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Gathering Feedback Policy

1. Purpose

The purpose of this policy is to set out the arrangements by which the domiciliary support service obtains, records, reviews, analyses and acts upon feedback about the quality of care and support it provides.

The service will maintain effective arrangements for monitoring, reviewing and improving the quality of care and support in accordance with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

In accordance with Regulation 8, the service provider will make arrangements for regularly seeking the views of:

• individuals receiving care and support;
• their representatives, unless this would be inappropriate or inconsistent with the individual’s well-being;
• service commissioners; and
• staff.

These views will relate to the quality of care and support provided by the service and how that care and support can be improved.

When making decisions about plans for improving the quality of care and support, the service provider will take account of the views obtained and will have regard to the Quality of Care Review report prepared by the Responsible Individual in accordance with Regulation 80.

In accordance with Regulation 76, the Responsible Individual will maintain suitable arrangements for obtaining the views of individuals, their representatives, service commissioners and staff about the quality of care and support and how it can be improved. The Responsible Individual will report those views to the service provider so that they can be taken into account when decisions are made about service improvement.

Feedback will be used to:

• monitor individuals’ experiences and outcomes;
• identify strengths, concerns, risks and areas requiring improvement;
• inform changes to care and support, policies, procedures, staff development and service delivery where required;
• support the monitoring, reviewing and improvement of the service;
• identify themes, patterns and lessons from feedback, concerns and complaints; and
• contribute to the Responsible Individual’s Quality of Care Review under Regulation 80.

2. Scope

This policy applies to the arrangements for obtaining and responding to feedback from:

• individuals receiving care and support from the service;
• representatives of individuals, unless their involvement would be inappropriate or inconsistent with the individual’s well-being;
• service commissioners;
• staff employed by or working within the service; and
• other relevant professionals or stakeholders where their feedback relates to the quality, safety or effectiveness of the service.

This policy applies to:

• formal and informal feedback;
• compliments, comments and concerns;
• feedback obtained through care and support reviews;
• surveys and questionnaires;
• discussions with individuals and their representatives;
• staff feedback;
• commissioner feedback;
• feedback obtained by the Responsible Individual;
• relevant information arising through complaints; and
• information used to monitor, review and improve the quality of care and support.

Feedback arrangements must be accessible and appropriate to the individual’s communication needs, language needs, level of understanding and any relevant disability or impairment.

Nothing in this policy replaces the service’s statutory Complaints and Compliments Policy, Safeguarding Policy or Whistleblowing Policy. Where information received as feedback constitutes a complaint, safeguarding concern, whistleblowing concern or other reportable matter, the relevant policy and statutory procedure must also be followed.

3. Methods of Gathering Feedback

We use a variety of methods to collect feedback, ensuring inclusivity and accessibility for all stakeholders.

3.1 Individual and Representative Feedback

The service will regularly seek the views of individuals receiving care and support about the quality of that care and support and how the service can be improved.

Where appropriate, the service will also seek the views of an individual’s representative. A representative will not be involved where the individual does not wish them to be involved, where they do not have appropriate authority or consent, or where their involvement would be inconsistent with the individual’s well-being.

Feedback may be obtained through:

• discussions during care and support reviews;
• one-to-one discussions and monitoring contacts;
• home visits;
• satisfaction surveys and questionnaires;
• telephone discussions;
• written or electronic feedback;
• meetings with representatives, where appropriate;
• the Responsible Individual’s engagement arrangements and statutory visits; and
• complaints, concerns, compliments and other comments received by the service.

The method used to obtain feedback must be appropriate to the individual’s age, level of understanding, communication needs and circumstances.

The service will take reasonable steps to meet each individual’s language and communication needs when seeking feedback. This includes, where required:

• providing information and feedback opportunities in Welsh;
• supporting an individual’s preferred language and method of communication;
• providing accessible or Easy Read information;
• providing information in large print or other appropriate formats;
• using appropriate communication aids or assistive technology;
• providing opportunities for verbal rather than written feedback;
• arranging interpreting or translation where required; and
• supporting access to advocacy where appropriate.

