Unit 2: Governance & Regulatory Processes

Course: NVQ Level 5 Diploma In Leadership & Management for Adult Care (RQF)

The unit ‘Governance and Regulatory Process’ explores legislation, regulation governance, compliance, and the inspection process in adult care settings. It also covers internal governance within your own organization as well the different roles that individuals play in this process; from managers or directors allocating resources to compliance officers making sure everything complies with national codes set out by law.

The course is designed for all staff working in a leadership position within the adult care sector who wish to gain a greater understanding of inter-organizational processes and how they work. It is also suitable for students seeking employment within the sector or those who are considering moving into an area of specialization that involves compliance procedures, inspection methods, and emergency response procedures.

LO1: Understand legislation and statutory requirements that underpin adult care provision

It is always important to follow the rules, for your own good and that of other people in a service. Failure can result in very negative things happening like an unsafe working environment which will have great effects on all those involved-including you! So make sure there are systems put into place when operating legally as this ensures compliance with regulations at every step possible.

Better quality care is provided when the staff understands how to deal with certain situations. Having a common language, environment, and procedure help create a safer, more comfortable living space for your residents. This section covers how to apply legislation to different aspects of your role in order to provide a better service overall.

Legislation and statutory frameworks

Legislation must be followed at all times as it helps to protect the people you work with from those who might want to hurt them. Consent is an important part of this as well as understanding what authority figures have the right to do certain things versus those that don’t. Being a good leader also requires that you take into consideration your end-users and let them be heard when it comes to the direction of your organization.

There are examples of legislation in this section that cover the elderly, children, people with learning disabilities and acquired brain injuries. This covers areas like education for young disabled students or adult training which is required if you are offering care to adults under 65 years of age.

Effects of legislation and policy on practice

If your organization is not in compliance with various legislation, you can risk losing government funding, fines, and even imprisonment. These rules must be followed at all times to avoid any issues. There are many rules and regulations you must abide by as a care provider such as time spent with people, training processes, facilities used, and others.

Understanding the requirements of legislation that ensure safety and quality in adult care provision helps everyone achieve their goals without breaking any rules or violating anyone’s rights. Compliance officers make sure that everything is up to date with laws set out by The Care Quality Commission for England which is updated regularly.

Drawing attention to potential conflicts

As a leader, you may face different scenarios that leave you in a tough place. You may have to make decisions that you feel are hard on some people but the situation leaves you little choice. This can be very hard as a leader as you have to make the correct decision which might be tough for some people.

For example, maybe during your military career, your platoon was ambushed and many of them were killed. You had no choice but to proceed with the mission even though most of those who were alive voiced their disapproval out of fear. This can be an example of a conflict that you will have to face as a leader.

LO2: Understand internal governance arrangements within own organization

Your organization must have a solid strategic plan that everyone can follow. This helps keep all of you on the same page and accountable for your actions.

The strategic plan is not all about what happens when something bad happens but also covers how best to protect those who are put into our care through promoting independence, dignity, health, etc. Maintaining these essential levels of care is vital to the organization and everyone associated with it.

Protecting your residents from both physical and emotional harm is a must which means you will need something in place that covers this for various scenarios. Having an incident procedure helps to ensure nothing like this happens and if it does, there are protocols in place to follow.

There are some common procedures covered more in-depth on this site such as first aid training and restraint that you must follow. You also need to know where various alarms and equipment such as panic buttons etc. are located so you can access them quickly if necessary.

Governance mechanisms

Governance mechanisms are used to ensure everyone is doing their part to protect those who are in our care, so it is necessary that staff do their job properly. These mechanisms include policies and procedures which take into account the unique needs of each site. The aim is that they are suitable for any situation that might be encountered.

An incident’s impact on an organization is dependent on the severity of the incident as well as how many people it affected. The entire site might be involved depending on the size of your organization. This can also cause a legal issue if negligence is determined to be a factor in the incident which could affect you and your staff directly.

Your policies and procedures should include strict penalties for not following the rules which means you and your staff will be more likely to follow them in order to avoid any problems.

There should also be an environment where people feel comfortable in raising concerns even if they think it might go against what is written in the policies and procedures. The aim of this is to ensure nothing slips through the cracks that could compromise the safety of your residents or staff.

