Regulation 17: Good governance

Page last updated: 11 August 2023
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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.—

  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—
    1. 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);
    2. 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;
    3. 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;
    4. maintain securely such other records as are necessary to be kept in relation to—
      1. persons employed in the carrying on of the regulated activity, and
      2. the management of the regulated activity;
    5. 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;
    6. 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 and by no later than 28 days beginning on the day after receipt of the request—
    1. 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
    2. 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

This sets out the guidance providers must have regard to against the relevant component of the regulation.

17(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.

17(2) Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to—

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);

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;

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;

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;

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;

17(2)(f) evaluate and improve their practice in respect of the processing of the information referred to in sub-paragraphs (a) to (e).

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—-

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.