GOVERNANCE STRATEGY & STRUCTURE

Transcription

1 GOVERNANCE STRATEGY & STRUCTURE CareTech Community Services CTCS (Adult Division) Victoria O Meara Victoria.omeara@caretech-uk.com Page 0 of 20

2 Contents Introduction... 2 What is governance and how do we deliver it?... 2 The governance framework... 2 What do we want to achieve?... 3 Our Vision and Values... 4 Key Objectives of this Strategy... 5 The PLC board... 7 The Executive... 8 Care governance and Safeguarding Committee Reporting Structure Our Clinical Governance Framework Company and Governance Structures Who s who? Financial Oversight Policy, Procedures & Information Governance Committee Page 1 of 20

3 Introduction All providers of health and social care are conscious of the need for management vigilance and the requirement to have a thorough commitment to delivering care that is safe and of a high quality. CareTech s approach to quality and safe service delivery is characterised by a mixture of a dedicated compliance team carrying out regular audits of inspection and a commitment to building quality into everything we do. What is governance and how do we deliver it? Governance is a word used to describe the ways that organisations ensure they run themselves efficiently and effectively. It also describes the ways organisations are open and accountable to the people they serve for the work they do. All effective public and private sector organisations want to have good governance. For CareTech Community Services, good governance is about creating a framework within which we: Provide the people we support with good quality Health and Social care services. Are transparent in the ways we are responsible and accountable for our work. Ensure we continually improve the ways we work. Good governance is maintained by the structures, systems and processes we put in place to ensure the proper management of our work, and by the ways we expect our staff to work. It s also about how we scrutinise our performance and deal with poor practice and other problems. And it about how we identify and manage risks, whether in terms of patient care, to our staff, and to the organisation as a whole. For example, by ensuring we manage our finances effectively. The governance framework We provide both Health and Social care services to Adults and Children with a variety of support needs including Learning Disability, ABI, Mental Health, ASD and physical health needs. Governance is defined as the combination of structures and processes at and below board level to lead on Company-wide quality performance including: Ensuring accountability for quality and required standards Investigating and taking action on sub-standard performance Identifying, sharing and ensuring delivery of best-practice Identifying and managing risks to quality of care Ensuring the organisation s culture supports effective engagement on quality Driving continuous improvement The aim of Governance is to provide the Company Board with assurance of effective and sustainable management of quality throughout CareTech. This strategy takes as its foundation the four domains and describes how CareTech measures itself against these basic principles. Page 2 of 20

4 The domains are: Strategy Quality drives the Company strategy The Board is aware of potential risks to quality Putting people who use our first overrides all other priority areas Capabilities and culture The Board have the leadership, skills and knowledge to ensure delivery of the quality agenda The Board promote a quality-focused culture throughout the Company Processes and structures There are clear roles and accountabilities in relation to governance There are clearly defined, well understood processes for escalating and resolving issues and managing quality performance The Board actively engage patients, staff and other key stakeholders on quality Measurement Appropriate quality information is analysed and challenged The Board are assured that the desired level of quality is being delivered in the development and delivery of Company services The robustness of the quality information and assurance quality information is used effectively. Some of the actions we will take to ensure our continual compliance with these principles include: Regularly reviewing and promoting our values and behaviours engendering a culture of openness and honesty. Drawing the clinical and corporate governance streams of work together in an integrated approach Embedding quality and accountability for quality in everything we do. Ensuring continuous improvement Putting people we support first and involving them in how their care is delivered and in service design. Ensuring people receive care and treatment that is safe, compassionate and clinically effective Assuring governance and management of risks is subject to rigorous challenge Strengthening the analysis and use of quality data and information Refining the Company escalation and assurance systems and processes As an organisation CareTech will also engage the wider health economy and work in partnership with commissioners, other providers, patients and other stakeholders to achieve the aims of this strategy. What do we want to achieve? We want to ensure that people who use our services can rely on consistently high quality care and experience. By developing transparent, rigorous and timely enquiry, review and assurance processes, staff will be provided with the data and feedback they require to engage with continuous improvement. Learning not Blaming (DOH 2015) identifies the following themes as integral to supporting our aims: Page 3 of 20