This ensures that your managers know what they can do in order to protect the people in their care and avoid any conflicts with policies and procedures. This is a very important part of ensuring everyone involved knows what they can do, so there are no false expectations set out about their role.

Personal accountability

There should be a system in place that holds every person accountable for what they have done. This is to ensure that everything you do as an organization is being covered by all levels of staff and everyone knows their role.

Your managers will also need a form of governance which means they can hold those working under them accountable. This way, your managers can properly evaluate the staff they supervise and take action as needed. If this is not done, staff who consistently fail to perform up to standards will go unnoticed which can be detrimental in an emergency situation.

Protocols, policies, and procedures

Every organization’s needs are different which is why there is no one-size-fits-all when it comes to policies and procedures. You need to know what works for your organization in order to protect the people in your care.

The people in your care will all have different needs which is why there are different levels of care. Every person has to be able to trust that you can protect them when needed. If an incident does occur, it’s your job as the leader in charge to determine what happened and how best to deal with it. You need all your staff to be fully aware of your protocol and procedures as well as what they should do in the event of an incident.

Staff also needs to know who they can turn to if they have any questions or concerns about something going on for themselves or others. This means everyone must be treated fairly without prejudice of any kind, so it is a good idea to have a support group available for staff to turn to if they are feeling unable or afraid to tell you.

Training is very important both in terms of your organization as well as the people who work there because it makes sure everyone understands their role and how they can best protect those in their care. It’s also vital that every employee knows how to work effectively with others in the organization.

LO3: Understand systems and requirements for regulation of adult care services

Every organization that provides certain types of care is regulated by an external body. Government funding that your organization might receive requires you to be regulated which means it’s in your best interest to go through voluntary registration rather than wait for a court order to do so. Depending on the level of care you provide, you might need to register with multiple organizations.

It is possible for an organization not to register but the penalties can be extremely severe such as loss of funding and inability to work in the adult care service industry. If these services are provided without any regulation it causes a higher risk level where things could slip through the cracks.

It is crucial that your organization does everything it can to protect those in its care because if any incident occurs you will be held responsible for the actions of those working under you. If services are provided without proper governance and support for staff as well as full accountability from everyone involved, incidents such as abuse might occur.

The inspection system in England

The inspection system in England is a very complex one which means it can be difficult to understand. There are many different regulations that need to be followed but the main one is what is referred to as the Statutory Framework for Social Care Inspection. All services must adhere to this framework or risk losing funding and being shut down.

The National Care Standards Commission oversees all organizations providing these types of care which means it makes sure they follow the standards outlined in the framework. It also makes sure all staff are fully trained in delivering care to those in need and that they understand their own roles within the organization. The commission is funded by the government so it is vital for both organizations providing social care as well as individuals receiving it that this system is adequate.

Services subject to registration and to inspection

All organizations that provide some form of adult social care are subject to two basic types of inspection. The first is referred to as surprise inspections while the other is scheduled inspection. A service must have a full risk assessment carried out by trained professionals who can assess where any risks might be in terms of hygiene, safety, safeguarding, and people’s rights. All staff must follow procedures that adhere to the Health and Social Care Act 2008 for carrying out assessments.

After the assessment is completed, a plan of action should be presented and followed before an official inspection can take place. The first part of this plan is to make sure all residents are fully involved in the process by explaining what is going to happen and why. They should be able to ask any questions that come to mind during the process of conducting an inspection of their service.

Any inspection that takes place is not only defining the level of care being provided, but it’s also a chance for residents and family members to provide feedback about how they feel things are going at the organization. This feedback is extremely valuable because it allows organizations to learn from their mistakes and improve their services while offering more people the chance to live in the comfortable environment that they deserve.

Key areas of inquiry for inspection

During the inspection process, a team of professionals evaluates different areas that must be compliant with regulations. These areas include:

The actual care and support services provided to residents; The staffing levels required for delivering this level of care; The management structure in place at your organization; Your policy and procedures for handling complaints from residents and families; And finally, the quality of the governance process in place to oversee these processes.

