In the ever-evolving world of healthcare, we’re constantly seeking ways to enhance quality of care, improve safety and streamline operational processes.
Our clinical governance framework ensures we provide the highest standards of care for the people we support and continuously improve our services.
It involves monitoring systems and processes to provide assurance of safety and quality of care.
Our Quality account 2024 provides an annual overview of key performance indicators (KPIs) and achievements focused on improving service user care and quality. It highlights progress made over the past year, including key initiatives and outcomes to enhance the health, wellbeing and quality of life of those we support.
"Once again, I’m pleased to present to the public we serve and to our stakeholders the quality account for Exemplar Health Care. Last year was another year of strong progression for our organisation.
"The most important people in Exemplar Health Care are our service users. Last year was exceptional for service user engagement.
"Six years ago, when our Service User Council was first established, it had just nine ambassadors. Today it has a membership of 61 and meets three times a year. This group is instrumental in shaping our organisation.
"Our headline quality ratings, based on CQC inspections, showed 83% of our homes were rated ‘Good’ or ‘Outstanding’ at the year end. This compares well against the 78% average across the sector especially given our level of acuity.
"We’re now in year four of a digital transformation which started with management information dashboards for all levels of our operations, medicines management, then rostering, incident reporting, and now sees us rolling out electronic care plans.
"The torrent of real-time information now coming from this integrated suite of digital technology enables us to learn and improve our care at a pace that was previously inconceivable."
Integrated governance structure
Our integrated governance structure ensures accountability and continuous improvement in the quality of our care systems.
It provides a coordinated framework that combines multiple governance functions - such as clinical, legal and operations - into a unified system.
This ensures comprehensive oversight and alignment with our overall goals, promoting quality, safety and compliance across all operations.
In the home
Daily unit huddles
Daily home huddles
Period heads of departments meeting
Monthly clinical governance meeting
Quarterly team meetings
Quarterly listening sessions
Quarterly health and safety meetings
Clinical
Quarterly clinical governance meetings
Bi-annual clinical nurse manager forums
Period clinical heads of departments meetings
Service users, families and friends
Monthly service user meetings
Bi-monthly families and friends meetings
Bi-monthly service user council meetings
Quarterly service user voice working group meetings
Operations
Period regional director reviews
Quarterly regional clinical governance meetings
Executive Team
Weekly Executive Team meetings
Quarterly business reviews
Legal
Raising concerns committee reviews
Bi-monthly information governance committee meetings
Quality assurance strategy
Service user voice
Customer satisfaction
Regular two-way feedback
Listening, learning and acting
Clinical excellence
Internal clinical expertise
Clinical training
PBS Champions
Sustainable outstanding quality
Leadership stability
Target staffing model
Qualified, knowledgeable
Digital transformation
Digital skills
Central eMAR system
Digital rota system
Digital incident management system
Digital care planning
Responsiveness
Alignment to CQC's evolving strategy
New care homes
Alignment to new Integrated Care Systems
Community engagement
Exemplar Quality Assurance (EQA) framework
The Exemplar Quality Assurance (EQA) framework ensures we maintain the highest standards of care and continuously improve.
It defines how we assess, monitor and enhance the quality and safety of our care, focusing on the experience of those we support.
The framework is built on seven pillars:
service user experience
clinical effectiveness
effective staffing
risk management
data and information governance
the Exemplar Health Care Academy
continuous improvement.
Each pillar includes systems and processes for assessing and monitoring quality and safety.
Pillar one: service user experience
Pillar one: service user experience includes:
life skills toolkit
Service User Council meetings
Service User Voice Working Group
community engagement toolkit
co-production
accessible information standard
you said, we did - compliments, complaints and feedback
service user and families and friends annual survey
service user monthly meetings
families and friends bi-monthly meetings.
Pillar two: clinical effectiveness
Pillar two: clinical effectiveness includes:
internal audits including annual comprehensive audits, period digital performance reviews and period regional director reviews
quality audits such as care plan, service user of the day, medication and nutrition audits
operational audits such as night visit and first impressions audits
hotel services audits such as dining, catering and housekeeping audits
health and safety audits
home meetings such as daily unit and home huddles, home manager walk rounds and heads of departments meetings.
Pillar three: effective staffing
Pillar three: effective staffing includes:
celebrations and achievements such as employee of the month and long service awards
safe staffing processes such as absence management and registered professional PIN checks
onboarding and induction processes such as company welcome inductions, role-specific inductions, the buddy process and probation reviews
colleague feedback processes such as colleague surveys, team meetings, listening sessions, supervisions and performance development reviews.
Pillar four: risk management
Pillar four: risk management includes:
trend analysis
incident response processes such as root cause analysis, lessons learned, safeguarding and CQC investigations, risk registers and whistleblowing.
Pillar five: data and information governance
Pillar five: data and information governance includes:
processes to manage risks such as data breaches and cyber security risks
processes to manage information such as subject access requests, freedom of information requests and policy updates.
Pillar six: the Exemplar Health Care Academy
Pillar six: the Exemplar Health Care Academy includes:
mandatory and statutory training
role essential training
Exemplar Positive Behaviour Support training
clinical skills training
leadership pathway programmes
role enhancement training such as CPD, apprenticeships and colleague forums.
Pillar seven: continuous improvement
Pillar seven: continuous improvement includes:
local change initatives
improvement workshops
best practice case studies
performance pentagon.
Accreditations, certifications and endorsements
We’re proud of the accreditations, certifications and endorsements we’ve received from health and social care professionals, charities and support organisations.
Exemplar Positive Behaviour Support training has achieved certification from Bild Association of Certified Training (Bild ACT), which confirms that the learning meets the Restraint Reduction Network (RRN) Training Standards 2019. Read about the certification.
Dearnevale in Grimethorpe, Greenside Court in Greenside and Kavanagh Place in Liverpool are quality assured by the Huntington’s Disease Association. The accreditation is a quality assurance programme that identifies the behaviours, cultures and specialist services required for a care home to specialise in caring for people living with Huntington’s disease.
Dearnevale in Grimethorpe and Greenside Court in Greenside have been awarded a national Gold Standards Framework (GSF) Quality Hallmark Award, in recognition of the way they care for people at their end of life.
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