Individuals will be given appropriate support to understand how they can provide feedback and will not be disadvantaged because of the nature of the feedback they provide.

3.2 Staff Feedback and Engagement

To maintain a positive and responsive workplace, we actively collect staff feedback through:

• Annual staff surveys assessing job satisfaction and workplace culture.
• Regular team meetings and supervision sessions.
• Exit interviews for staff leaving the organisation.
• Open-door policy, allowing staff to raise concerns with management.
• Whistleblowing (Speaking Up) Policy (DCW29), ensuring staff can report concerns confidentially.

3.3 Service Commissioner and Relevant Professional Feedback

The service provider will maintain arrangements for seeking the views of service commissioners about the quality of care and support provided by the service and how it can be improved.

The Responsible Individual will also maintain suitable arrangements for obtaining the views of service commissioners in accordance with Regulation 76 and will report those views to the service provider.

Where relevant to the care and support provided, feedback may also be obtained from professionals and agencies working with individuals, including:

• social workers;
• local authority commissioning and monitoring officers;
• NHS professionals;
• GPs;
• district nurses;
• allied health professionals;
• advocacy organisations; and
• other professionals involved in an individual’s care and support.

Feedback relevant to service quality will be recorded, considered and, where necessary, incorporated into improvement actions and the service’s quality-monitoring arrangements.

3.4 Complaints and Compliments as Feedback

• All formal complaints and compliments are recorded and reviewed as part of our quality improvement strategy.
• Compliments are shared with staff to promote good practice.
• Complaints are investigated promptly, with findings used to improve services.

3.5 Responsible Individual Engagement and Statutory Visits

The Responsible Individual will maintain suitable arrangements for obtaining the views of individuals receiving care and support, their representatives where appropriate, service commissioners and staff about the quality of care and support provided and how it can be improved.

In accordance with Regulation 73, the Responsible Individual will undertake an in-person statutory visit to the service at least once every three months.

As part of these visits, the Responsible Individual will engage meaningfully with people supported by the service and members of staff. With the individual’s consent, this may include meeting individuals privately and, for the domiciliary support service, visiting a representative sample of individuals in their own homes where appropriate.

The Responsible Individual’s statutory visits will be recorded and documented. Records will include:

• the date of the visit;
• details of discussions with staff and individuals receiving care and support;
• details of relevant records reviewed;
• any feedback, concerns or areas requiring improvement identified; and
• the outcome of the visit, including actions taken or required to improve the service.

The Responsible Individual will report the views obtained through engagement to the service provider so that those views can be taken into account when decisions are made about plans for improving the quality of care and support.

Information obtained through the Responsible Individual’s engagement and statutory visits will contribute to the Quality of Care Review required under Regulation 80.

4. Recording, Reviewing and Analysing Feedback

Feedback received by or on behalf of the service will be recorded, reviewed and used as part of the service’s arrangements for monitoring, reviewing and improving the quality of care and support.

4.1 Recording and Confidentiality

Feedback will be recorded accurately and in sufficient detail to enable the service to identify the issue raised, any action required and the outcome.

Records of feedback will be kept securely and handled in accordance with applicable data protection and confidentiality requirements and the organisation’s Confidentiality and Data Protection Policy.

The service will maintain arrangements that enable feedback to be collated and analysed for relevant themes, patterns and trends.

Where feedback is provided anonymously, this will not prevent the service from considering or acting upon the information where sufficient information is available to do so.

Where feedback identifies or indicates:

• abuse, neglect or improper treatment;
• a safeguarding concern;
• a complaint;
• a whistleblowing concern;
• a significant risk to an individual;
• an incident requiring notification; or
• another matter requiring action under a separate statutory procedure,

the relevant policy and statutory process will be followed without delay.

4.2 Analysis, Improvement and Quality of Care Review

The service provider will ensure there are effective arrangements for monitoring, reviewing and improving the quality of care and support.

