Governance & Quality Assurance Policy

What is a quality assurance policy in a care home?

A quality assurance policy sets out how a care home checks, monitors and improves the quality and safety of its care. It names who is responsible for each part and shows how the provider stays in control. The law behind it is regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which calls this good governance. CQC lists governance and quality assurance policies among the documents it expects when you register.

This template is written for care homes, with or without nursing.

What the policy covers

• Duties for the Registered Manager, care staff and the provider, including the nominated individual (the person named to CQC as responsible for supervising how the service is managed)

• A governance meeting at a frequency you set, with minutes that record decisions, owners and deadlines

• An audit timetable split into daily, weekly, monthly, quarterly and yearly checks

• How audit findings become actions on one service improvement plan

• The notifications the home must send CQC, with the time limits for each

• Rules for showing your CQC rating at the home and on your website

The audit timetable

Daily checks include handover, a walk round the home and a look at medicines records for gaps. Most checks are monthly. They cover medicines, infection control, care plans, falls, weight loss, pressure ulcers, the safeguarding and complaints logs, and a tracker for deprivation of liberty applications. Once a year the home surveys residents, families, staff and visiting professionals, and reviews its statement of purpose and fire risk assessment.

Each audit has an action plan, and each action has an owner and a date that the provider checks at its visits and governance meetings. If a check finds a risk to someone's safety, the manager acts the same day.

Before you use this quality assurance policy

Start with the gaps. Add your own meeting dates, audit tools and the names of the people in each role, and set how often the provider visits. Then hold the timetable up against what your home does now, because CQC warns that a third-party template must suit your service type. The manager looks at the timetable again at six months to check it still fits the home. The policy itself is due for review after 12 months, or sooner if the law, CQC guidance or the service changes.

The weekly fire checks in the timetable follow your Fire Safety Policy & Procedure, and the yearly review covers your Statement of Purpose. Home care services should use the Governance & Quality Assurance Policy (Dom Care) instead.