD paid for by Guernsey Mind, staff are committed to share their learning with colleagues either formally at team meetings, or through ad hoc advice.

2.4 The Guernsey Mind approach to training for staff is set out in the Staff Handbook.

3. Workplace audit

3.1 Workplace audit is the review of performance and the refinement of practice as a result. Within Guernsey Mind this may refer to:

• The use of appropriate wellbeing measures to support client outcomes at a population level based on evidence-based surveys.

• The use of case studies to highlight specific issues that are then generalised at a population level.

• Service performance audits carried out quarterly which result in improvements in practice.

• CPD, appraisal and mandatory training compliance.

• Comments and complaints

3.2 The monthly team meeting provides a forum for the dissemination of the results of audits and the exchange of opinions about how results can be used to improve Guernsey Mind practice. The range of topics covered in audits should meet one of the following key criteria:

• Provide a regular update to identify service performance and population level outcomes for clients.

• Respond to a particular event or substantiated complaint.

3.3 It is the responsibility of the Executive Director to arrange for an evaluation to be presented on any topic that is causing particular concern wither locally or more widely.

4. Service effectiveness

4.1 Service effectiveness is about providing the best evidence-based care for Guernsey Mind clients at a population level. Guernsey Mind does not provide one-to-one support except to enable signposting to other agencies, and therefore does not measure effectiveness at a individual level.

4.2 Staff are expected to read journals and/or websites regularly to maintain current awareness of best practice. This should include signing up to the daily news bulletin from national Mind.

5. Research and development

5.1 Guernsey Mind is actively involved in community research to identify local trends in mental health and wellbeing. Staff with the relevant knowledge and skills are expected to participate in the collection of research data to informal studies where appropriate. All research and development will be based on evidence-based practice.

5.2 Quarterly meetings to discuss up-to-date evidence based practice will be held between the Executive Director and Mental Health Adviser to Guernsey Mind.

6. Openness

6.1 Processes which are are open to public scrutiny, while respecting individual client and staff confidentiality, are an essential part of quality assurance.

6.2 Guernsey Mind staff uses a number of mechanisms to enable clients and other interested parties to be involved in identifying needs and making improvements. These include:

• Guernsey Mind website – promotes regular and ad hoc services, along with information about the staff, the complaints procedure and a comment facility.

• Complaints – all client complaints are managed through the Executive Director, scanned regularly for learning points and for patterns. Complaints about service delivery are shared immediately with the individual involved and with the Guernsey Mind chair.

• Suggestions – a suggestions box with forms to complete is available at all times in the waiting area.

• Any client complaints involving the Executive Director will be sent directly to the Chair who will manage this in liaison with the Board.

6.3 Guernsey Mind aims to co-operate at all times in a spirit of openness with other charities and the States of Guernsey.

7. Risk Management

7.1 Risks – to clients, staff and the organisation as a whole – are managed through a range of policies and protocols, through risk assessment and through regular team meetings.

7.2 The key policies relating to minimising risk are:

• Safeguarding Adults Policy

• Safeguarding Childrens Policy

• Confidentiality Policy

• Data Protection Policy

• Risk Assessment Policy

• Health and Safety Policy

• Environment Policy

• Risk Management Policy

• Lone Worker Policy

7.3 All of these are available on the Guernsey Mind website.

7.4 Risks are minimised through attention to education and training, audit and performance monitoring. Guernsey Mind takes a ‘no blame’ approach and encourages all staff to discuss any incident that has or could have posed a risk or actual harm. The learning from incidents is shared across Guernsey Mind, and any actions are reviewed until fully implemented.

7.5 All staff, Board members and relevant volunteers must provide Guernsey Mind with Police Checks as requested by the Executive Director.

8. Information Management

8.1 Guernsey Mind will use client data for purposes consistent with our Data Protection Policy and will maintain clinet confidentiality at all times. As Guernsey Mind does not provide one-to-one services for individuals, staff should not retain any individual information except for the purposes of registrations and database membership.

8.2 Guernsey Mind will use client data for purposes consistent with our Data Protection Policy and will maintain clinet confidentiality at all times. As Guernsey Mind does not provide one-to-one services for individuals, staff should not retain any individual information except for the purposes of registrations and database membership.

9. Human Resources

9.1 Guernsey Mind is committed to delivering effective services through suitably experienced and trained members of staff, supported by an adequate administrative resource. Guernsey Mind regularly reviews the skillset of its staff team, offering development opportunities where appropriate and recruiting when necessary.

9.2 When recruiting new staff, the interview will always include questions designed to demonstrate an awareness of clinical governance procedures.

9.3 Guernsey Mind operates within a whole suite of human resources policies and protocols to ensure that every member of the team is working with the best interests of the clients in mind at all times.

10. Implementation

10.1 The Clinical Governance lead for Guernsey Mind is the Executive Director. It is the Executive Directors responsibility to ensure that the principles in this Policy are implemented effectively. Specifically the Executive Director will:

• Provide governance leadership and advice

• Promote high quality practices within Guernsey Mind

• Ensure all staff have received the appropriate level of training

• Deal with complaints and significant events

• Initiate and review local audits as appropriate.

Reviewed and agreed – 18/10/2018
Review Date – 10/2020
Authors: Emily Litten, Executive Director