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Functions and duties of Clinical Governance Officer

Healthcare Services (General) Regulations 2021

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—(1) The principal functions and duties of a licensee’s Clinical Governance Officer appointed for a licensable healthcare service or specified service (as the case may be) are as follows:(a)to provide clinical governance and technical oversight over the licensable healthcare service or specified service, as the case may be;(b)to assist the licensee in the day‑to‑day management of the clinical and technical aspects of the licensable healthcare service or specified service, as the case may be;(c)to ensure the implementation and regular review of policies and systems for clinical governance, clinical risk management, effective quality management systems and any other clinical and technical related matters for the licensable healthcare service or specified service (as the case may be), so as to detect and address in a timely manner any risks affecting the safety and welfare of, or the continuity of care provided to, patients;(d)to ensure that any weakness or inadequacy related to any clinical or technical aspect of the licensable healthcare service or specified service (as the case may be) is promptly identified and remedied, including informing the licensee of the weakness or inadequacy, and proposing and implementing measures to prevent the recurrence of the weakness or inadequacy;(e)to ensure that the licensee’s personnel involved in the clinical or technical aspects of the licensable healthcare service or specified service (as the case may be) comply with the appropriate policies and processes concerning clinical and technical standards;(f)to ensure that there is close supervision, adequate training and regular competency assessments of the licensee’s personnel involved in the clinical or technical aspects of the licensable healthcare service or specified service (as the case may be), to enable them to perform their work effectively and safely;(g)to immediately notify the licensee of any matter within the Clinical Governance Officer’s purview that may affect compliance with any licence condition applicable to the licensable healthcare service or specified service, as the case may be.(2) For the purposes of paragraph (1)(b), the Clinical Governance Officer’s duty in relation to the day-to-day management of the clinical and technical aspects of the licensable healthcare service includes the following:(a)where a matter requires the Clinical Governance Officer’s attention —(i)the Clinical Governance Officer must be available to handle the matter; or(ii)if the Clinical Governance Officer cannot be so available, the Clinical Governance Officer must appoint a suitably qualified and competent personnel of the licensee to handle the matter on the Clinical Governance Officer’s behalf;(b)the Clinical Governance Officer must at all times be contactable by any personnel.(3) To avoid doubt, paragraph (1) does not restrict any other regulations made under the Act from prescribing additional functions and duties of a Clinical Governance Officer in respect of a licensable healthcare service or specified service.

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