Quality & Governance

We clearly recognise the need for Quality within our services in all that we say and all that we do and firmly believe that this can only be achieved by employing the right people and that we provides a framework for continuous measuring, monitoring and improving our performance,


“Is a framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical and nursing care and support will continually improve and flourish”.

Our principles of governance underpin and direct the clinical, operational and corporate objectives of ASC Healthcare and our recognisably high standard of service delivery.

Audit and compliance

The Breightmet Centre operates within statutory requirements for this type of healthcare setting and conforms to regulatory requirements as set out by the Care Quality Commission, Clinical Commissioning Groups, Local Authorities, National Health Service and Environmental Health Departments to ensure we meet and often exceed the standards they each impose.

To view details of our registration for The Centre please visit http://www.cqc.org.uk/provider/1-784840237/registration-info

Following an unannounced inspection visit undertaken by The CQC on 4th of November, our report has now been published and can be viewed here:http://www.cqc.org.uk/directory/1-881538544

Regular benchmarking against our own KPI’s guidance and legislation is undertaken internally via our own robust audit and governance procedures.

Risk Assessment and Management

Clinical and organisational risk management is an essential ongoing element within the Breightmet Centre for Autism. We consistently ensure that The Centre retains its fitness for purpose to maximise the safety of those in our care. All staff are DBS checked for their suitability to work with our vulnerable patients.

Our policies and procedures give clear directives on such matters as adult protection and safeguarding. All causes for concern / alerts are carefully logged and reported to all relevant parties including the local SOVA Team, appropriate commissioners, the CQC and family members to ensure thorough and detailed actions are taken, allowing us to respond and monitor appropriately within given timescales.

Off-site activities are always subject to extensive forward planning and risk assessment.

Corporate Governance

ASC Healthcare is committed to robust corporate governance and has developed a wide system to enable frequent and routine review. This is undertaken in conjunction with external specialist healthcare consultants as required to ensure both an independent review and a means of benchmarking company performance against industry trends. Corporate governance issues are also reviewed quarterly with the board of directors which also underpins a whole organisation approach to quality and compliance.

Our Staff

ASC Healthcare operate on a multi-professional team model. We have dedicated Human Resource staff in place who conduct regular staff surveys. We acknowledge the challenges presented by working in our particular field and ensure that every possible support is given, including the provision of a free Employee Assistance Programme provided by ‘Westfield Health’.

Delivery of Our Care Quality Plan

The care quality plan for ASC Healthcare is based on Standards for Better Health domains. Under each domain ASC Healthcare will itemise the standards, processes and procedures that must be in place to ensure that service delivery is being managed effectively.

First domain – Safety

Patient safety is enhanced by the use of healthcare processes working practices and systemic activities that prevent and reduce risk of harm to patients – this includes:

  • Recruitment and retention policies including DBS checks.
  • Policies and procedure for safeguarding vulnerable adults.
  • Policies and procedures for safeguarding children.
  • Health and safety policies.
  • Infection control policies.
  • Identification of incidents and accidents.
  • The use of effective monitoring systems including risk rating and severity scores.

Second domain – Clinical and Cost Effectiveness

Care delivery must conform with nationally agreed best practice evidenced by NICE guidelines effective applications of The Mental Health Act 1983 (2007) and all regulatory requirements as per the Care Quality Commission. This includes:

  • All care staff to undertake effective induction programme and to have CPD programmes agreed with the registered centre manager.
  • ASC Healthcare will have patient record systems that enable effective and appropriate care delivery underpinned by the Care Programme Approach.

Third domain – Managerial Clinical Leadership and Accountability

To ensure its ongoing and consistent approach to Clinical Leadership and Accountability, The Breightmet Centre will have in place:

  • A Clinical Governance Committee
  • A Health and Safety Committee
  • A Corporate Governance Committee

These all meet at agreed intervals as per terms of reference as set out by ASC Healthcare.

Fourth domain – Patient Focus

ASC Healthcare will deliver their services in partnership with patients, their parents / family members.

  • All patients will be treated with respect and supported to monitor the persons dignity.
  • Patient views will be accurately taken account of. There will be demonstrable compliance to meet the requirement of the mental health act 1983 regarding consent to treatment.
  • Patient forum in place which will be managed by the local advocacy service MhIST.
  • Comprehensive user guides will be available prior to admission as part of The My Shared Pathway.
  • Complaints procedure will be available and easy to apply.
  • All patients will be supported and encouraged to monitor a state of good physical health through routine access to mainstream primary care services and other local facilities for the purpose of undertaking exercise.
  • Food will be provided so that patients have a choice. The food will be, provided in a manner that provides a balanced diet for each individual and takes into account their preferences and dislikes.

Fifth domain – Patients to Receive Services Promptly

Once a patient is referred the pre-admission assessment must take place or an agreed appointment must be in place within 48 hours of referral.

Sixth domain – Care Environment

Care is provided in environments that promotes patients and staff well-being

  • The Centre will provide an annual report on Health and Safety which will inform the on-site risk register.
  • All accidents and incidents will be graded and logged and supervised in order to monitor frequency, intensity and incident type to enable review of risk and avoid future occurrence.
  • Medicine errors will be reported to the health and safety committee.
  • Annual ligature audits and elimination plans will are place within The Centre.