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QQ87 -Quality and Quality Assurance Policy and Procedure
Quality Assurance - Management of Quality Assurance
| Last Reviewed 23 Nov '23 | Last Amended 23 Nov '23 | Next Planned Review in 12 months, or sooner as required. |
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| Business Impact | Changes are important, but urgent implementation is not required, incorporate into your existing workflow | |
| Reason for this review | Scheduled review | |
| Were changes made? | Yes | |
| Summary: | This policy explains how quality assurance can be achieved through meeting best practice and legislation, and creates a framework to identify and ensure quality by using tools to measure progress and development. It has been reviewed and updated with some changes made to streamline the policy. Underpinning Knowledge and further reading references have been reviewed and updated. For some customers, the reference number on the policy may have changed. | |
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| Underpinning knowledge - What have we used to ensure that the policy is current: |
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| Equality Impact Assessment: | QCS have undertaken an equality analysis during the review of this policy. This statement is a written record that demonstrates that we have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. | |
1. Purpose
1.1 To detail what Care 4 You Care Agency defines as 'quality' through best practice and legislation.
1.2 To set out how Care 4 You Care Agency intends to achieve continuous improvement in the services it provides, reflecting national and local requirements as well as the priorities of Care 4 You Care Agency.
1.3 To ensure the consistent delivery of safe, effective care that results in a positive Service User experience.
1.4 This policy should be read in conjunction with the following
- i. Quality Assurance Surveys
- ii. Management Meetings Policy and Procedure
- iii. Quality Meetings Policy and Procedure
- iv. Good Governance Policy and Procedure
- v. Mental Capacity Act (MCA) 2005 Policy and Procedure
1.5 To support Care 4 You Care Agency in meeting the following Key Lines of Enquiry/Quality Statements (New):
| Key Question | Key Lines of Enquiry | Quality Statements (New) |
|---|---|---|
| CARING | C2: How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible? | QSC2: Treating people as individuals |
| EFFECTIVE | E1: Are people’s needs and choices assessed and care, treatment and support delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes? | QQSE1: Assessing needs
QSE2: Delivering evidence-based care & treatment |
| EFFECTIVE | E2: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care and support? |
QSE2: Delivering evidence-based care & treatment
QSE3: How staff, teams & services work together |
| RESPONSIVE | R2: How are people’s concerns and complaints listened and responded to and used to improve the quality of care? | QSR4: Listening to and involving people |
| SAFE | S2: How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected? | QSS4: Involving people to manage risks
QSS5: Safe environments |
| SAFE | S3: How does the service make sure that there are sufficient numbers of suitable staff to support people to stay safe and meet their needs? | QSS6: Safe and effective staffing |
| WELL-LED | W2: Does the governance framework ensure that responsibilities are clear and that quality performance, risks and regulatory requirements are understood and managed? | QSW5: Governance, management and sustainability |
| WELL-LED | W3: How are the people who use the service, the public and staff engaged and involved? | QSW3: Freedom to speak up |
1.6 To meet the legal requirements of the regulated activities that {Care 4 You Care Agency} is registered to provide:
- Data Protection Act 2018
- The Care Act 2014
- Equality Act 2010
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
- Health and Social Care Act 2008 (Registration and Regulated Activities) (Amendment) Regulations 2015
- Health and Safety at Work etc. Act 1974
- Human Rights Act 1998
- The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009
- Management of Health and Safety at Work Regulations 1999
- Mental Capacity Act 2005
- Safeguarding Vulnerable Groups Act 2006
- UK GDPR
2. Scope
2.1 The following roles may be affected by this policy:
- i. All staff
2.2 The following Service Users may be affected by this policy:
- i. Service Users
2.2 The following stakeholders may be affected by this policy:
- i. Family
- ii. Advocates
- iii. Representatives
- iv. Commissioners
- v. External health professionals
- vi. Local Authority
- vii. NHS
3. Objectives
3.1 To create a framework to identify and ensure quality at Care 4 You Care Agency that staff, Service Users and other stakeholders understand.
3.2 To confirm the commitment of Care 4 You Care Agency to quality and ensuring that robust governance processes exist, which meet the needs of its Service Users, its employees, CQC and other key stakeholders.
3.3 To have the tools to measure the progress and development of Care 4 You Care Agency and its staff in meeting quality in every aspect of the service.
