QUALITY ASSURANCE
Standard 4: I am confident in the organisation providing my care and support
Principle: Responsive care and support
Scope
- Policy Statement
- The Policy
- Our Commitment
- Responsibilities of Staff
- Audits
- Related Policies
- Related Guidance
- Training Statement
Policy Statement
This policy is intended to set out the values, principles and policies underpinning this organisation’s approach to maintaining and improving quality and high standards.
We place a strong emphasis on providing the highest-quality service possible for all our service users. We work on the basis that, no matter how good our present services are, there is always room for improvement. We are committed to continuous improvement and have established a quality management system that provides a framework for measuring and improving our performance.
We have the following system and procedures in place to support us in our aim of service user satisfaction and continual improvement throughout our organisation:
- Regular gathering and monitoring of feedback from service users, family or other relevant people.
- Quality Circles
- Co-production (giving power to Service Users)
- A complaints procedure.
- Selection and performance monitoring of suppliers against set criteria.
- Robust and value-based recruitment, selection and retention process.
- Training development for every employee.
- Regular monitoring and observation of staff.
- Regular audit of internal processes.
- Measurable quality objectives that reflect organisational aims.
- Management reviews of audit results, feedback and complaints.
We believe that having the highest-quality care is the absolute right of all our service users. The continuing aim of the organisation is to provide a professional and efficient service to meet all the requirements of our service users, and the long-term goal is to obtain the highest possible level of satisfaction from service users and relatives.
Service users’ views will be sought, collated and used to inform the services we provide.
Our Quality Management Systems are based on the ISO principles of Plan, Do, Check, Act – more commonly known as the PDCA Cycles. This is the fundamental basis of Continuous Improvement:
Plan
Plan how you deliver the service (Business Plan, Policies, Compliance to regulations, system design).
Do
Deliver the service in accordance with your plan.
Check
Check the service is operating in accordance with the plan (Audit, Reviews, Service User feedback).
Act
Take action where deficiencies are identified or where good practice can be shared.
The cycle then starts all over again until the issue is resolved = continuous improvement.
The Quality Management System will be:
- Co-produced
- Written down
- Communicated to all stakeholders
- Regularly reviewed and updated
The Director has overall accountability for the effectiveness of the Quality Systems.
We believe that all service users should:
- Receive the highest-quality care and support possible.
- Have a say in the running of the organisation. Information is gathered through routine evaluations and a larger survey of service user opinion is carried out on an annual basis. Although confidential, the results of this survey are published and distributed to all service users and purchasers. Comments and feedback are also sought from service users’ relatives, carers, friends, advocates and other stakeholders.
- Be free to complain about any aspect of the running of the services provided and to have their complaints welcomed and acted upon promptly. To this end, the organisation operates a robust complaints procedure.
Responsibilities of Staff
All staff, including senior managers, are expected to demonstrate their commitment, understanding and adherence to delivering the highest-quality care to all our service users, in all aspects of their day-to-day roles, and to discharge their responsibilities accordingly:
- The owner and management team bear the responsibility for establishing, maintaining, and implementing a quality management system. This system helps to set standards and to make changes to achieve improved standards. The process is reviewed regularly.
- Every employee is responsible for the quality of their work and is trained to perform their duties to the required legal and organisational standard.
- Contractors employed for specific functions must meet specified standards.
- The organisation has an annual development plan for quality improvement, drawn up as part of its business plan, and based on feedback from service users, staff and relatives. The plan is costed, focusing on specific measurable standards, and includes named staff as responsible for each aspect.
- The organisation listens constantly to its service users and stakeholders and conducts annual service user satisfaction and feedback surveys, via a standardised questionnaire and follow-up interviews with a random sample of service users, representatives and stakeholders. The findings are analysed and incorporated into the organisation’s development plan.
- • Managers closely monitor the quality of work through regular supervision, which includes direct observation of staff members’ care practice and unannounced visits to service users’ homes when staff members are expected to be there.
