GRACE & MERCY HEALTHCARE LIMITED

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Governance Policy

APRIL 2024

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Introduction

This and the accompanying policies show how GRACE & MERCY HEALTHCARE LIMITED
is organized and managed in line with the requirements of Regulation 17 Good Governance
of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This
regulation requires GRACE & MERCY HEALTHCARE LIMITED to have methods to:

• assess, monitor and improve the quality and safety of the services provided including
the quality of people’s experience in receiving the services
• assess, monitor and mitigate risks to the health, safety and welfare of people who use
services and others involved, which includes risks to staff
• keep securely accurate records of the care and treatment provided to each person and
of decisions taken about their care and treatment
• keep securely other records on staff and those required for the management of the
service
• seek and act on feedback from people who use services and others in order to be
assessing and improving the services
• ensure that the care service’s methods of governance and management remain
effective.

The regulation also requires GRACE & MERCY HEALTHCARE LIMITED to reply to CQC
requests for information (for example, in response to concerns or queries about the service
or to complete a Provider Information Return) 28 days from receiving the request.

GRACE & MERCY HEALTHCARE LIMITED is also mindful of Key Question “Is it Well-led?”
and seeks to answer in its governance practices all questions relating to:
• its promotion of a person-centred care culture
• efficient and effective management
• commitment to continuous improvement
• inclusive engagement and involvement

• co-operative partnership working
• workforce wellbeing
• encouraging staff to speak up about their concerns and to suggest improvements
• developing sustainable environments.

Description of Service

GRACE & MERCY HEALTHCARE LIMITED is seeking registration with the Care Quality
Commission to deliver the regulated activity of Personal Care.

It has as a limited company the legal entity as: Organization (Individual)

Nominated Individual: MARIA AFRANE-TWUM

Registered Manager as: MARIA AFRANE-TWUM

GRACE & MERCY HEALTHCARE LIMITED is a domiciliary care service to Children and
Adults 18–65 years and people who are over 65 years who need help with their personal
care because of physical disabilities and long-term health conditions.

GRACE & MERCY HEALTHCARE LIMITED — Governance and
Organisation Overview

GRACE & MERCY HEALTHCARE LIMITED plans to run the service with the following
structure, which will be made subject to review with the development of the service.

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REGISTERED PROVIDER: GRACE & MERCY HEALTHCARE LIMITED.

LOCATION ADDRESS:
45 Pitcairn Road
Smethwick, Birmingham
B67 5NE

MANAGING AND SOLE DIRECTOR: MARIA AFRANE-TWUM is the Managing Director of
the business and will act as NOMINATED INDIVIDUAL for CQC purposes.

REGISTERED MANAGER: MARIA AFRANE-TWUM will be the Registered Manager.

MARIA AFRANE-TWUM will oversee the business development and ensure the company
follows the policies and procedures to enable them to be compliant with the quality of
care.

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GABRIEL AFRANE-TWUM will be responsible for developing all aspects of the business,
including financial management and marketing of the service.

As Registered Manager, MARIA AFRANE-TWUM will be responsible for all aspects of
day-to-day operations with the care setting. This includes, recruiting and managing staff,
managing budgets and ensuring that the quality of the services provided meets national
care standards.

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Proposed Division of Responsibilities (These might change with the
development of the service)

1. Care management and co-ordination

MARIA AFRANE-TWUM will carry out all initial care assessments and will coordinate the
service delivery prior to any appointment of a dedicated care co-ordinator role.

2. Staff supervision and management

MARIA AFRANE-TWUM will be responsible for staff supervision and management.

3. Staff development and training

MARAI AFRANE-TWUM will be responsible for organising staff training (as shown by the
training matrix). Some training delivery may be out sourced.

Induction will be in line with the Care Certificate Standards framework, which includes all
mandatory training subjects such as moving and lifting, medicines support, safeguarding
and mental capacity.

4. Quality assurance and compliance

GABRIEL AFRANE-TWUM will set up the systems to carry out the required quality checks
initially. (See attached policy.)

