Clinical Governance Policy

The Warren Neurodiversity Service Clinical Governance Policy February 2025.pdf

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Revised February 2025 for review February 2026

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1. Introduction This policy sets out The Warren Neurodiversity Service's approach to clinical governance. Clinical governance refers to the structures, processes, and culture in place to ensure high standards of care, continuous improvement, and accountability throughout the organisation.

This policy applies to all members of the team, including clinical, administrative, and support staff.

2. Governance Leadership Structure

• Executive Director: Edward Goredema – Responsible for strategic leadership, compliance, and resource allocation.

• Clinical Director: Dr Yann Welton – Leads on clinical safety, evidence-based practice, and service-wide clinical accountability.

• Operational and Clinical Governance Lead: Lee Barrett – Oversees day-to-day operations and implements governance strategy at service level.

All staff report through this framework, ensuring effective clinical oversight and accountability from board level to frontline delivery.

3. Clinical Accountability and Governance Processes

3.1 Clinical Audit and Review

• Monthly clinical audits aligned with national guidance, incident reviews, or newly commissioned therapies.

• Findings are reviewed in multidisciplinary meetings.

• Focus areas include safeguarding, prescribing, patient outcomes, and record keeping.

• Audits feed into the organisation's Quality Improvement Register, which documents findings, actions, and outcomes.

3.2 Risk Management

• Risk is managed through proactive assessment and incident reporting via a no blame Significant Event Toolkit.

• Annual risk assessments, plus additional reviews after incidents.

• Findings are discussed in policy and clinical review meetings.

3.3 Policy Compliance Core policies include:

• Infection Control

• Safeguarding (Children and Adults)

• Consent

• Confidentiality

• Chaperone Policy

All staff receive training on these, with annual updates and compliance monitored via in ternal audit.

3.4 Patient Involvement and Feedback

• Feedback mechanisms: surveys, suggestion boxes, complaints forms.

• Reviewed quarterly by the Clinical Governance Lead.

• Feedback outcomes shared with staff and service users.

• Annual summary report shared with commissioners and Patient Participation Group (PPG). 3.5 Professional Development

• Clinicians: funded CPD, protected study time, annual appraisals.

• Non-clinical staff: access to role-specific training.

• All staff maintain a personal development log.

3.6 Evidence-Based Practice

• All clinical care is aligned with NICE guidance and ICB pathways.

• Regular review of published evidence and policy changes.

3.7 Strategic Capacity

• A rolling three-year strategic plan guides service delivery.

• Reviewed annually by the Executive and Clinical Directors.

• Shared with staff and updated in governance meetings.

4. Learning and Quality Improvement

We promote a learning culture that informs service development:

• Quality Improvement Log maintained by Lee Barrett.

• Example: 2024 safeguarding audit led to standardised documentation and training updates.

• Example: patient feedback in 2023 prompted appointment of a patient liaison officer. These examples are reviewed annually in a formal Quality Impact Report shared with stakeholders.

5. Digital and Information Governance

• Data protection is aligned with the NHS Data Security and Protection Toolkit.

• Systems are DTAC-compliant and allow for clinical audit, performance monitoring, and secure record-keeping.

• All staff are trained on information governance and confidentiality.

6. Reporting and External Assurance

• Governance outcomes (audit results, complaints themes, QI outcomes) are re ported quarterly to: o Internal clinical board o ICB contract monitoring team o Patient Participation Group (PPG)

• Annual Governance Summary shared with commissioners and included in CQC preparation materials.

7. Implementation and Oversight

Lee Barrett, as Clinical Governance Lead, is responsible for:

• Promoting a culture of safety and quality

• Reviewing incidents and audits

• Maintaining the Quality Improvement Register

• Ensuring staff training and policy compliance The leadership team meets monthly to review governance outcomes and identify areas for enhancement.

Approved by:

Edward Goredema, Executive Director

Date: February 2025