5 People and professionalism The right culture from top to bottom Openness, honesty and candour Listening to people who use our services, families and staff Finding and facing the truth Learning from errors and failures in care These themes are underpinned by the Company s visions and values. Our Vision and Values Our vision is holistic, embracing not just material needs, but all aspects of a person s life from health and education to social and vocational skills development, as well as recreation and leisure activities. As part of our personalisation strategy, we launched a staff engagement survey and a re-launch of our values in 2015: FRIENDLY - we promote an environment in which staff feel comfortable to share opinions/views and in which individuals can live to their full potential. POSITIVE - we embrace positive change which results in better outcomes for individuals and staff. EMPOWERING - by empowering everyone, we are confident that each individual will be able to live fulfilling lives and employees will feel valued. INNOVATIVE - we tailor our services to meet the needs of individuals. Staff provide innovative and creative support to achieve positive outcomes. PERSON-CENTRED - we respect and value our staff and individuals, recognising that we can create positive outcomes for all. Page 4 of 20

6 Key Objectives of this Strategy This strategy details the key objectives for: Governance including Risk Management and Regulatory Assurance The Safety of people who use our services The experience for people who use our services Outcomes, both Clinical and holistic and Effectiveness NB Information Governance is an important thread that runs throughout these objectives. Governance Objectives The principle aim is to maintain a robust framework for Governance with realistic goals that take into account an organisational context and strive for continual improvement. Within that the following objectives have been identified: Strategy - Clear direction and realistic goals Ensure the governance and risk management framework continues to be fit for purpose at all levels Be compliant with the terms of Care Quality Commission registration (Adult Division), regulations, standards and inspection. Capabilities and Culture leadership and quality Ensure that explicit and robust accountability arrangements are in place and effective at all levels of the Company Demonstrate that our Board have the leadership, skills and knowledge to ensure delivery of the quality agenda and promote a quality-focused culture throughout the Company. Work with our Divisions on maintaining the improvements in governance work streams. Further develop and embed local process and meetings so that governance is everyone s business Processes and Structures accountability, escalation and resolution Work with key stakeholders such as commissioners, staff, regulatory bodies, patients and the public to ensure engagement with, and accountability to, those who pay for and use our services Embed and develop defined, well understood processes for reviewing assurances and escalating and resolving quality and performance issues Regularly review the effectiveness of our committee structures and policy management system to ensure they are fit for purpose Measurement - monitoring improvements and intelligent information Ensure collation of intelligent information and data which is robust, well analysed and used effectively in the production of regular reports and identification of hot spots to support decision-making and effective operation of the Company at all levels Use our Quality assurance framework and compliance audit programme as a driver for improvement across all services. Continue to use Quality Reviews (based on CQC inspection regime methodology) Promote and enhance our involvement in external audit/peer review/ benchmarking initiatives Page 5 of 20

7 Risk Management Objectives A key component of Governance and Assurance is sound risk management practice and the Company has set clear risk management objectives to support the achievement of the objectives within this strategy. Make further improvements in the systems we have introduced for our policies management and ensure procedural documents are user friendly and updated in a timely manner. The Company is committed to providing high standards of person centred care in all settings. All services are required to focus on safety, experience, outcomes and quality of care whilst acting with responsibility within the financial and performance framework of the Company. We continue to: Review our risk management and assurance systems regularly to ensure they are robust Continue the development of the processes, scrutiny and monitoring systems for the accreditations and inspections taking place throughout the organisation to ensure our services meet the standards of our regulators, reviewers and accreditation bodies and ensure any improvements to compliance are addressed promptly Continue to adapt our systems and practices to meet the needs of regulatory and legislative changes and developments Use both internal and external learning and benchmarking to ensure continuous quality improvement Develop standardised risk and quality reports for our Divisions so they know what they are doing well, what needs improvement and understand their accountability to continuously monitor and improve. Publish further information on our services and performance in our annual report Build on our Governance Framework and further develop our Assurance and Escalation processes to ensure our assurances are robust Review our governance committee structure to ensure it remains efficient, effective and appropriate Page 6 of 20