5. Infection prevention and control (including Covid-19 measures)

MARAI AFRANE-TWUM will be directly responsible for all infection control measures and
risk assessments in line with current requirements and infection prevention and control
compliance, including supporting staff vaccination, testing and use of PPE. (See separate
policy.)

6. Safeguarding

MARAI AFRANE-TWUM will act as the safeguarding lead and be responsible for
safeguarding training programmes — this role could be delegated as the business grows.
(See separate policy.)

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7. Health and safety

GABRIEL AFRANE-TWUM will initially act as Health and Safety Officer. A Health and
Safety Consultant could be employed later to audit the health and safety systems and
methods.

8. Service delivery patterns. Our plan is [Adapt]

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Every person using services will have a named care worker reporting to MARIA AFRANE-
TWUM/manager who will ensure needs are addressed and there is continuity of service.

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GRACE & MERCY HEALTHCARE LIMITED aims to develop “core teams” to ensure
continuity and consistency of care and which will change only when necessary. This should
also contribute to infection prevention and control arrangements through reducing
interactions between staff.

How GRACE & MERCY HEALTHCARE LIMITED Will Provide “Good
Governance”

GRACE & MERCY HEALTHCARE LIMITED is developing a suite of polices and matching
procedures that show in detail its compliance with Regulation 17 and the fundamental
standards.

1. Promotion of an open, transparent, person-centred culture
See:
• Statement of Purpose
• Leadership and Management Policy
• Information for People Using Services Policy
• Website (if available).
2. Oversight of governance arrangements
• As described in this document.
• Fit and Proper Person Requirement for Directors Policy.

3. Assessing quality, safety and promoting continuous development and
improvement
GRACE & MERCY HEALTHCARE LIMITED refers to and uses the following policies and
procedures.
• Quality Assurance and Management Policy.
• Complaints and Compliments.
• Questionnaires and survey forms.
• Complaints forms.
• Business planning policy.
4. Assessing and controlling risks to welfare and safety
• Safeguarding People Using a Care Service from Abuse or Harm policies.
• Human Rights and Deprivation of Liberty Policy.
• Health and Safety Policy.
• Infection Control Policy.
• Medication Management Policy
5. Keeping records and record keeping systems
• Records and Record Keeping Policy.
• Access to Social Care Records — People Receiving Care Policy.
• Records Kept in the Homes of People Who Use Care at Home Services Policy.
• Care records auditing forms.
6. Data Protection Act and General Data Protection Regulation (GDPR)
• Data Protection and Compliance with the General Data Protection Regulation Policy.
• GDPR Forms including:
– Statement of Compliance
– personal data processing
– privacy notice
– privacy policy for website
– Information Asset Register

– data protection checklist.
7. Responding to the CQC’s Requests for Information
• Statutory Notifications Policy.
• Completion of PIRs on request.
• Completion of forms Issued by the CQC.
8. Partnership working including commissioners, safeguarding, health services and
the CQC
• Working with Other Providers and Agencies Policy.
• Stakeholder feedback form and questionnaire.
9. Monitoring and Auditing

The registered manager and management team, as it develops, will carry out regular
scheduled checks on:
• care practices and recording
• administration of medicines
• use of equipment and devices used in the delivery of care
• checking of location premises for health and safety and security, including fire safety
• checking of infection control and cleanliness measures (including for Covid-19)
• current safeguarding and complaints’ issues, including any alerts to the local
safeguarding authority
• checks on staffing availability and performance
• Continuity of care: travel and care time.

There will be a rolling schedule of audits on a one to three-month basis to carry out full
checks on the above areas together with:
• risk assessments and control measures, including mental capacity issues
• staffing complements, staff supervision and training
• all health and safety issues
• Infection prevention and control issues.

There will be at least an annual self-evaluation of the service’s performance against each of
the five key questions using suitable professional tools, which include obtaining
systematised feedback from people receiving care and stakeholders.

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Review
Signed: MARIA AFRANE-TWUM
Date policy created:
Date of this review:
Next review date:

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