Governance & Assurance

Governance is the process by which organisations ensure that decision-making is effective, risk is managed and that there are appropriate systems in place to support and drive improvement to the quality of care and services they deliver.

Assurance is having appropriate systems and policies in place that can be monitored to ensure that organisations meet relevant statutory requirements and national guidance.

As former healthcare regulation lawyers, our governance and assurance team has over 35 years’ combined legal experience advising the health and social care sector on risk and compliance. We are uniquely placed to support providers in identifying regulatory risks, compliance gaps and governance shortfalls, and can craft solutions to deliver board assurance.

At ibex gale, all the work we undertake for clients is impartial, objective, and of the highest professional standards.

Everything we do is underpinned by our commitments to combining professional rigour with compassion, being fully invested in an organisation’s culture and people, and enabling progress and positive change.

Whistleblowing/ Freedom to Speak Up is the process through which a worker raises a concern with someone in authority – internally and/ or externally (for example to regulators, MPs, or the media) – about wrongdoing, risk or malpractice that affects others.

We conduct independent investigations in response to these disclosures. We can assist by identifying patient safety and service failure concerns; assist organisations to take swift action to address systemic deficiencies or concerns regarding a health professional’s conduct and/ or capability; and support an open and transparent culture where individuals feel empowered and able to raise concerns.

We provide clear, and actionable recommendations to facilitate and develop board assurance.

A ‘Patient Safety’ incident is ‘any unintended or unexpected incident which could have, or did, lead to harm, for one or more patients receiving healthcare’ (NHS England).

The core purpose of a Patient Safety Incident Investigation is to learn from mistakes and to take action to keep patients safe.

A Patient Safety Incident Investigation led by an external and independent investigator can provide valuable oversight and assessment of how an organisation’s practices and systems may have contributed to a Patient Safety Incident and what improvement actions can be taken to ensure high quality and safe patient care.

MHPS and UPSW are national frameworks which govern the approach and management of conduct and capability concerns about doctors and dentists in the NHS. The outcomes from a MHPS/UPSW investigation are wide-ranging and can include disciplinary action being taken by the Trust/Health Board and referrals being made to a practitioner’s regulator.

We are experienced and independent MHPS/UPSW case investigators, who undertake complex and challenging investigations, which often involve senior and board level members of staff in England and Wales.

When concerns are raised about a director or individuals performing functions equivalent to the functions of a board director, a provider must carry out a sufficiently thorough investigation to enable it to reach a decision as to whether the director or equivalent meets the Fit and Proper Person requirements.

CQC’s guidance about these requirements highlight the fact that it may be appropriate for this investigation to be undertaken by an external, independent decision maker, and we can support with such investigations as well as providing assistance with any compliance issues identified by CQC.

Information Governance investigation

We assist organisations to investigate and respond to data breaches. We help clients to navigate reporting requirements, communicate with the Information Commissioner’s Office, and if necessary, the data subject(s) concerned.

We work closely with organisations to produce thematic reviews to identify trends and areas of risk. This data is then used to produce recommendations to ensure compliance with UK data protection legislation and associated guidance.

Information governance reviews

Ensuring you have robust information governance policies and procedures in place is an essential part of regulatory compliance and will assist to reduce the reputational risks associated with data breaches. We provide expert regulatory analysis of information governance practices including review of policies and procedures, and data protection training and guidance for staff.

Working closely with organisations, we identify potential areas of non-compliance with data protection legislation in order to develop practical recommendations to reduce risk and improve efficiency and working practices within the organisation.

We work with organisations supporting the establishment and development of good clinical governance across the wider organisation to ensure visibility from ‘ward to board’. Our methodology for data gathering includes interviews, document review and analysis, listening groups and surveys.

Our reviews include consideration of board awareness of quality and safety issues, effectiveness of quality and safety committees and sub-groups, effectiveness of quality and safety reporting structures within the organisation, and compliance with the regulatory framework and internal procedures and policies.

We will work closely with you in relation to the outcomes of the review, and support the implementation of any recommendations.

We work closely with our Organisational Culture specialists to provide expert regulatory analysis and assessment following the completion of in-depth culture reviews.

We analyse the findings from a culture review and identify any potential risks of non-compliance with an organisation’s CQC regulatory requirements and healthcare practitioners’ professional obligations.

Our analysis includes an assessment of the potential impact of the findings on CQC’s rating of the relevant service and/ or wider organisation, together with tangible actions for the client to take to mitigate the risks of rating downgrades.

Well-led is defined by the CQC as ‘the leadership, management and governance of the organisation assures the delivery of high quality, person-centred care, supports learning and innovation, and promotes an open and fair culture.

Demonstrating to the CQC that your organisation is ‘Well-led’ will increase the CQCʼs confidence in you as provider and is the route to obtaining ʻGoodʼ and ʻOutstandingʼ inspection ratings.

The key to maximising an organisation’s chances of obtaining a positive rating in the ‘Well-led’ domain is to ensure that relevant team members who are likely to be interviewed by the CQC are thoroughly prepared and knowledgeable regarding the issues facing the organisation.

We can assist with this by:-

• Delivering board/senior management level training on ‘Well-led’ including what to expect at a CQC inspection and key areas of concern/focus for the CQC.

• Mock ‘Well-led’ interviews with senior individuals who are likely to be interviewed by the CQC.

• ‘Well-led’ compliance/gap analysis report based upon the outcomes of the ‘Well-led’ interviews, with reference to the CQCʼs ‘Well-led’ assessment framework.

• Production of a quick reference well-led handbook containing the key information that the CQC will expect leaders to know about their organisation.

We have significant experience in undertaking and project managing comprehensive regulatory due diligence exercises on mergers, acquisitions, and sales of health and social care businesses and producing regulatory due diligence reports highlighting key areas of health or social care regulatory risk for UK and international clients.

We can offer a stand-alone regulatory due diligence service or work alongside your corporate legal team to input our specialist health and social care regulatory expertise into the wider due diligence exercise. We can also support UK and overseas public and private health and social care organisations on the regulatory implications of acquiring or selling health or social care businesses in the UK.

The cost of your project depends on a number of factors including the size and complexity of issues involved. In advance of a project starting, you will be provided with a project plan which includes a breakdown of our costs, and you will be regularly updated both in terms of progress, and costs incurred.

We would be happy to discuss this further with you. Please use our ‘Contact Us’ page and complete the Contact form and a member of our team will get in touch.

Your main point of contact will be one of our specialist governance and assurance team. As former healthcare regulation lawyers, our team has over 35 years’ combined legal experience advising the health and social care sector on risk and compliance. We are uniquely placed to support providers in identifying regulatory risks, compliance gaps and governance shortfalls, and crafting solutions to deliver board assurance.

Your project will be overseen by one of our highly experienced Associate Directors or Directors at ibex gale.

At ibex gale, we monitor the quality of our governance and assurance reviews with:

– A supervision system, whereby a supervisor is assigned to all projects to support the team member(s) carrying out the work and monitor quality of service and delivery against timescales; and

– A peer review process whereby all investigation and outcome reports are reviewed by the nominated supervisor prior to release to the client to ensure that they meet our rigorous quality standards.

– We also obtain feedback from our clients on the quality of work that we have produced and their experience of working with us and use that feedback proactively to both benchmark the quality of the work that we produce and develop and enhance our service offering.

Please use our ‘Contact Us’ page and complete the Contact form and a member of our team will get in touch.