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Regulation 17: Good governance
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17
The intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice.
In addition, providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity.
As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement.
When requested, providers must provide a written report to CQC setting out how they assess, monitor, and where required, improve the quality and safety of their services.
CQC can prosecute for a breach of part of this regulation (17(3)) if a provider fails to submit such a report when requested. CQC may consider that this failure could prevent the provider from taking appropriate, timely action. CQC could therefore move directly to prosecution for a breach of this part of the regulation without first serving a Warning Notice.
Regulatory action can be taken for other parts of the regulation. See the offences section for more detail.
CQC must refuse registration if providers cannot satisfy us that they can and will continue to comply with this regulation.
The regulation in full
17.—
- Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.
- Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to—
- 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);
- 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;
- 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;
- maintain securely such other records as are necessary to be kept in relation to—
- persons employed in the carrying on of the regulated activity, and
- the management of the regulated activity;
- 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;
- evaluate and improve their practice in respect of the processing of the information referred to in sub-paragraphs (a) to (e).
- The registered person must send to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request—
- 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
- 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.
Guidance
Component of the regulation |
Providers must have regard to the following guidance |
17(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. |
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17(2) Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to— |
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17(2)(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); |
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17(2)(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; |
Note: In this regulation, 'others' includes anyone who may be put at risk through the carrying on of a regulated activity, such as staff, visitors, tradespeople or students. |
17(2)(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; |
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17(2)(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; |
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17(2)(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; |
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17(2)(f) evaluate and improve their practice in respect of the processing of the information referred to in sub-paragraphs (a) to (e). |
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17(3) The registered person must send to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request—- |
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17(3)(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 17(3)(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. |
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Related legislation
Control of Substances hazardous to Health regulations 2002
The Electricity at Work regulations 1989
Freedom of Information Act 2000
The Gas Safety (Installation and Use) regulations 1998
The General Data Protection Regulation
The Hazardous Waste (England and Wales) Regulations 2005
Health Professional Council – legal framework
Health and Safety at Work etc. Act 1974
The Ionising Radiations Regulations 1999
The Ionising Radiation (Medical Exposure) Regulations 2000
Management of Health and Safety at Work Regulations 1999
The Manual Handling Operations Regulations 1992
The Health and Safety (Miscellaneous Amendments) 2002
The Medical Devices Regulations 2002
The Medical Devices (Amendment) Regulations 2012
Mental Capacity Act Code of Practice
Code of Practice (Mental Health Act 1983)
The Regulatory Reform (Fire Safety) Order 2005
Safeguarding Vulnerable Groups Act 2006
The Workplace (Health, Safety and Welfare) Regulations 1992
The Health and Safety (Miscellaneous Amendments) Regulations 2002
Related guidance
Buildings/premises and equipment
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DH health building notes (Department of Health)
Electrical safety and you (Health and Safety Executive)
Electrical safety at work (Health and Safety Executive)
Gas safety toolbox (Health and Safety Executive)
Lighting at work (Health and Safety Executive)
PAT - Portable appliance testing FAQs (Health and Safety Executive)
Safe premises (Health and Safety Executive)
Health technical memoranda series (Department of Health)
Policies and principles of healthcare engineering (HTM 00) (Department of Health, 2014)
Domestic gas health and safety (Health and Safety Executive)
DSDC Good practice guidelines on lighting (Stirling Dementia Service Development Centre)
Health technical memoranda series (Department of Health)
Policies and principles of healthcare engineering (HTM 00) (Department of Health, 2014)
Care, treatment and support
Adult social care outcomes framework 2015/16 (Department of Health)
Complaints
Ombudsman decisions: adult care services (Local Government and Social Care Ombudsman)
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The prep handbook (Nursing and Midwifery Council)
Nursing standards for competence (Nursing and Midwifery Council)
Midwives rules and standards 2012 (Nursing and Midwifery Council)
Midwives rules and standards 2012 (Nursing and Midwifery Council)
Confidentiality
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Confidentiality: NHS Code of Practice (Department of Health, 2003)
Confidentiality: NHS Code of Practice (Department of Health, 2003)
Continuing professional development
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Standards for continuing professional development (Health and Care Professions Council)
COSHH
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Control of Substances Hazardous to Health (COSHH) (Health and Safety Executive)
Data protection
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Data Protection Act 2018: guidance
ICO guidance on data protection (Information Commissioner's Office)
Information governance and Caldicott principles (Department of Health)
Deprivation of liberty
Equality and human rights
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Eemployment statutory Code of Practice (Equality and Human Rights Commission)
Guidance about age discrimination (Equality and Human Rights Commission)
A refreshed equality delivery system for the NHS (NHS England, 2013)
A refreshed equality delivery system for the NHS (NHS England, 2013)
General resource
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National Institute for Health and Care Excellence (NICE)
NHS Constitution for England 2013
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Guidance for health and social care services (Health and Safety Executive)
Health and safety in care homes (Health and Safety Executive, June 2014)
Natural rubber latex sensitisation in health and social care (Health and Safety Executive)
NHS Employers: Workplace health and safety standards
Selection latex gloves (Health and Safety Executive)
Sharp Instruments in Healthcare Regulations 2013 (Health and Safety Executive)
Sharps injuries (Health and Safety Executive)
Infection control/cleanliness
Mental capacity
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Mental Capacity Act 2005 Code of Practice
Mental Capacity Act resources (Social Care Institute for Excellence)
Mental health
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Code of Practice: Mental Health Act 1983 (Department of Health)
Moving and handling
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Hoisting (Health and Safety Executive)
Moving and handling in health and social care (Health and Safety Executive)
Into practice guide (National Institute for Health and Care Excellence)
NHS England Accessible Information
Prevention of future death reports (previously Rule 43 reports) by the Chief Coroner
Professional Standards Authority
Quality Outcomes Framework (QOF) resources (National Institute for Health and Care Excellence)
General Dental Council legal framework
Records
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Records Management Code of Practice for Health and Social Care 2016
Safety
Health care professionals Alerts Notices Directions 2006 (Department of Health)
Staff support and training
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Resuscitation Guidelines 2010 (Resuscitation Council UK)
Developing skills and services resources (Social Care Institute for Excellence)
National Minimum Data Set for Social Care (NMDS-SC) (Skills for Care)
Staffing and recruitment
- Last updated:
- 23 May 2019