3.4 To ensure continuous quality improvement at Care 4 You Care Agency, emphasise that the provision of evidence-based best practice underpins all activity within Care 4 You Care Agency and that its processes are benchmarked against NICE guidelines and other best practice guidance.
3.5 To ensure that employees of Care 4 You Care Agency understand the quality assurance process and roles and responsibilities to achieve consistently good service outcomes against quality markers.
4. Policy
4.1 Care 4 You Care Agency will deliver safe, caring, efficient and high-quality Care services which fully integrate quality, performance and governance as detailed in its vision and values to:
- Provide care and support to Service Users and their families which is in accordance with the individual wishes of the Service User, whilst fully supporting their human rights and the principles of the Mental Capacity Act 2005
- Deliver a management style, policies and day-to-day practices that promote open communication, a culture of problem resolution rather than blame, and the involvement of all stakeholders.
- Nurture a culture that is supportive of continuous improvement that is maintained by way of regular audit and review of standards of performance across the service, followed by open discussions about strengths and weaknesses, with action-planning to resolve weaknesses
4.2 Registered Manager Responsibilities
- Ensuring there is ongoing compliance with regulatory and contractual requirements
- Ensuring compliance with policies and procedures
- Ensuring there are sufficient numbers of staff with suitable skills, experience and knowledge to deliver safe Care and maintain a high-quality service
- Reviewing and learning from accidents, incidents (including safeguarding) and complaints, and sharing this learning with staff
- Seeking feedback from Service Users and stakeholders
- Acting on results of audits and reviews of the service
- Developing systems for achieving continuous improvement
- The collation, reporting and use of data to inform stakeholders of the quality of the service
- Promoting a supportive, transparent culture where Care 4 You Care Agency can learn from any mistakes
- Collaborative working with commissioners and commissioning bodies to identify opportunities to meet the needs of the local community
Results are analysed and used to:
- Develop action plans
- Steer the direction for quality initiatives and review of the strategy of Care 4 You Care Agency
- Form supervision, training and performance management where necessary
This does not replace any additional, more frequent quality assurance checks that are completed as locally agreed by Care 4 You Care Agency.
4.3 Governance
Care 4 You Care Agency will ensure that there is effective governance in place, including
assurance and auditing systems
and processes. These will assess, monitor and drive improvement in the quality and safety of
the services provided,
including the quality of the experience for Service Users. The systems and processes will
also assess, monitor and
mitigate any risks relating to the health, safety and welfare of Service Users and others.
Care 4 You Care Agency is committed to ensuring that it continually evaluates and seeks to
improve its governance and
auditing practice.
4.4 Person-Centered Care
Care 4 You Care Agency recognises that a quality service is one that understands the needs
and circumstances of each
Service User, because they are supported to give their views and express their wishes in
every aspect of their care from
design through to delivery. Care 4 You Care Agency will ensure full Service User engagement
in all elements of the
service and will ensure best interest decisions are made if a Service User is assessed as
lacking capacity, consulting
with the Service User's representatives, family and assigned professionals.
Care 4 You Care Agency is dedicated to providing a quality service that ensures care is
accessible, appropriate, safe
and effective for all in the local community, and that this includes protected
characteristic groups. Care 4 You Care
Agency will ensure that the workplace is free from discrimination so that staff can
thrive and deliver excellence.
4.5 Anticipate Change
Care 4 You Care Agency will anticipate and be responsive to the regulatory frameworks, the
changing needs of its diverse
Service Users and the changing needs within its local area, working in partnership to
understand the present and future
needs.
Care 4 You Care Agency is committed to providing the best possible Service User Care and
values the professionalism of
its staff.
4.6 Resources
Care 4 You Care Agency will ensure that necessary resources are available to effectively
monitor key performance
indicators. This data will be used to inform management decisions which support the delivery
of quality services,
ongoing quality improvement and business planning decisions.
4.7 Areas of Responsiblity
Within Care 4 You Care Agency, key individuals with the appropriate skills, experience and knowledge will be identified to have responsibility for the following:
- Implementation of quality procedures and systems
- Meeting legal, regulatory and contractual compliance
- Auditing of the service
- Collation of data and information to monitor performance against agreed quality standards
- Listening and responding to Service Users' concerns, feedback and views
- Listening and responding to concerns raised by staff at Care 4 You Care Agency and other key stakeholders
5. Procedure
5.1
Quality will be assured by the existence of, and adherence to, the relevant policies and
procedures within the
management system.
