Safe, effective and accountable care
MACC operates within a clear clinical governance framework, with defined responsibilities for safety, quality, safeguarding and information governance across all ADHD and Autism (ASD) pathways.
What clinical governance means at MACC
Clinical governance is the system we use to ensure that care is:
- Safe
- Effective
- Person-centred
- Consistent
- Continually improving
It covers how we design pathways, train and supervise staff, monitor quality, manage risk and respond when things go wrong.
Governance structure
We maintain a governance structure that includes:
- Clinical leadership – responsible for clinical standards and overall safety
- Medical leadership – responsible for medical decision-making, complex cases and medication governance
- Quality & risk leadership – responsible for risk registers, audits and improvement plans
- Safeguarding leadership – responsible for safeguarding children, young people and adults
- Information governance leadership – responsible for confidentiality, data protection and records management
- Clear reports and recommendations for GPs, schools, colleges and workplaces
Together, these roles provide oversight of our ADHD and Autism services and ensure there are clear lines of accountability.
Safe clinical pathways
Our ADHD and Autism pathways are designed with:
- Structured assessment processes and documentation
- Clear inclusion and exclusion criteria
- Guidance on when to escalate to MDT review or emergency services
- Defined follow-up options and handover arrangements
Pathways are reviewed regularly and updated in response to new guidance, emerging evidence, audit findings and feedback.
Safeguarding
Safeguarding is everyone’s responsibility. We ensure that:
- All staff receive safeguarding training appropriate to their role
- There are clear procedures for recognising, responding to and recording safeguarding concerns
- Clinicians know how to escalate concerns to the Designated Safeguarding Lead or Deputy
- We work with local safeguarding partners and agencies when needed
- Safeguarding cases are discussed in supervision and governance meetings as appropriate
Our safeguarding policy sets out how we protect children, young people and adults at risk, and how we share information when necessary to protect someone from harm.
Risk management & incidents
We operate a structured approach to clinical risk:
- A clinical risk register identifies key risks and sets out mitigating actions, owners and timescales
- Clinicians are supported to identify, document and escalate individual risk concerns during assessments and follow-up
- Adverse events, near misses and complaints are logged as incidents, reviewed and, where needed, investigated
- Learning from incidents leads to clear actions, which are tracked through governance meetings
Our aim is to learn from things that go wrong or nearly go wrong, and to reduce the chance of similar issues occurring in future.
Quality assurance & audit
To maintain and improve quality, we use:
- Report quality reviews – sampling of assessment reports against agreed standards (for example clarity, completeness, clinical reasoning and recommendations)
- Pathway audits – checking that key steps are completed consistently (for example, use of questionnaires, documentation, communication with GPs and schools)
- Supervision-linked grading – structured feedback mechanisms for clinicians’ work, particularly during induction and early independent practice
- Patient and family feedback – surveys and qualitative feedback to understand experience of care
Findings are discussed in governance meetings and used to update training, templates, policies and pathways.
Information governance & data protection
We take information governance and data protection seriously. This includes:
- Using secure systems for storing and sharing clinical records
- Limiting access to patient information to staff who need it for clinical or operational reasons
- Applying clear policies on confidentiality and information sharing
- Providing staff with data protection and information governance training
- Having defined processes for responding to data breaches or information incidents
We provide clear information to patients and families about how their data is used, stored and shared.
Policies, procedures & training
Our governance framework is supported by written policies and procedures covering areas such as:
- Safeguarding
- Clinical risk and escalation
- Complaints and compliments
- Information governance and data protection
- Record keeping and retention
- Remote consultation standards
- Incident reporting and learning
Staff are expected to read and follow relevant policies and to complete mandatory training modules on a regular basis.
Feedback, complaints & improvement
Feedback, concerns and complaints are seen as opportunities to improve. We:
- Encourage patients, families and professionals to tell us what is working well and what could be better
- Have a clear complaints process, with timeframes for acknowledging and responding
- Review complaints at governance meetings and use them to identify themes and actions
- Update pathways, training and policies in response to patterns in feedback
We aim to respond openly and constructively when people raise concerns about their care.
Transparency & accountability
We are committed to being transparent about:
- How our pathways work
- How long key steps are likely to take
- What is and is not included in each package
- How we handle risk, safeguarding and incidents
If you would like more information about our governance arrangements or specific policies, you can contact us directly.