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Clinical Governance


 Clinical Governance


It is a framework through which this organisation is accountable for continuously improving the quality of our service. Ensuring safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.


Clinical Governance describes a systematic approach to monitoring and improving the quality, safety and effectiveness of clinical interventions.


The key elements of Clinical Governance are:


  • Framework – the various activities included in clinical governance are set within a framework that enables assurance for all aspects of clinical activity in a comprehensive and systematic way.


  • Accountability – We have a statutory duty to assure ourselves on the quality of care we provide.  Our regulatory authority, the Commission for Social Care Inspection (CSCI) ensures our accountability for clinical governance.


  • Quality – our clinical governance alcohol  detox aims to ensure that treatment is safe, evidence-based, cost effective, available and accessible.  Also that it delivers the best possible service user experience.


  • Environment – in which we can all openly and honestly examine our own practices and take responsibility for changes to improvement our environment.


What is Clinical Governance in relation to Serenity Health?


At Serenity Health, we utilise the ‘seven pillars’ model which was developed by the Commission for Health Inspection.  The seven pillars are:


  • Risk Management.
  • Clinical Effectiveness.
  • Education, training and continuing personal and professional development.
  • Use of Information.
  • Staffing and Staff Management.
  • Clinical Audit.
  • Service User (client) involvement.




How do we ensure good Clinical Governance at Serenity Health



  1. By adhering to the National Care Standards (2000) and undertaking regular inspections from our regulating authority, the Commission for Social Care Inspection (CSCI).


  1. By regularly reviewing our policies and procedures, updating and re-writing them as necessary on an annual basis.


  1. By providing interventions in line with the latest evidence-based treatment, taking into account evidence from authoritative research such as NICE Guidelines and the Drug Misuse and Dependence UK Guidelines on Clinical Management (2007).


  1. By collating data which will provide the evidence needed for assuring that standards are being met. Data such as NDTMS and TOPs, Client surveys, including detoxification surveys.  Prescribing data and audit of medications used, case notes, staff training records and appraisal records.


  1. By holding regular meetings with senior managers and middle managers which will review retentions, planned discharges, and unplanned discharges to review the systems we have in place currently and to check on their effectiveness.


  1. By providing staff training in areas pertinent to working with substance misusers and checking regularly if the training provided is effective and beneficial to staff.


  1. By regular contact with service purchasers to check on satisfaction, value for money and retention rates to see if any improvements can be made.


  1. By regular meetings with senior management to check on the services we provide and if these are meeting the needs of the substance misuse community as a whole and if not, what changes we need to make to ensure that our service is more accessible.


  1. By working within the Investors in People framework to provide good quality training and educational opportunities for all grades of staff.





Clinical Governance

Prepared by: 

The Management Team

Issue/review date:

January 2018

Review date:   

January 2019


Approved Rachael Ball – Care Home Manager


January 28, 2018


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