5.2 Quality Framework
Care 4 You Care Agency will embed a quality framework that includes:
- Clearly defined quality objectives that are specific, measurable, achievable and time-sensitive
- Supporting Service Users to fully contribute to the quality assurance framework wherever possible
- Ensuring a person-centred approach to the Care of each Service User
- Enabling Service Users to set their personal objectives and have full involvement in the review process
- Setting targets that are focused on meeting the needs of its Service Users, its business and other stakeholders
- An organisational structure that identifies who provides vision and direction within Care 4 You Care Agency
- An implemented, up-to-date suite of policies and procedures that are evidence-based, reflect best practice and the needs of Care 4 You Care Agency, and dovetail with any contractual requirements
- Regular audit cycles must also be in place to ensure compliance
- A robust business plan that details the strategic priorities for the next five years
- Personal development plans, supervision and appraisal systems for staff to ensure that they have the relevant skills, knowledge and expertise
- The use of effective communication tools to minimise any internal or external communication barriers
- An active internal and external audit process with outcomes feeding back into the quality cycle
- An infrastructure and resources that can support the delivery of aims and strategic priorities
- The building of positive relationships with partners and others working in the sector to enable sharing of experiences, to pool expertise and work in partnership for the best interests of Service Users
- A means of evaluating all activity on a continuous basis and using feedback gained to inform the development of services
5.3 Service Users
Foremost, Care 4 You Care Agency and its staff must always ensure that Service Users have
the opportunity to make a full
and meaningful contribution to any and all aspects of their Care. Where this is not possible
due to a lack of capacity,
decisions will always be made in the Service User's best interest.
Care 4 You Care Agency will ensure that all Service Users have a person-centred Care Plan
that meets their needs,
expectations and wishes, created (where possible) before their Care starts. Care 4 You Care
Agency will also ensure:
- Care Plans will be reviewed within 6 weeks of Care starting
- That risk assessments and Care Plans are reviewed when needs change, when there is an incident, concern or near miss, within 6 weeks of Care commencing and at least annually
- That Service Users are at the heart of any Care planning and (with their consent) their family or someone who can advocate on their behalf will be involved
- That Service Users know how to raise concerns, share their views and get involved with shaping service delivery. Care 4 You Care Agency will listen and respond, documenting any action taken
- That it audits the consistency and reliability of Care and takes remedial action where required
- That principles of privacy, dignity and respect underpin all Care delivery, and this will be audited
5.4 Staff
The Registered Manager will promote a culture that is open, honest, transparent, safe and
caring. The Registered Manager
will ensure that:
- Staff are given the opportunity to take part in surveys that are anonymised, collated and used to determine trends
- Processes support a person-centred, 'fair blame' culture that actively encourages Service Users, their families or carers to report their concerns
- Whistleblowing and safeguarding policies and procedures are widely publicised and linked to the procedures
- A learning culture is promoted, with audit and investigation outcomes being disseminated to staff, so that lessons can be learnt and measures put in place to ensure that incidents do not arise again
- Any identified actions required as a result of audits will be implemented in a timely manner
5.5 Culture
- Recruitment will be values-based and robust, to ensure that the right people are recruited for the right job
- There is a formal induction process for all staff to ensure that they are provided with the skills and knowledge to gain competence to fulfil their roles
- Recruitment will ensure that all pre-employment checks are undertaken and documents are held in line with data protection requirements
- Care 4 You Care Agency will undertake observations/spot checks of practice on every Care Worker within Service Users' private environments to witness Care delivery. This will take place at a frequency agreed by Care 4 You Care Agency
- Care 4 You Care Agency must gain consent from the Service User in advance to arrange observations/spot checks to ensure that the Service User knows the arrangements in advance
- Care 4 You Care Agency must ensure that all staff have regular supervisions. These will include a mix of one-to-one and group supervisions at a frequency agreed by Care 4 You Care Agency
- New staff will undergo supervision more frequently and where concerns arise about any member of staff, supervision frequency will increase
- Priority must be given to training and personal and professional development, with the need to attend mandatory training emphasized
5.6 Policies and Procedures
The Registered Manager:
- Has responsibility for ensuring that staff can access policies and procedures via the QCS Online Management System or the QCS Mobile App; these will be made available to ensure a consistently high-quality standard of Care is delivered
- Must review the policies and procedures to ensure that they meet the needs of Care 4 You Care Agency, and make amendments where required to meet local policy requirements
- Must ensure that the policies and procedures are implemented and embedded within Care 4 You Care Agency, and will undertake regular compliance audits
- Must keep up to date with any local policy or best practice changes and ensure these changes are cascaded to staff
- Will utilise the QCS Mock Inspection Toolkit to support any audits
5.7 Training
The Registered Manager:
- A training matrix is in place and all staff undergo training needs analysis
- Training and development are given high priority and Care Workers have a requirement to attend.
