Governance Policy
| Policy area | Governance |
| Document type | Policy |
| Applicable to | Beyondlimits Care & Support Services |
| Version | 001 |
| Date approved | 19/08/2024 |
| Approved by | Managing Director |
| Next review date | Every 12 Months |
| Related policies | Risk Management Policy Emergency and Disaster Management Policy Safeguarding Against Violence, Abuse, Neglect, Exploitation and Discrimination Policy Conflict of Interest Policy Incident Management Policy Client Feedback and Complaints Management Policy Continuous Improvement and Quality Management Policy Covid-19 Response Policy Client Health and Wellbeing Policy Emergency and Disaster Management Policy Duty of Care Policy Diversity Policy Privacy Policy Work Health and Safety Policy Waste Management Policy Human Resource Management Policy Information Management Policy |
| Authority | NDIS Act 2013 NDIS Practice Standards and Quality Indicators NDIS Code of Conduct Aged Care Act 1997 Aged Care Quality and Safety Standards Aged Care Code of Conduct Privacy Act 1988 |
PURPOSE
The purpose of this policy is to explain our organisation’s commitment and approach to maintaining an effective governance framework and processes.
SCOPE
This policy applies to all our workers (employees, contractors and volunteers).
DEFINITIONS
| Term | Definition |
|---|---|
| Antimicrobial Stewardship | The Australian Commission on Safety and Quality in Health Care defines this as the ongoing effort from a health service organisation (led by the board and senior management) to optimise antimicrobial use among patients to improve patient outcomes and reduce antimicrobial resistance. For more on this, see the Infection Management Procedure. |
| Governance | The rules, relationships, systems and processes by which an organisation is directed, controlled and held accountable. |
| Key Personnel | Person or people responsible for the executive decisions of the organisation – in other words those who plan, direct and/or control the activities. For example, directors, board chair, CEO and other senior managers. |
| Mission | An organisation’s core purpose, intention and objectives. |
| Vision | What the organisation hopes to achieve, or become, in the future. |
| Values | Articulates the organisation’s core principles and ethics that guide and direct it. |
CONTEXT
Our organisation recognises the importance of an effective governance framework and processes to ensure safe and quality service delivery and business operations. We will establish a governance framework that:
- is proportionate to the size and scale of our organisation and the scope and complexity of supports provided;
- integrates with effective risk management and compliance processes;
- ensures transparency and safeguards against unethical or unlawful practice;
- has clearly articulated mission, vision and values which are understood across all levels of the organisation;
- ensures clear, consistent and transparent delegations of authority, reporting lines and internal controls;
- maintains effective continuous improvement, quality management, complaints management and incident reporting processes; and
- maintains effective information, financial, human resource and work health and safety management processes.
POLICY STATEMENT
#1
Governance and Compliance Framework
- We will maintain a governance framework that supports compliance with applicable legislation, regulations, standards and our contractual and funding requirements, including maintaining current applicable licences, insurances and registrations.
- Where clinical care is provided, we will implement and maintain a compliant and effective clinical governance framework, including antimicrobial stewardship, minimising the use of restraint and demonstrating open disclosure.
#2
Key Personnel
- Our board/management committee will guide our organisation’s mission, vision and values.
- We will appoint key personnel who are suitably screened, skilled and competent to undertake their role, with clearly defined responsibilities, authority and accountability for the provision of services and supports.
- We will keep key personnel information and contact details up to date in our registration records and notify the relevant regulator if there are any changes to key personnel and/or governance processes.
#3
Policies and Procedures
- We will develop and maintain policies, procedures and processes that are compliant, ethical and consistent with our mission, vision and values.
- We will ensure our documented policies and procedures are current, regularly reviewed, informed by contemporary, evidence-based practices, and are understood and accessible by workers.
- Our policies and procedures guide the way our workers undertake their roles.
#4
Business Planning and Partnerships
- We will undertake business and strategic planning in a spirit of continuous improvement and develop, review, implement, monitor and evaluate business plans, and make adjustments as required to ensure safety and quality of services.
- We will provide opportunities for clients to contribute to the governance of our organisation and partner with them to develop and improve organisational policy and processes in relation to support provision and protection of client rights.
- We will seek to address, through strategies and business planning, service access issues for diverse/special needs groups (e.g. Aboriginal and Torres Strait Islander Peoples, people experiencing homelessness, people living with dementia).
#5
Reviewing and Monitoring Processes
- We will review board and management processes to ensure roles and responsibilities align with mission, vision and strategy.
- We will conduct internal and external audits to ensure integrity of our governance processes and operations and make any required adjustments.
- We will monitor financial investment in priority areas to deliver improved outcomes for clients.
- We will review and revise our policies, procedures, forms and templates to ensure currency, accuracy and compliance.
#6
Information and Record-keeping
- We will ensure information and records are accurate and up to date.
- We will ensure the client has provided us with all required written consents.
- We will store the information securely to ensure privacy, dignity and confidentiality and make sure it is accessible to the client and only other stakeholders authorised to access it.
#7
Worker Training and Supervision
- We will maintain a skilled and trained workforce, which is kind and caring, supports our mission, vision and values and is aware of their responsibility to comply with organisational requirements.
- We will maintain processes to adequately monitor and supervise workers.
SUPPORTING DOCUMENTS
Related procedures and forms include:
- Delegation of Authority Procedure
- Risk Management Procedure
- Emergency and Disaster Management Procedure
- Safeguarding Against Violence, Abuse, Neglect, Exploitation and Discrimination Procedure
- Reportable Incident Management Procedure
- Incident Management Procedure
- Covid-19 Response Procedure
- Diversity Procedure
- Continuous Improvement and Quality Management Procedure
- Client Feedback and Complaints Management Procedure
- Complaint and Feedback Form
- Anonymous Complaint and Feedback Form
- Complaints Process Checklist
- Complaint Register
- Continuous Improvement Procedure
- Continuous Improvement Plan Register
- Service Agreement
- Internal Audit Schedule
- Risk Management Plan Register
- Workforce Management Planning Tool
- Board Meeting Agenda and Minutes
- Business Plan and Strategy Plan
- Conflict of Interest Register
RESPONSIBILITIES
Managing Director is responsible for:
- maintaining this policy, its related procedures and associated documents;
- ensuring the policy is effectively implemented across the service;
- monitoring workers compliance with the requirements of this policy; and
- ensuring training and information is provided to workers to carry out this policy.
All workers are responsible for complying with the requirements of this policy.
COMPLIANCE
Deliberate breaches of this policy will be dealt with under our misconduct provisions, as stated in the Code of Conduct Agreement.
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