8 The PLC board The company is managed through four business segments and supported by a Support team based in Potters Bar, Hertfordshire. There are also regional offices in the West Midlands and Ashford and support offices within domiciliary agencies nationwide. We have four care pathways and these are also the five business segments for reporting purposes: Adult Division (split into 2 regions- North/Midlands and South/Central) Adult Division Specialist services Young People Residential Services Foster Care and Family Services Learning Services Our PLC main Board comprises of: Farouq Sheikh Executive Chairman Haroon Sheikh Chief Executive Officer Michael Hill Finance Director Page 7 of 20

9 The Executive Julian Spurling - Managing Director Adults South Division & Mental Health As Managing Director for the South, my primary role is to ensure that each service is sufficiently resourced and supported to provide high quality support & care to the individuals who live in and use our services. In doing so, we aim to grow our reputation amongst commissioners, regulators, families and care support teams, and thereby our service offering which in turn offers career development opportunities for all staff within a growing and financially strong company. Charlotte Smith - Managing Director North Division It is a pleasure to share with you my role as Managing Director for North Region. I am committed to ensuring the Region delivers the highest quality care to the people in our services, to ensure our staff are motivated, trained and live the values and ethos of the CareTech family. I only believe in delivering outstanding Care - Everyday. Another key part of my role is ensuring the region performs well financially and commercially, managing and meeting the expectations of our funders and regulators in the current challenges of the economic climate. I continue to strive to build continued commercial stability, excellence in all we do and opportunity for all those who join my team Helen Stokes / Managing Director for Specialist Services Rob McKay Managing Director Children s Division John Ivers- Chief Operating Officer Amanda Sherlock- Director of Compliance & Regulatory Management Nasir Quraishi- Group HR Director Andrew Lee- Commercial Director Dr. Junaid Bajwa- Clinical Director The executive board meets on a monthly basis to review the month s operational successes, issues and share information. What this means to our staff and the people we support We have a process that means our board have oversight of the issues and challenges that we may face and are able to make decisions to improve the lives of the people we support and the staff who work at CareTech. Page 8 of 20

10 Service user meetings Staff Meetings People who use our services and staff have regular meeting to discuss matters that are important to them. Managers will share important information from their Locality meetings. Locality meetings Managers attend monthly management meetings, share good practice and any concerns and pass on success stories. The Locality managers will share information from the SMT- Senior Management team meeting. This will include specific information on Risks and Health and Safety SMT/ Regional Each month, the Locality managers and their Operational manager/director and support services such as Quality, Compliance, HR, Training, Recruitment meet to discuss new initiatives, share information and the key issues arising each month. From this, members of the SMT (Senior Management Team) will have actions to take forward. QCRM (Regional) & National Health and Safety Committee The Quality, Compliance, Risk Management group meets every quarter. The Directors and Operations managers along with the Director of Compliance and Regulation and Head of Quality meet to review the Risk Register. Here, information from the SMT s is reviewed and themes are examined. Actions will be taken away to complete by members of this group, or taken to the board at Care Governance meetings. Policy, Procedures & Information Governance Committee Clinical Governance & Safeguarding Committee Care Governance & Safeguarding Committee The Care Governance Committee meets quarterly. This comprises of the Director of Compliance and Regulation and members of the Board. Here, the group meets to review themes, listen to current concerns and review risk registers from all divisions. Page 9 of 20