- Achievement is tracked
- Training and development are also given high priority for other staff within Care 4 You Care Agency to ensure a knowledgeable and competent workforce
- An environment is created where staff are committed to develop and change practice and systems, in light of research, good practice and evidence-based Care
- Care 4 You Care Agency will review training materials alongside any published policies and procedures to ensure consistency and ensure that they dovetail, where necessary
- Training is reviewed as part of root cause analysis and lessons learnt when things go wrong. The Registered Manager will ensure that mechanisms are put in place to ensure any gaps in training are closed
5.8 Audit
The Registered Manager or a delegated other will undertake monthly quality control audits
and reviews of the service as dictated by the quality framework. These service reviews will
include the
following umbrella terms:
- Financial transactions
- Health and safety
- Accidents and incidents
- Safeguarding
- Compliments, concerns and complaints
- Service User and staff feedback
- Infection control
- Support/care and safety performance, e.g. care documentation, medicine management, nutrition, skin integrity
- Observations/spot checks
- Thematic audits and national audits will also be used to provide focused reviews of quality
- Data protection
- Industry best practice standards will also be applied
Results will be analysed and used to:
- Develop action plans
- Steer the direction for quality initiatives and review of the strategy of Care 4 You Care Agency
- Form supervision, training and performance management where necessary
5.9 Quality Improvement
Findings from audits will highlight areas for improvement and what is working well.
Individual concerns identified will be addressed through the appropriate policies and
procedures.
The Registered Manager will report through the governance structures at Care 4 You Care
Agency to ensure that
system-wide improvements can be made where trends are identified through audits.
5.10 Corporate Social Responsibility
Care 4 You Care Agency is a socially responsible business and recognises the active role it
can play in helping to build
happier and healthier communities. Care 4 You Care Agency will do this by:
- Ensuring ethical purchasing with due diligence carried out on its supply chains
- Adhering to modern slavery and human trafficking laws as part of its purchasing strategy
- Complying with local waste reduction and recycling requirements
- Striving to be a responsible neighbour in the community in which it operates by ensuring the safety and security of the premises of Care 4 You Care Agency
- Finding and investing in technological solutions where possible, such as low energy lighting systems that can help it to use energy resources more efficiently
- Being a ‘champion’ of change, showing how much it cares about the need for a low carbon economy and reducing its carbon footprint by ensuring that staff can keep car journeys to a minimum with careful rostering
- Motivating staff to actively care about the environment, giving them guidance and information to help them make a real difference
6. Definitions
6.1 Quality Assurance
- Quality assurance is a process-driven approach with specific steps to help define and attain goals
- Quality assurance is the process of verifying or determining whether products or services meet or exceed user expectations
- This process considers design, development, implementation and evaluation
- It is essentially about learning what works well and striving to do it even better
- It also means establishing what could be changed to meet a need
6.2 Policy
- A policy is a deliberate system of principles to guide decisions and achieve rational outcomes. A policy is a statement of intent, and is implemented as a procedure or protocol
6.3 Quality Framework
- It sets out expectations in domains for quality and represents a single framework through which can be the evaluation, management and improvement of the quality of the service
- A quality framework is a structure which defines quality in practical terms for an organisation
6.4 Person-Centred Care
An approach where the person using care and support is at the centre of the way care is
planned and delivered. It is
based around their individual needs, preferences and priorities. It treats people as an
equal partner, and puts into
practice the principle of 'no decision about me without me' - (GOV.UK: Adult Social
Care, Quality Matters)
Key Facts - Professionals
Professionals providing this service should be aware of the following:
- Care 4 You Care Agency will work to a quality framework to ensure that all areas of practice comply with regulation, legislation and national evidence-based best practice
- Professionals have a duty to review their quality assurance systems to ensure that they remain fit for purpose and are current and reflective of national best practice recommendations as well as changing legislation and regulation. Quality changes all the time
