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  7. Standard 2 Governance & Regulatory Processes

2.4a Ask your line manager(s) what regulation and inspection processes your organisation might be subject to and complete the following exercise.

 

Regulation ProcessWho is involvedImpact on organisationFrequencyInformation/evidence required
e.g. RIDDOR – Reporting of injuries, diseases and dangerous occurrences regulations 2013
  • Employers
  • Registered Managers
  • Line Managers
  • Employers
  • Registered Managers
  • Line Managers
As and when incidents happen according to the RIDDOR regulationsOrganisations policy

RIDDOR reports needed

Accident book

CQC Inspection
  • Registered Manager
  • Line Managers
  • Employers
  • Employees
Benchmark how we are doing and how we can improveInfrequent but to be expected at any timeSpeaking with clients and staff

Viewing policies and procedures

Viewing other records

Internal Quality Assurance
  • Compliance Manager
  • Line Managers
Ensure we are providing support correctly and to a high standard

Highlight any areas that require improvement

Every 3-6 monthsCompliance checklist

Policies and procedures

Other records

2.2b KLOEs: Outline what each question might mean for your setting. Think about areas where this might apply and what evidence you may be able to provide for that. You may want to work with other members of your team or your line manager to review this plan and consider what evidence might be helpful.

 

Key lines of enquiry
AreaApplication in own settingEvidence
SafeClients are protected from avoidable harm and injury? Clients are safeguarded from abuse.   Accident book, property maintenance log, recorded smoke alarm, carbon monoxide and electrical safety tests, safeguarding policy, staff safeguarding training
EffectiveClients have a good quality of life and achieve good outcomes.      Speaking with clients, daily records, activity planner, meal planner, MAR sheets, support plans, well-trained staff
CaringClients are treated with compassion, kindness, dignity and respect.     Speaking to clients, observations, well-trained staff, policies and procedures, risk assessments, support plans  
ResponsiveClients needs are met and support is well-organised and flexible.Shifts based on client needs and wishes, client is able to go on regular holidays and other activities they wish to do, dialogue between staff and clients on their requirements, shifts can be changed when required, procedures and policies that provide support to staff for emergencies or unforeseen circumstances
Well ledGood leadership and management. A learning culture.   Staff training and personal development, organisational charts (hierarchy), regular supervision, appraisal, observations and professional discussions, honesty and transparency, company policies and procedures.

2.2a Ask your line manager if you can put together an action plan against one of the fundamental standards where you both agree that improvement is needed. Considering standard 1, how will you lead change/inspire your colleagues – what leadership style(s) will you consider using and what procedures and audit tools will you use to monitor/manage compliance.

Take a look at CQC’s Fundamental Standards here.

In brief, they are:

  • Person-centred care
  • Dignity & respect
  • Consent
  • Safety
  • Safeguarding from abuse
  • Food & drink
  • Premises & equipment
  • Complaints
  • Good governance
  • Staffing
  • Fit & proper staff
  • Duty of candour
  • Display of ratings
Fundamental standardDignity & Respect     
IssuesWhen a client gets upset he likes to go to his bedroom for some quiet time to calm down. He has complained that support staff constantly disturb him to ask him how he is and if he wants anything, which aggravates him further, despite him telling them that he wants to be left alone.

There is no valid reason to disturb him if he wants to be left alone and staff should respect his privacy whenever he wants it. There is also no associated risk with him being left alone.

Speaking to staff, the reasons for their actions are to try to help the individual and because they are worried about him when he is upset.

How will you inspire colleagues?During the next team meeting, the manager will raise the concerns of the client. Staff will discuss privacy, respect and choice. They will be asked to think about what it would be like to have constant support whether they want it or not and how it would feel to not be able to experience alone time without someone disturbing them regularly.     
Leadership style(s) to useDemocratic and coaching     
How will you monitor compliance?Weekly dialogue between client and manager to discuss the issue.

Client to keep a record of any disturbances to his alone time, including date, time, staff member, reason for disturbance etc. to be given to manager weekly.    

Audit tools required

 

 

Record sheet for client     

 

2.1b Choose one key piece of legislation or driver that’s relevant to your organisation and do a brief overview that could be shared with others in your organisation to enhance their learning.

 

Name of legislationMental Capacity Act 2005   
Summary of key areasCapacity should be assumed until proven otherwise.

An individual cannot be said to lack capacity until all reasonable steps to support them to make a decision have been tried.

Making unwise decisions does not mean lack of capacity.

Decisions made on behalf of an individual must be done in their best interests.

Before a decision is made about an individual, the situation must be reviewed to check that the results cannot be achieved in a less restrictive way.

Relevance to your organisation/settingSome clients may lack capacity to make decisions in certain areas.  
What it means for your team/organisationRead Care Plans!

Assume clients have the capacity to make a decision unless it is documented that they cannot.

Actions needed to be taken by members of your team/organisationIf in doubt about a client’s capacity to makes a decision, this should be raised with senior staff or management.

Staff should support clients to make informed decisions where they have been deemed to have capacity.    

Who else might need to know about this legislation – people who access care and support/carers?Clients

Client’s family and friends

Other professionals     

Who else does the legislation apply to?Everybody    

2.1a Choose three pieces of legislation that might be particularly relevant to your organisation and the setting in which you work and explore the impact in more detail

Consider the following list of legislation taken from the CQC website page referenced above. Choose three pieces of legislation that might be particularly relevant to your organisation and the setting in which you work and explore the impact in more detail using the table to record your findings.

 

LegislationRelevant sectionsMust haveNice to know
 Safeguarding Vulnerable Groups Act 2006 AllAll staff (both paid and unpaid) must have a DBS check. This is a legal responsibility of the employer. There are two types of DBS check – one for working with vulnerable adults and another for working with children.
 Equality Act 2010 AllAll staff must be treated equitably and given the same opportunities.The Equality Act supercedes several other pieces of legislation including the Disability Discrimination Act, Equal Pay Act, Sex Discrimination Act etc.
 MCA Code of Practice AllIndividuals should be assumed to have capacity to make decisions unless it has been proved otherwise. Making unwise decisions does not mean lack of capacity,Individuals must be assessed on a decision-by-decision basis. Individuals should be given all the support they need to make informed decisions before being assessed as lacking capacity.