All of this information is then compiled into a report that outlines everything that was found during the investigation. Although there are many areas reviewed, not all will be provided in detail because some are specific to your organization. The entire inspection process takes about 20 hours which includes time for reviewing paperwork and meeting with management team members and residents.

The reports themselves are not released to the general public since they contain sensitive information about your service, but each inspector is required to provide a summary of their findings at the end of this process. This summary is an overview of what was found and includes details that can help you evaluate how to move forward and improve the level of care being provided.

Grading system and implications

When all of this information is compiled, a grading system is established to allow the regulator to offer an overall rating for your organization. The guidelines that are set out by the CQC outline at what level your care should be delivered and if you fall below these standards then it should be discussed with management immediately because changes should be made in order to improve your services.

A rating of 0-3 denotes a service that is at the top of its level and can be considered excellent; ratings from 4 to 5 mean it’s satisfactory, but there are some concerns; while anything between 6 to 9 signifies that an area in need improvement or in serious danger of being rated lower. If you receive a rating of 9, your services will be placed in special measures which means the CQC has serious concerns and further action is required.

Staffing levels and service delivery will always play a major role throughout this entire process. If you find that you’re receiving a low grade, it’s not just because certain areas aren’t compliant, it’s also because of the fact that you’re not providing all of the necessary resources needed to deliver the level of care that your residents need.

Sources of information and support

The CQC has a lot of valuable resources available on its website that can help organizations understand how to improve the level of care being provided. This includes information about what needs to be in place during the inspection process, which areas are most important to review, and where policies should originate from.

During an inspection itself, you’ll have a full guide that clearly outlines how things should be done and what you’re going to be expected to provide. This information is extremely useful during the process because it provides clarification regarding your record-keeping system, staffing levels, complaints policy, and more.

LO4: Understand roles and responsibilities in registered services

In order to ensure that everything is being done efficiently, every individual who works within your organization must be aware of his or her role in the process. This isn’t always easy especially when you have a larger team because it can sometimes be difficult to communicate with everyone; however, giving them a breakdown of specific responsibilities will make this process much easier.

The CQC is also convinced that it’s essential for the counselor and the counselor to understand exactly what they should expect from each other. It may seem like a lot of information, but after reviewing everything in detail, you’ll notice that this is actually the biggest component of the entire process; in fact, it makes up about 70% of your inspection.

So what areas should be focused on when preparing for the assessment? Each inspector holds an extensive report with everything they need to know, but there are certain aspects that will take precedence over others. Although these things aren’t listed in order of importance, it’s essential for you to understand all of them because your organization can be rated poorly if you fail to provide an aspect that is deemed vital.

Roles and responsibilities of key people

it is important to you to be aware of the roles and responsibilities of the key people.

The inspectors are primarily concerned with the roles and responsibilities of the chaplaincy team, management team, nurse, registered manager/counselor, administrative staff member, first aider, care worker, coder, care coordinator, social work manager, another health professional (for example physiotherapist) and volunteers.

During the inspection, the CQC will be checking a number of different things including training, skills, and qualifications as well as first aid compliance. If you have any questions about this, it’s essential that you clarify them before going into an inspection because failing to comply can result in your organization being placed on special measures or even closed down.

LO5: Understand inspection processes

The CQC isn’t only concerned about what you do, but they also want to understand how your organization goes about doing it.

Every inspection is conducted differently because the inspectors will ask different questions based on what they are looking for, but you can always expect them to be extremely thorough. They won’t leave any stone unturned and they will take as much time as they need to understand how your organization works.

Before the process begins, you’ll be asked to fill out a risk assessment which provides information regarding whether there are any risks associated with caring for people in your facility. Although these questions seem fairly straightforward, it is important that you answer them properly because this can determine whether or not you’re going to pass an inspection. The inspectors will also likely ask about the decisions and processes behind hiring and retaining staff members so be prepared to explain why you chose certain individuals over others.

Persons involved in inspection processes

The CQC is primarily concerned with members of staff because they are responsible for caring for people, but that doesn’t mean that the inspectors won’t be asking about other individuals as well.

While the CQC is primarily concerned with the quality of care provided as part of your organization, they also check on an individual’s satisfaction. They want to know that the people who come into your facility are getting satisfactory treatment and it’s up to you to confirm this.

