Quality, Governance & Compliance

At Cartwright Care Ltd, we clearly recognise the need for Quality within our services in all that we say and all that we do and firmly believe that this can only be achieved by employing the right people and that we provides a framework for continuous measuring, monitoring and improving our performance,

Governance “Is a framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical and nursing care and support will continually improve and flourish”.

Our principles of governance underpin and direct the clinical, operational and corporate objectives of Cartwright Care and our recognisably high standard of service delivery.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 PART 3, SECTION 2, Regulation 17 makes specific reference to Good Governance, The Act describes Good Governance as services having the ability to demonstrate the following:

(1)  Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.
(2)  Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to—
(a)assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services);
(b)assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity;
(c)maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided;
(d)maintain securely such other records as are necessary to be kept in relation to— (i)persons employed in the carrying on of the regulated activity, and
(ii)the management of the regulated activity;
(e)seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services;
(f)evaluate and improve their practice in respect of the processing of the information referred to in sub-paragraphs (a) to (e).
(3)  The registered person must send to the Commission, when requested to do so (a)a written report setting out how, and the extent to which, in the opinion of the
registered person, the requirements of paragraph (2)(a) and (b) are being complied
with, and
(b)any plans that the registered person has for improving the standard of the services provided to service users with a view to ensuring their health and welfare.

While Regulation 17 makes specific reference to Good Governance, having adequate and robust systems in place across services is vital to be demonstrated across all Regulations to ensure and support the need to adequately Assess and Monitor the Quality of Service that each person within any provision should benefit from. This includes their individual safety, quality care, treatment and support, effective decision making and the management of risks to their health, welfare and safety.
To demonstrate ‘Good Governance’ and comply with these regulations, we have our own Quality and Governance systems as follows:

What We Have in Place?

•         Robust pre-admission assessment/admissions processes.
•         Plans for care and support.
•         Systems for the involvement of the individual, their families / carers and Care Commissioners.
•         Individuals being supported to lead and be involved in the management of their care.
•         Record keeping on the care provided enabling effective care delivery and care practice evaluation.
•         Staff delivering the care being recruited in a manner that reflects best practice as described within HR policies and procedures.
•         Staff being assessed to have the right skills and knowledge for the role they are recruited to undertake.
•         Staff engaging in and having available effective supervision, support and on-going training which reflects the needs of individuals being supported / cared for.
•         Monitoring being in place to ensure adequate staffing arrangements are maintained and reflective of effective recruitment and retention of quality staff.

Our Management Systems

•         Monthly Staffing / Management Meetings
•         Care / Governance, Governance Meetings to be held monthly with specific terms of reference
•         Corporate Governance Meetings to be held quarterly again with specific terms of reference
•         Health and Safety information is incorporated into both Staff and Care / Clinical Governance meetings to be held monthly – information from these meetings will be summarised for submission to the Corporate Governance Meeting
•         All of our residents and their respective family members will have the opportunity to take part in feedback opportunities and surveys and receive appropriate feedback

Information Management

·         We routinely collect data and information information to support learning and service / organisational development.
•         The above to impact on care / support delivery to each service user.
•         The data we collect is able to evidence and demonstrate that service users are receiving care that is relevant, beneficial to them and effective.

How Do We Achieve This?

The Care Quality / Governance Plan for each of our homes is based on seven key principle standards as its operating structure. Each domain provides information relating to standards, processes and procedures that must be in place to ensure that service delivery is being managed effectively.

First domain – Care Effectiveness & Research

•         It builds on care audits and quality improvement and provides a framework for linking research, implementation and evaluation in practice” …..It is “about doing the right thing in the right way for the right person at the right time”.

Second domain – Audit

•         Audit is a quality improvement process that seeks to improve care / support and outcomes through systematic review of care against explicit criteria and the implementation of change to achieve the desired and required level of service.

Third Domain – Managerial / Risk Management

•         Risk Management is about Identifying, assessing, analysing, understanding and acting on risk issues to reach an optimal balance of risk taking, the benefit and outcomes.
•         Each of our homes has effective systems for management and leadership of their teams and adopt our governance framework

Fourth Domain – Education & Training

•         This is about the education and training we may already provide or may need to provide to individuals or collective groups of staff and allows feedback relating to all training available and its delivery.
•         Within this area planning can take place relating to future training requirements and needs which will help ensure that staff have the necessary skills and qualifications to respond to changing residents needs.

Fifth Domain – Service User & Public Involvement

•         We actively engage with and involve all of our residents and members of the ocal community in shaping the development of the care and support we provide and actively provide feedback accordingly.
•         This is also about giving people the chance to get involved in improving services by offering their views and making recommendations for changes in the future.

Sixth Domain – Using Information & Information Technology

•         This is about the way we can use technology to access information that may inform our policy, practice and service delivery in support of our development, inclusion and engagement with wider audiences.
•         This area also includes the control of information and safeguards we must have in place to protect sensitive and confidential information relating to the home, its staff and each and every resident.

Seventh Domain – Staffing and Staff Management

This is about having the right staff in the right quantity and of the right quality in place at the right times. It also considers staff delivering the care being recruited in a manner that reflects best practice as described within Regulatory Requirements, our HR policies and procedures, staff being assessed to have the right skills and knowledge for the role they are recruited to undertake and staff engaging in and having available effective supervision, support and training.
•         This area also includes reporting on the monitoring systems in place which support the management of sickness absence or any poor parctice issues that may crop up from time to time allowing for swift resolution and and to ensure effective retention of quality staff.


Each Home has a Registered Manager in post. It is the responsibility of the Registered Manager to ensure that this minimum quality criteria is in place. All services to be delivered must be compliant with the Care Standards Act 2008 updated 2014 and the terms of their regulated activity.

Policies can we add download links?
Duty Of Candour