Feedback from individuals, representatives, service commissioners and staff will be analysed and taken into account when decisions are made about plans for improving the service.

The service will be able to demonstrate:

• what feedback has been received;
• how that feedback has been analysed;
• what themes or trends have been identified;
• what decisions or actions have resulted from the feedback;
• who is responsible for implementing improvement actions;
• whether the actions have been completed; and
• whether the action taken has resulted in improvement.

The Responsible Individual will maintain a system for monitoring, reviewing and improving the quality of care and support in accordance with Regulation 80.

The quality of care and support will be reviewed as often as required and at least once every six months.

As part of each Quality of Care Review, the Responsible Individual will make arrangements for considering:

• the outcome of engagement with individuals, representatives, service commissioners and staff in accordance with Regulation 76;
• aggregated information relating to incidents and notifiable incidents;
• safeguarding matters;
• whistleblowing matters;
• concerns and complaints;
• action taken in relation to complaints; and
• the outcome of audits concerning the accuracy and completeness of required records.

Following each Quality of Care Review, the Responsible Individual will prepare a report to the service provider, where required by Regulation 80, which includes:

• an assessment of the standard of care and support provided by the service; and
• recommendations for improvement.

The findings and recommendations from the Quality of Care Review will be used to inform the service provider’s decisions and improvement planning.

Quality monitoring, feedback records, action plans and Quality of Care Review documentation will be retained as evidence of regulatory compliance and made available to Care Inspectorate Wales where lawfully required as part of its regulatory functions.

5. Acting on Feedback and Improvement

The service provider will take account of the views obtained from individuals, representatives, service commissioners and staff when making decisions about plans for improving the quality of care and support.

The service provider will also have regard to the findings and recommendations contained in the Responsible Individual’s Quality of Care Review report.

Where feedback identifies that improvement or corrective action is required, the service will:

• identify the action required;
• allocate responsibility for completing the action;
• establish an appropriate timescale;
• record the action taken;
• monitor progress;
• assess whether the action has achieved the intended improvement; and
• take further action where the required improvement has not been achieved.

Actions resulting from feedback may include changes to:

• an individual’s care or support arrangements;
• staff practice;
• training or supervision;
• communication arrangements;
• policies or procedures;
• quality assurance systems; or
• wider service-delivery arrangements.

Where feedback indicates an immediate risk to the safety or well-being of an individual, the service will take appropriate action without delay and will follow any relevant safeguarding, incident-reporting or notification procedure.

Where feedback affects an individual’s care and support, relevant changes will be reflected in the individual’s records, assessments or personal plan where required.

6. Fairness, Confidentiality and Safe Feedback

The service will provide opportunities for individuals, representatives, staff and other relevant persons to provide feedback openly and, where practicable, confidentially.

Feedback will be treated fairly and respectfully. No individual will receive poorer care or treatment because they, or a person acting appropriately on their behalf, have raised a concern, criticism or complaint.

The service will protect confidential information in accordance with applicable data protection and confidentiality requirements.

The service will not promise absolute confidentiality or anonymity where information must lawfully be shared in order to:

• protect an individual from abuse, neglect or improper treatment;
• respond to a safeguarding concern;
• prevent serious harm;
• comply with a legal requirement;
• make a required referral or notification; or
• respond appropriately to another significant risk.

Where feedback raises a safeguarding concern, the Safeguarding Adults from Abuse and Improper Treatment Policy or other applicable safeguarding procedure will be followed immediately.

The service will ensure that feedback arrangements are accessible and appropriate to the individual’s communication needs, language needs, level of understanding and circumstances, and will provide appropriate support to enable the individual to express their views.

7. Regulatory Oversight and Quality Assurance

The service will maintain evidence demonstrating compliance with its statutory arrangements for obtaining views, monitoring service quality and using feedback to improve care and support.

