CQC Assessment at The Vesey

Domain:

Well Led

Category:

Governance, management and sustainability

Governance, management and sustainability

There is an inclusive and positive culture of continuous learning and improvement. This is based on meeting the needs of people who use services and wider communities, and all leaders and staff share this. Leaders proactively support staff and collaborate with partners to deliver care that is safe, integrated, person-centred and sustainable, and to reduce inequalities.

There are effective governance and management systems. Information about risks, performance and outcomes is used effectively to improve care.

Governance, management and sustainability

Our Evidence:

Governance, management and sustainability

We organise our corporate meeting schedule as follows, with structured agenda's:

April - Annual General Meeting

  1. WELCOME (15min)
    1.1 Chair’s Introduction and Apologies
  2. MINUTES OF LAST MEETING AND ACTION LOG (15min)
    2.1 Approve minutes of previous meeting
    2.2 Action Log
  3. YEARLY PERFORMANCE STATISTICS (1hr)
    3.1 Performance
    3.2 Areas of Improvement
    3.3 Actions
  4. YEARLY FINANCE STATISTICS (1hr)
    4.1 Performance
    4.2 Areas of Improvement
    4.3 Actions
  5. SAFE (1hr)
    5.1 Performance
    5.2 Areas of Improvement
    5.3 Actions
  6. EFFECTIVE (1hr)
    6.1 Performance
    6.2 Areas of Improvement
    6.3 Actions
  7. RESPONSIVE (1hr)
    7.1 Performance
    7.2 Areas of Improvement
    7.3 Actions
  8. WELL-LED(1hr)
    8.1 Performance
    8.2 Areas of Improvement
    8.3 Actions
  9. CARING (1hr)
    9.1 Performance
    9.2 Areas of Improvement
    9.3 Actions
  10. STRATEGY (1hr)
    10.1 Vision
    10.2 Aims
    10.3 Goals


Quarterly - Medical Advisory Committee

The Vesey has a Medical Advisory Committee (MAC) to ensure we achieve and maintain medical excellence across all our services.

Medical Practitioners at The Vesey are appointed to the MAC, which offers guidance and advice on all areas of clinical practice and meets at regular quarterly intervals through the course of the year. The MAC has a robust clinical governance strategy with appointed leads for clinical governance and clinical audit. This ensures robust controls are always in place for the quality and effectiveness of care we deliver.

Our Medical director and our head of governance and audit is Mr Gunaratnam Shyamalan

We believe this closely joined governance and reporting structure ensures clinical safety is maintained across all our services.

Monthly 28th - Staff Meeting

  1. WELCOME (5min)
    1.1 Chair’s Introduction and Apologies
  2. MINUTES OF LAST MEETING AND ACTION LOG (5min)
    2.1 Approve minutes of previous meeting
    2.2 Action Log
  3. MONTHLY PERFORMANCE STATISTICS (10min)
  4. STAFF FORUM (20min)
    4.1 Issues
    4.2 Discussion
    4.3 Action
  5. PATIENTS (20min)
    5.1 Complaints
    5.2 Feedback
    5.3 Incidents
  6. PEOPLE (5min)
    6.1 New starters
    6.2 Leavers
    6.3 Soft intelligence
  7. SERVICES (20min)
    7.1 Service Review
    7.2 Equipment review
    7.3 New equipment requests - Capital
  8. CLOSING MATTERS (5min)
    8.1 Items to escalate to directors.
    8.2 Any Other Business
    8.3 Date and time of next meeting:


Weekly - Senior Management Meeting [Directors only]

  1. WELCOME (5min)
  2. MINUTES OF LAST MEETING AND ACTION LOG (5min)
    2.1 Approve minutes of previous meeting
    2.2 Action Log
  3. PERFORMANCE STATISTICS (10min)
    3.1 Approve minutes of previous meeting
  4. WORKFORCE (10min)
    4.1 Issues
    4.2 Discussion
    4.3 Action
  5. PATIENTS (10min)
    5.1 Complaints
    5.2 Feedback
    5.3 Incidents
  6. PEOPLE (10min)
    6.1 New starters
    6.2 Leavers
    6.3 Soft intelligence
  7. SERVICES (10min)
    7.1 Service Review
    7.2 Equipment review
    7.3 New equipment requests - Capital
  8. PRIVATE SESSION (60min)
    8.1 Discussion of Confidential Business matters.
  9. CLOSING MATTERS (5min)
    9.1 Items to escalate to directors.
    9.2 Any Other Business
    9.3 Date and time of next meeting:

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Relevant review:

Governance, management and sustainability
Our thoughts: