Quality and governance

Governance you can evidence, not just claim

For commissioners, ICBs and case managers, assurance has to be demonstrable. This page sets out how Ultimate Complex Care governs quality across North Somerset, Weston-super-Mare and the Devon ICB area, and the evidence we can share with you on request.
Current CQC rating

RMN

Operational leadership

9

Governance systems

100%

Mandatory training compliance target
Governance structure

Five layers of accountability

Clear lines of responsibility from board to front line, so every decision is owned, recorded and open to scrutiny.
01

Board and RMN leadership

Strategic oversight from a board that includes a Registered Mental Health Nurse, setting clinical direction, risk appetite and quality priorities.
02

Registered Manager

CQC registered leadership accountable for regulatory compliance, safe staffing and the day to day quality of every package of care.
03

Clinical and PBS Leads

Specialist leads who author support plans, oversee positive behaviour support in partnership with Thrive Behaviour Support Services, and assess clinical competence.
04

Team Leaders

Named team leaders for every package who supervise rotas, run reflective practice and act as the first escalation point for families and professionals.
05

Competency-assessed support teams

Support workers matched to each person, trained to the specific needs of the package and signed off as competent before working unsupervised.
Audit cycle

Continuous improvement cycle

Quality is not a one-off inspection exercise. It is a repeating cycle that every package of care moves through, month after month.
01

Plan

Person-centred plans built from assessment, risk profiles and the outcomes commissioners have asked us to deliver.
02

Deliver

Competency-assessed teams deliver against the plan with accurate, contemporaneous record keeping.
03

Audit

Scheduled and unannounced audits across medication, records, safeguarding, training and the environment of care.
04

Learn

Audit findings, incidents and feedback are reviewed in governance meetings and turned into shared learning.
05

Improve

Actions are tracked to completion, with plans, training and practice updated so improvement holds.
Governance systems

Nine governance systems

Nine interlocking systems keep quality visible, measurable and open to commissioner scrutiny. Evidence from each is available on request.
Openness and protection

Safeguarding and Duty of Candour

Protection and honesty are governed processes here, not aspirations. Both are audited, and both are open to commissioner review.

Safeguarding

Safeguarding runs through recruitment, training, supervision and daily practice. Concerns are recognised early, recorded properly and escalated without delay.

Duty of Candour

When something goes wrong we say so, put it right and show what changed. Our Duty of Candour process is documented, audited and led from the top.
Workforce

Workforce capability

Specialist capability is built in-house and evidenced, not assumed. Every role sits within a supervision and competency framework.

RMN leadership

A Registered Mental Health Nurse leads operations, keeping clinical judgement close to every package of care.

In-house trainers

Our own trainers deliver mandatory and specialist training, so content stays current and compliance stays visible.

Medication assessors

Qualified assessors sign off medication competence before any staff member administers unsupervised.

PBS Leads

Positive behaviour support leads shape proactive strategies in partnership with Thrive Behaviour Support Services.

PBS Practitioners

Trained practitioners embed positive behaviour support in daily routines, reducing the need for restrictive practice.

Supervision and CPD

Regular supervision, appraisal and continuing professional development for every role, recorded and audited.
Evidence of standards

Accreditations and memberships

CQC rated Good, Care Quality Commission rating
Regulated and inspected by the Care Quality Commission.
Skills for Care
Workforce development aligned to Skills for Care standards.
BILD member, British Institute of Learning Disabilities
Working to BILD standards for learning disability support.
Restraint Reduction Network member
Restraint Reduction Network member, committed to minimising restrictive practice.
Dementia Friends
Dementia Friends, with awareness embedded across our teams.
Disability Confident employer
Disability Confident employer with inclusive recruitment.
Homecare Association (UKHCA) member
Homecare Association member, working to the sector code of practice.
UKLICA member, UK Live-in Care Association
UKLICA member for safe, accountable live-in care.
Work with our governance team

Commission care you can stand behind

Request our latest audit summaries, training matrix and governance reports, or talk through a placement with our Registered Manager. We respond quickly and we welcome scrutiny.

Governance questions

What commissioners and professionals ask

How is your service governed?

Through a defined accountability chain: board and Registered Mental Nurse leadership, a Registered Manager, Clinical and PBS Leads, team leaders and competency-assessed teams. Each layer has named responsibility, so oversight does not depend on one person.

What quality systems do you operate?

Nine core systems including safeguarding, medication governance, competency-assessed workforce, PBS leadership, MCA and DoLS, audit and quality assurance, digital care planning, incident learning, and mandatory training with supervision.

How do you handle incidents and things going wrong?

Incidents are recorded, reviewed and used to change practice, and we apply Duty of Candour. The purpose of incident learning is to alter what happens next, not to produce a paper trail. Themes are reported through governance rather than closed at team level.

How do you evidence staff competence?

Competence is assessed against the specific person and task, not signed off generically. We have in-house trainers and our own medication assessors, with supervision and CPD recorded. Evidence is available to commissioners on request.

How do you apply the Mental Capacity Act and DoLS?

Capacity is assessed decision by decision and recorded, with best-interests processes where someone lacks capacity for a specific decision. Restrictions are reviewed against least restrictive practice and Restraint Reduction Network principles.

Can you provide governance evidence for a tender or panel?

Yes. We can supply policies, training matrices, audit outputs and accreditation evidence for commissioning panels, ICB processes and tenders. Contact us with what your process requires and the timescale.

Make a referral

Make a Referral

Tell us about the support required and our team will contact you to discuss the next steps.