11 Care governance and Safeguarding Committee Our Governance structure ensures that there are channels of communication from the service to the Board with the Director of Compliance and Regulation attending the Care Governance and Safeguarding Committee meeting and Health and Safety Committee meetings and the Managing/Operations Directors and Head of Quality attending the QCRM and SMT and holding regular meetings with Locality managers. The committee s principal duties are to closely examine and pursue improvements to all matters relating to care governance and the safeguarding of those we support, including oversight of Health and Safety. The Committee appointed by the Board is a formal sub-committee of the Board to be chaired by a Non-Executive Director. The majority of the Committee will be Non-Executive members. Members: Non-Executive Directors CTCS Chief Operating Officer Director Quality, Compliance & Regulation. Current memberships are Mike Adams (Chairman), Haroon Sheikh, Michael Hill. Other Board members or Directors are invited through the Chair as appropriate. Committee Duties To provide oversight and assurance on the quality, safety and compliance of all CTCS on behalf of the Board through: Scrutiny and oversight of all matters concerning safeguarding, serious incidents and accidents and care safety across CTCS Oversight of care quality and compliance performance across CTCS Oversight of the three compliance sub-committees: Health & Safety; Clinical Governance & Safeguarding; Strategy, Policy & Information Governance. Committee role & responsibilities Monitor and advise on safeguarding of adults and children across the group Promote best practice in all safeguarding duties Oversee the health & safety committee and ensure all mandatory and statutory obligations are fulfilled across the group Advise on and sign off relevant policies and procedures and ensure there are review systems in place for all relevant policies and procedures Advise on and consider mandatory and specialist training programmes across the group Page 10 of 20

12 Review and monitor serious case reviews any criminal or civil cases or Coroners Inquests. To ensure learning from such incidents is cascaded and embedded across the group Provide oversight of all external inspection activity ensuring highest standards of compliance with regulation To provide oversight of relevant change programmes to provide assurance on the management of compliance risk across the group To advise on the implications across the group of national policy change or health and social care guidance as it relates to the group. Board Care Governance Committee Policy, Procedures & Information Governance Committee Clinical Governance & Safeguarding Committee Health & Safety Committee The Quality Assurance framework consists of Operational reports submitted centrally on a monthly basis, prescribed Auditing following regulation and legislation from the Care Quality Commission, CSIW, and the Health and Social Care Act, and the formal governance structure of meetings in information from services to the Senior Management team and Board. Reporting Structure Each service produces a report monthly which captures Health and Safety, Human Resource, Occupancy, Compliance, Safeguarding, Complaints and Compliments, Regulatory visits, Operational visits and feedback received. The monthly report is submitted to the area manager (Either Locality or Operations Manager) and collated at a divisional level. The information is then collated for discussion at SMT. All meetings are minuted and produce action plans for either individuals or support functions. Page 11 of 20

13 Human resource information is collated by our HR business partners and support identified, whether this is HR support, Occupational health support or support for staffing and recruitment. Focused action plans are developed to support recruitment where this is identified as an issue. Safeguarding and complaints are compiled monthly and analysis completed at a local and regional level. Themes are discussed at QCRM, and further at Care Governance. Health and Safety Data is collected via a variety of routes to be reviewed at Care Governance level. Incidents and Accidents are uploaded to our Health and Safety Partners via on-line portals at service level. Citation, our partners for Health and Safety and Acoura for Specialist services, provide a platform for the recording and analysis of incidents and accidents which allows oversight at all levels of management. Data is entered onto Monthly reports for monthly analysis at a service level. Specific Health and Safety meetings are held at service and locality level, reviewed at SMT and QCRM where themes or issues are identified and then further at the Health and Safety Committee. Care Governance Health and Safety Commitee SMT (Bi-Monthly) Locality / Area Meeting (Monthly) QCRM (Bi- Monthly) Service Team Meeting (Monthly) Service Team Meeting Service Team Meeting Page 12 of 20

14 Managing Risk Each division has a Risk register. This is updated at QCRM meetings and is based upon the information provided at SMT INCLUDING Health and Safety and current Operational and organisational challenges. There is a Corporate Risk Register which collates the Divisional registers for review at Board governance level. Page 13 of 20