- Quality is determined and led by Service Users, their relatives, advocates and related professionals
- All staff must adhere to total commitment to quality and improvement in every aspect of their work
- The purpose of having policies, procedures and guidelines in place is to detail how a quality delivery of service is to be achieved
- Supporting Service Users in a person-centred, safe, effective, responsive and caring way to maximise their independence is paramount in defining quality at Care 4 You Care Agency
- The culture at Care 4 You Care Agency is one of continued review to ensure that quality Care and service is delivered
- As part of this framework, staff will be expected to participate in contributing their views and feedback that will influence the quality framework and therefore the quality of Care that Service Users receive
- Care 4 You Care Agency will benchmark current performance against agreed performance standards and ensure it makes changes to improve performance. It will seek new ways of working to continuously improve
Key Facts - People affected by the service
People affected by this service should be aware of the following:
- Care 4 You Care Agency is fully committed to providing the highest possible quality of service to you
- Care 4 You Care Agency provides evidence-based Care and continually monitors services to ensure they provide the highest quality of care and best value
- Care 4 You Care Agency obtains feedback from others who are involved with its services to ensure that they remain fit for purpose and reflect your needs and wishes
- Your safety and wellbeing are a priority for Care 4 You Care Agency and we will make sure that you know how to tell us if you are worried about being harmed or you have been harmed
- We always want to hear what you think about the service. Care 4 You Care Agency will ask you for your feedback and views to make the service better so we are always improving. You are able to give feedback at any time to a member of staff
- Care 4 You Care Agency continually monitors the quality of its service and the Care provided to ensure that it meets your needs
- Care 4 You Care Agency will make sure that all our staff are trained on how to keep you safe and well in your own home
Further Reading
As well as the information in the 'underpinning knowledge' section of the review sheet we recommend that you add to your understanding in this policy area by considering the following materials:
The National Institute for Health and Care Excellence (NICE) has a host of best practice documents relevant for both health and social care as well as audit tools and e-learning: https://www.nice.org.uk/
The Social Care Institute for Excellence (SCIE) has a page on their website dedicated to available quality assurance resources and services: https://www.scie.org.uk/atoz/?f_az_subject_thesaurus_terms_s=quality+assurance&st=atoz
CQC has a range of resources that can be accessed via: https://www.cqc.org.uk/publications/themes-care/themes-health-social-care
Think Local Act Personal: A national partnership transforming health and care through personalisation and community-based support. It published its 'Driving up Quality' paper with key principles for quality assurance and has a range of resources on its website: https://www.thinklocalactpersonal.org.uk/
The Healthcare Quality Improvement Partnership (HQIP) offers a range of resources including audits and guides for the social care sector and care homes: https://www.hqip.org.uk/
Outstanding Practice
To be ‘ outstanding ’ in this policy area you could provide evidence that:
- Care 4 You Care Agency has a culture of learning, reflecting and reviewing of processes to ensure they remain fit for their purpose and are the most effective and efficient that they can be
- Care 4 You Care Agency seeks feedback from stakeholders at every opportunity to mould the service around the needs of the Service User
- Staff have access to a range of best practice resources and have a competent understanding of quality and quality assurance
- Care 4 You Care Agency subscribes to quality marks and initiatives to raise quality standards and takes part in national audits relevant to its service. It embeds any recommendations from the outcome of these
- Care 4 You Care Agency utilises mock inspection toolkits to identify where quality and compliance can be improved. Corrective action is taken as necessary and is documented
- Systems are in place to measure quality assurance and actions are completed in a timely manner which demonstrates embedment and sustainability
- The wide understanding of the policy is enabled by proactive use of the QCS App
- Care 4 You Care Agency reviews practice to ensure that policies, procedures and audits are embedded and part of daily working practice
Forms
Currently there is no form attached to this policy.
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