This will include, as applicable:

• records of feedback obtained from individuals and representatives;
• records of commissioner feedback;
• records of staff feedback;
• evidence of the Responsible Individual’s engagement under Regulation 76;
• records of the Responsible Individual’s statutory visits under Regulation 73;
• feedback analysis;
• improvement plans and records of actions taken;
• evidence of monitoring the effectiveness of improvement actions; and
• Quality of Care Review reports prepared in accordance with Regulation 80.

The Responsible Individual will report the views obtained under Regulation 76 to the service provider.

The Responsible Individual will ensure that the quality of care and support is reviewed as often as required and at least every six months in accordance with Regulation 80.

Where required by Regulation 80, the Responsible Individual will prepare a Quality of Care Review report for the service provider containing an assessment of the standard of care and support provided and recommendations for improvement.

Relevant records will be maintained and made available to Care Inspectorate Wales where required in connection with its regulatory and inspection functions.

8. Staff Responsibilities

Staff must understand their responsibilities for supporting individuals to express their views about the quality of care and support they receive.

Staff must:

• listen to individuals respectfully and take their views seriously;
• support individuals to communicate using their preferred and appropriate method of communication;
• record feedback accurately in accordance with the service’s procedures;
• ensure relevant feedback is passed to the appropriate manager or person responsible for quality monitoring;
• distinguish between general feedback and information which constitutes a complaint, safeguarding concern, whistleblowing concern, incident or other reportable matter;
• follow the appropriate policy and procedure where feedback identifies a complaint, safeguarding concern, whistleblowing concern or risk to an individual’s safety or well-being;
• cooperate with feedback, quality assurance and Responsible Individual engagement arrangements; and
• implement improvement actions relevant to their role.

Staff must not discourage an individual or representative from expressing concerns, criticism or dissatisfaction with the service.

Managers must ensure relevant feedback is incorporated into the service’s monitoring and quality-improvement arrangements and escalated to the Responsible Individual where appropriate.

9. Related Legislation, Guidance and Policies

This policy must be read and implemented alongside the following legislation and statutory requirements:

• Regulation and Inspection of Social Care (Wales) Act 2016;
• Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• Welsh Government statutory guidance for service providers and Responsible Individuals on meeting service standard regulations for care home and domiciliary support services;
• applicable data protection legislation; and
• applicable CIW regulatory requirements.

Particular regard must be given to:

• Regulation 8 – Requirements in relation to monitoring and improvement;
• Regulation 23 – Information;
• Regulation 24 – Language and communication;
• Regulation 64 – Complaints policy and procedure;
• Regulation 73 – Responsible Individual visits;
• Regulation 76 – Engagement with individuals and others;
• Regulation 77 – Duty to ensure systems are in place to record incidents and complaints;
• Regulation 79 – Duty to ensure policies and procedures are up to date; and
• Regulation 80 – Quality of Care Review.

This policy should also be read alongside:

• Complaints and Compliments Policy (DCW33);
• Whistleblowing (Speaking Up) Policy (DCW29);
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13);
• Confidentiality and Data Protection Policy (DCW34); and
• Quality Assurance and Continuous Improvement Policy (DCW35).

10. Policy Review and Responsibilities

This policy will be reviewed at least annually and sooner where required because of:

• changes to legislation or statutory guidance;
• changes to CIW regulatory requirements;
• changes to the service or its Statement of Purpose;
• findings from a CIW inspection;
• findings from a Quality of Care Review;
• feedback, complaints, safeguarding matters or other quality-monitoring information indicating that amendment is required; or
• identified changes in practice.

The service provider is responsible for ensuring that effective arrangements are in place for monitoring, reviewing and improving the quality of care and support in accordance with Regulation 8.

The Responsible Individual is responsible for maintaining suitable arrangements for obtaining and reporting the views required under Regulation 76, undertaking statutory visits in accordance with Regulation 73, ensuring suitable arrangements are in place to keep policies and procedures up to date in accordance with Regulation 79, and maintaining the Quality of Care Review system required under Regulation 80.

The Registered Manager is responsible for the day-to-day implementation of this policy, ensuring that staff understand and follow the required procedures and that relevant feedback is appropriately recorded, escalated and used to support improvement.

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