They will ask a number of questions regarding how frequently residents, relatives, or other visitors raise concerns about certain issues. These could be anything from complaints about staff members to problems with food and facilities.

How to prepare for inspection

Although the CQC is primarily concerned with what your organization does, they also want to understand how you go about doing it.

Before an inspection, you’ll be asked to fill out a risk assessment which provides information regarding whether there are any problems associated with caring for people in your facility. Although these questions seem fairly straightforward, it is important that you answer them properly because this can determine whether or not you’re going to pass an inspection. The inspectors will also likely ask about the decisions and processes behind hiring and retaining staff members so be prepared to explain why you chose certain individuals over others.

Lastly, if your organization is either on probation or has been put under special measures in the past, expect to answer a barrage of questions regarding what you’ve changed since then. These are important questions because the CQC is interested in learning how your organization has changed to ensure that people are safe and receiving proper care.

Inspection process and information required

Although inspections can be unannounced, the Care Quality Commission (CQC) will usually provide two weeks’ notice in writing. In most cases, they will also inform you as to what they are going to inspect.

You are responsible for providing inspectors with all necessary information, including documents, records, plans, and policies associated with your facility. These might include but are not limited to minutes from meetings, recruitment files, staff training notes, complaints documentation, patient complaints, or corporate risk registers.

The inspection process involves interviewing individuals involved in the provision of care. This can include staff members, volunteers, relatives, or patients. Inspectors will also speak to your managers and supervisors before making their decisions regarding whether or not to approve your facility.

Ways to address the outcome and impact of an inspection

Once the inspectors have completed their assessments, they will make recommendations to ensure that your facility is following all of the necessary procedures and protocols. They will also inform you as to whether or not you’ve passed inspection and if you haven’t, there are a number of things that you can do about it.

First and foremost, you need to take these recommendations into consideration and do everything you can to implement them. Many of the problems associated with failing an inspection simply come down to poor communication within your facility; if staff members don’t know what they are supposed to be doing or how they are expected to perform, this is going to reflect poorly on your organization as a whole.

LO6: Understand wider ranges of regulatory requirements that apply to services

You can never be too careful when it comes to regulations and that is particularly true for organizations looking after vulnerable populations. Operating a facility is complicated enough as it is, which is why you need to take every regulation from the CQC seriously or else face severe penalties. Because regulations are always changing, it’s important to stay on top of any updates so you don’t put your facility at risk.

In order to avoid potentially disastrous situations, companies need to ensure they have detailed knowledge regarding regulations associated with their industry and region. This will require an ongoing effort because regulations, by nature, change frequently and there is no guarantee that a particular law won’t be enforced in the future.

Regulation processes that apply to the service or aspects of it

In some cases, failure to follow a particular regulation can result in more than just an inspection. In fact, there is a high chance that your organization will face financial penalties if you aren’t adhering to a certain piece of legislation.

For example, failing to meet standards outlined by the CQC could result in a significant fine. Fines are typically proportional to the size of your organization, so hospitals and other bigger conglomerates face far steeper penalties than individual clinics.

This is especially true when you consider that fines are rarely used as a way to punish organizations for their mismanagement or poor practices. Instead, they are usually meant to encourage companies into improving their services by punishing them financially instead of taking away their license altogether.

Types of information required for regulation processes

No matter what the regulation process is for your organization, you are going to need documentation. The documentation can vary depending on where you are located and what kind of business you’re running but it must be provided whenever confronted with a board member, inspector, or other regulators.

For example, if your facility receives funding from the government or third-party organizations, then its operating grant agreement should be available to any regulator who asks for it at any point in time. Without this document present during an inspection, regulators might believe you have done something untoward with the grant funds associated with your project.

Regulatory frameworks presenting conflicting requirements

One of the most common problems associated with existing regulations is when they present conflicting requirements. For example, if you are running a hospital that needs to provide care 24 hours per day but there’s only one nurse on duty, then no one can be properly covered by the facility’s current policies. This is not something that officials will let slide during an inspection and it could cause your organization to lose its license entirely.

The solution here isn’t necessarily more funding but instead better communication between staff members and management regarding what they should expect from each other in order to ensure patient safety at all times of the day.