- The organisation has a timetable for regularly self-assessing its activities, information from which informs its improvement and annual development plans.
The registered manager is responsible for ensuring quality within the company.
The is responsible for preparing and distributing the annual questionnaires, and for collating the results.
However, all staff are responsible for complying and working in accordance with the company’s Quality Management Systems. Staff will be trained during induction about our Quality System and their responsibilities when carrying out their duties.
Audits
At least one across the business quality audit is conducted annually. This audit will cover all the business operations and will include auditing the Quality Systems to ensure they are fit for purpose.
The data collected from these audits are reviewed by the Quality Lead and Board of Directors to identify trends or emerging themes.
The Quality Group will identify all areas of non-compliance and compile Quality Improvement Action Plans to resolve the issues. These action plans will be co-produced with service users where possible and will be agreed upon and discussed with all staff members to ensure there is a consistent management approach. Action plans will be:
- Written Down
- Shared with all staff and service users
- Routinely reviewed
- Updated and revised for project slippage
- Signed off as complete
- Reviewed at 6 months to ensure changes are being applied
Customer Surveys/Feedback
Gaining feedback from customers is essential for maintaining responsive services. Gaining feedbacking must be embedded in day-to-day practice but there must also be more formalised methods of gaining feedback from service users and the wider stakeholder group – such as family members and informal carers.
Methods include:
- Monthly Satisfaction Questionnaires (Service users and Staff)
- Detailed 6 monthly Satisfaction Questionnaires.
- Monthly analysis of complaints and compliments
- Monthly analysis of incidents (Safeguarding, Accidents etc.)
- Annual Stakeholder Questionnaires (Local Authority, GP’s etc.)
- Client Forums
- Staff Meetings
- Spot checks
- Supervision
Getting feedback is pointless unless the information is collated and analysed to identify trends or emerging themes. The Quality Lead is responsible for communicating any issues of non-compliance to the board so that robust action plans can be put in place to rectify them.
Our Quality Management System requires us to carry out regular internal audits of key activities and functions to ensure our service continually monitors its performance and where deficiencies are identified clear and robust action plans are implemented. This ensures that this organisation is a Learning Organisation that embraces the principles of Continuous Improvement.
Audits will include:
- Medication Management
- Information Governance
- Infection Control
- Adult Safeguarding
- Training and Workforce Development
- Equality and Diversity
- Health & Safety
- Regulatory Compliance
- Complaints & Compliments
- MCA/Dols
- Internal Systems and Processes i.e. Staff Rotas or Scheduling Systems
- Recruitment and Selection
The frequency of audits will depend upon the subject matter. For example, medication audits should be carried out monthly by the designated medication lead. The Nurses and the Senior care workers will produce an audit schedule that details all the planned audits for the year and their frequency.
Effective Auditing is a comprehensive subject matter in itself. Please refer to separate Audit Policy for more detailed information as listed in the Related Policies below
Related Policies
Audit
Complaints
Duty of Candour
Good Governance
Meetings Needs
Related Guidance
Care Inspectorate, Quality Conversations: http://www.careinspectorate.com/index.php/quality-conversations
Care Inspectorate, Self-Evaluation for Improvement – Your Guide: https://hub.careinspectorate.com/media/3783/self-evaluation-for-improvement-your-guide.pdf
Scottish Social Services Council, Code of Practice for Social Service Workers and Employers:
http://www.sssc.uk.com/about-the-sssc/codes-of-practice/what-are-the-codes-of-practice
ISO – PDCA
Training Statement
This organisation is committed to the continuous improvement of its services and views staff learning and training as core to delivering a quality service. With the Health and Social Care Standards and Principles, and associated codes of practice, we will take the opportunity to review our learning and training programme to ensure that the standards and principles are fully embedded and that they are reflected in all we do.
Date Reviewed: November 2023
The person responsible for updating this policy: Blessing Ashinze
Next Review Date: November 2024