15 Our Clinical Governance Framework Whilst we have a standardised Quality Assurance framework for the Adult Division, we also have specialist services which require additional safeguards to ensure the quality of service provision and adherence to additional MHA and Clinical procedures. In addition to the quality assurance structure within the Adult division, specialist services also review Clinical practice. Each service holds a Clinical Governance meeting on a monthly basis. This is attended by the Operations manager, Service management and support functions within the service. In addition to internal quality Assurance procedures, Uplands Hospital also holds a CQRM attended by CCG s and Senior management with available CQC representation. This provides stakeholders with information such as: Updates & actions of previous meeting Care Tech presentations Innovations, good news Serious Incidents/ Alerts themes, safeguarding. CQC notifications Action Plan updates (if not covered in other items) Reports to formally receive Agree Items for escalation to internal mechanisms Any other business relating to Quality The CareTech Specialist Services Division Contract Clinical Quality Review Meeting (CCQRM) provides a clinical quality focus for the CareTech services and address any contractual issues between CareTech and its Commissioners and promote real, substantial and sustainable continuous quality improvement across the Specialist Services Division in terms of patient safety, outcomes and experience as well as value for money. This covers Serious Incidents Page 14 of 20

16 Requiring Investigation, Never Events, Infection Control (by exception), Safeguarding/CQC notifications, staffing and workforce, Complaints and compliments, Risk Register, Health & Safety Action Plan updates and Progress reports. The primary purpose of the Group is to jointly oversee quality assurance and quality improvement in line with the requirements of the standard and specialist contracts specifically including: Quality requirements SUIs and Never Events Nationally mandated incentive schemes Commissioning for Quality and Innovation (CQUIN) Service development and improvement plans Service user, carer and staff surveys Transfer of and discharge from care protocols Safeguarding adults Specialist services CQC requirements, conditions, reports and associated action plans Page 15 of 20

17 Company and Governance Structures Who s who? The Compliance and Regulation Team We have an independent Compliance and Regulation Director on the Executive Team. Amanda Sherlock is the lead for all divisions for internal inspection, Policy approval and Regulatory compliance. The role reports directly to the CEO on behalf of the board to ensure a level of internal challenge and independence on our reporting. Amanda leads a Team of Compliance and Regulation Heads and Managers who provide independent auditing for all services within each Division. Each Inspection follows the Regulatory framework as defined by the Care Quality Commission. The compliance team also provide support for Regulatory submissions, Health and Safety matters including RIDDOR and Safeguarding. The Director of Compliance and Regulation also monitors and reports on performance against national standards. The Quality Team The Head of Quality, (Victoria O Meara) reports to Operational Directors for North, South and Specialist Services. This role specifically supports the Adult division with development of Policy, procedure and approval of forms. The Quality Assurance Framework for the Adult division is developed by the HoQ with input from Operational colleagues. On a practical level, the quality team has support resources such as Service Improvement Managers, Psychology and Behavioural support. Page 16 of 20

18 Financial Oversight Our market The care market in which the Group operates is a UK market worth an estimated 10bn per annum across the Adult Services for adults over the age of 18 and Children Services for children and young people up to the age of 18. The principal driver for commissioners in local authorities and the NHS is value. This is interpreted by them as the optimum balance between quality and price, but has an underpinning criterion determined by outcomes. CareTech has been aligned to this set of purchasing principals and we work closely with commissioners to ensure that we stay in tune with their approach to market management. Our understanding of the social care market and our relationships with local authority commissioners is vital to our strategy. We are sensitive to the complex financial position that local authorities are in and their need to have trusted business partners who can help them deliver statutory duties efficiently and with care. Social care expertise Employing numerous qualified and skilled care workers, foster carers, teachers and managers, the CareTech front line teams are supported by a wide range of high level professionals such as social workers, nurses, therapists, psychologists and a skilled Medical Director with oversight of all interventions. High quality The driver for social care is an organisation s ability to deliver high quality care, with reliable outcomes at a fair price. We believe that the market has recognised that CareTech offers the best possible balance between quality and value and understands the need for progressive thinking and innovation to deliver ongoing results. 1. Service offer and user needs We have to create and staff a service offering which matches the needs of the service user and can be communicated to commissioners so it is carefully recorded locally at every service in order to reduce the risk of service users moving to other service providers. 2. Quality and safety A health and safety breach would impact reputation, brand and compromise the safety of those in our care. This could impact on the demand for our business as well as incur costs to rectify. We have to provide and deliver safe care of a high quality and the Group utilises Acoura, an independent supplier, to audit and report monthly on Health and Safety matters Page 17 of 20

