Quality & Governance

Governance Framework

Our governance structure ensures accountability, leadership and oversight in accordance with HIQA Regulation 17: Governance and Management and HSE Service Arrangements. Governance is led by the Board and Senior Management, supported by registered managers and team supervisors.

• Strategic Level: Led by Directors overseeing compliance, finance, and operations across The Elm Collection.
• Managerial Level: Quality and compliance oversight through internal audits, supervision, and reporting.
• Operational Level: Frontline staff delivering person-centred care under professional supervision.
• External Oversight: Engagement with the HSE, HIQA and other statutory agencies to ensure transparency and regulatory alignment.

Quality Assurance & Monitoring

Our Quality and Assurance Policy (EHC006) outlines how we monitor performance and outcomes using a mix of proactive and reactive systems:

• Monthly internal audits and supervision reports.
• Quarterly management reviews covering health & safety, training, and safeguarding.
• Regular reviews of all policies and procedures.
• Regular feedback from staff, service users, and families.
• Compliance tracking and corrective actions documented through audit logs.

These mechanisms promote accountability, learning, and ongoing service enhancement.

Continuous Improvement (CQI)

We follow the Plan–Do–Check–Act (PDCA) model of continuous improvement as described in our Quality Improvement Plan (EHC073):

• Plan: Identify issues or improvement goals through audits, feedback and reviews.
• Do: Implement solutions and assign responsibilities.
• Check: Monitor and evaluate progress using measurable outcomes.
• Act: Embed successful practices into standard operating procedures and share learning.

The Quality Improvement Plan is reviewed quarterly to track progress and ensure that identified actions are completed and sustained.

Data & Reporting

Quality data is collected from a range of sources including incident reports, complaints, audits, training compliance, and user feedback. Reports are analysed to identify trends, risks, and opportunities for improvement.

Quality Reporting Calendar:

• Weekly: Care log reviews, incident monitoring, risk register updates.
• Monthly: KPI reporting, supervision audits, and health & safety checks.
• Quarterly: Quality and Governance Review Meeting with leadership.
• Annually: Comprehensive Quality Review and service improvement plan.

Staff & Service User Involvement

Quality improvement is everyone’s responsibility. Staff and service users actively participate through feedback surveys, reflective supervision, and open forums. All contributions are logged and reviewed by management, ensuring that learning translates into real service enhancement.

Commitment to Transparency

We are committed to open disclosure, accountability, and a culture of safety. Lessons learned from incidents, audits, and complaints are shared across teams to support best practice and continual learning.