19 as well as all RIDDORS (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) so that all incidents are recorded and acted upon. 3. Service value The service offer has to be provided to meet the needs of the commissioners at a fair price and this is coming under increased scrutiny as commissioners regularly review value for money so the Group communicates frequently with its commissioners locally. 4. Reputation The Group has to have a reputation for delivering a service that is good value and takes account of all risks. The Group maintains a Risk Register which includes all key risks, including reputational risk, and how they are mitigated through quality of service and good communication with service users and Local Authorities and this Risk Register is reviewed within our Governance framework. 5. Growth funding So that the Group can keep growing adequate funding has to be anticipated and put in place and the Group ensures that all of its facilities are monitored and reviewed regularly, particularly during its Budget and forecasting processes. 6. Manage debt The level of debt obtained to fund operations and ensure that growth can occur has to be carefully managed and the different forms of leasing and debt are reviewed quarterly when all of the covenants are also reviewed. Each division has a dedicated Business Unit Controller. When budgets are set and new developments are planned, this is with full consultation of the Operational and service managers ensuring that the focus on quality is maintained where it matters- on our front line delivery of services. The Board meets on a quarterly basis for Performance review and each Divisional Director collates a board report monthly to ensure that key performance indicators are reviewed and financial performance is maintained. This report summarises all areas of Operational performance including agency, occupancy, compliance, Health and Safety, Safeguarding and also motivates additional support for areas such as Recruitment, Training, Estate management and Quality. Page 18 of 20

20 Policy, Procedures & Information Governance Committee This committee provides governance, oversight and scrutiny to all policies and procedures in place across CareTech Community Services Ltd. The committee meets 6 monthly and additional meetings are held as required. Its aims are: To promote consistency and best practice across all CareTech services through the adherence to up-to-date and best practice policies and procedures To sign off on behalf of the Board and Care Governance Committee the review and update of existing policies and any policy or procedure prior to implementation across the Group. To oversee the introduction of regulatory changes to policies and procedures, for example GDPR across the Group. Meetings are quorate with a minimum of: Chairman or nominated Deputy. One Managing Director or nominated Deputy. Relevant Executive Director if subject of policy/ procedure covers their area of responsibility. Chairman action may be taken to approve any policy with the agreement of a Board Executive Director. Membership: Chairman Director Compliance & Regulation. Head of Compliance & Regulation. Head of Operational Quality (Adults). Head of Quality & Performance (Children). MD or senior representative (all divisions). HR Business Partner. Duties To oversee and quality assure all proposed new policies and procedures and to sign off as fit for purpose prior to introduction across CareTech. To review all new national guidelines / guidance where applicable to CareTech services and to recommend any amendments to existing policy or procedure or commission the production of new policy or procedure. To oversee the implementation of GDPR requirements and Information Governance across CareTech. To provide a forum for discussion, debate and decision on policy & procedure across CareTech. To provide the governance and sign-off process for policies and procedures and to ensure all are reviewed at the scheduled review date. Page 19 of 20

21 To provide assurance to the Board Care Governance Committee on the efficacy and quality impact of all policies and procedures. To oversee the Rezume contract on behalf of the Board. To promote best practice and a culture of continuous learning across CareTech. To make recommendations where appropriate to the Board / Executive on the need for new policy or procedures. To advise and support operational staff on adoption of policies and procedures. To advise the Executive on any recommendations as they apply to policy and procedure that may be made by regulatory bodies. Page 20 of 20