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Quality Assurance Policy

1. Purpose and Scope

This Quality Assurance Policy outlines our commitment to providing the highest standard of care. It applies to all staff, managers, and stakeholders involved in our services. The purpose of this policy is to ensure a consistent approach to quality across our care home, driving continuous improvement so that residents receive safe, effective, and compassionate care. By implementing this policy, we aim to meet and exceed regulatory requirements and maintain care services that residents, families, and regulators can trust.

2. Policy Statement and Commitment to Quality

We are dedicated to a culture of continuous quality improvement. No matter how good our current services are, we believe there is always room for improvement. Our residents have an absolute right to high-quality, person-centred care that respects their dignity, choice, and independence. Key principles of our quality commitment include:

Person-Centred Care: Services will be tailored to each individual’s needs and preferences. We uphold residents’ rights to privacy, dignity, and independence, involving them (and their families or advocates) in decisions about their care. We support each person’s choices and encourage feedback to shape the way care is delivered.

Safety and Effectiveness: The care we provide will protect residents from harm and be based on best practices. We ensure care and clinical interventions (where applicable in nursing care) are evidence-based and aligned with professional standards. Risks are proactively identified and mitigated to keep people safe, and any incidents are learned from to prevent recurrence.

Caring and Compassionate Service: All staff are expected to demonstrate kindness, respect, and compassion in every interaction. We foster a caring environment that promotes dignity and respect for everyone. Residents and their families should feel listened to, valued, and confident in the care they receive.

Responsive and Inclusive Care: Our services adapt to the changing needs and choices of residents. We respond promptly to feedback, concerns, or changing health needs, ensuring that care plans are updated and resources adjusted to meet each resident’s requirements. We also value equality and diversity, making sure care is inclusive and accessible for people of all backgrounds.

Well-Led Services: Strong leadership and governance are essential for quality. Our management will promote an open, no-blame culture where problems are addressed constructively and staff are empowered to contribute ideas. We ensure clear communication, accountability at all levels, and robust systems to monitor performance. Leaders will allocate resources and support necessary for maintaining high quality care.

3. Regulatory and Best Practice Framework

Our quality assurance system is built around the Care Quality Commission’s assessment framework, which is structured around five key questions (Safe, Effective, Caring, Responsive, Well-led) and the quality statements that sit under each key question. We use the quality statements as our “golden thread” to evidence how we deliver safe, person-centred care and how we continuously assess and improve quality, rather than relying only on periodic inspections.

We also ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended), including the Fundamental Standards (Regulations 9 to 20A). In particular, we meet Regulation 17 (Good Governance) by operating effective systems and processes to:

assess, monitor and improve the quality and safety of the services we provide (including people’s experience),

assess, monitor and mitigate risks relating to health, safety and welfare, and

maintain complete, accurate and contemporaneous records and governance information required to manage the regulated activity.
Our internal audits and governance checks are explicitly baselined against Regulations 4–20A, and our systems are reviewed routinely to ensure they remain fit for purpose and drive timely improvement.

Fundamental Standards Compliance Map (Regs 9–20A)
To ensure we can evidence ongoing compliance, our QA programme includes specific monitoring against each relevant regulation, including (but not limited to):

Reg 9 (Person-centred care) – care plan audits, reviews of involvement/choice, and outcome tracking.

Reg 9A (Visiting and accompanying in care homes) – auditing visiting arrangements, communication to families, and any restrictions to ensure they are lawful, proportionate and documented.

Reg 10 (Dignity and respect) – observational audits, feedback/surveys, and privacy/dignity spot checks.

Reg 11 (Need for consent) – MCA/consent documentation audits, best-interest decision audits where applicable.

Reg 12 (Safe care and treatment) – medication audits, infection prevention and control audits, risk assessments, equipment checks, and incident trend review.

Reg 13 (Safeguarding from abuse/improper treatment) – safeguarding reporting audits, allegation handling, and staff competence checks.

Reg 14 (Nutrition and hydration) – nutrition audits, MUST/weight monitoring audits (as applicable), mealtime observations.

Reg 15 (Premises and equipment) – environmental audits, maintenance compliance, safety checks.

Reg 16 (Receiving and acting on complaints) – complaints timeliness/learning audits and “you said, we did” evidence.

Reg 17 (Good governance) – governance calendar compliance, KPI dashboards, audit-to-action tracking, record quality audits.

Reg 18 (Staffing) – safe staffing reviews, dependency tools (where used), rota audits, supervision compliance.

Reg 19 (Fit and proper persons employed) – recruitment file audits (DBS/refs/right to work/qualification checks).

Reg 20 (Duty of candour) – notifiable safety incident reviews and duty of candour compliance audits.

Reg 20A (Display of performance assessments) – audits that required ratings/posters/website displays are in place and current.
Evidence from these checks is logged, reviewed at QA meetings, and used to generate improvement actions with owners, deadlines, and verification of completion.

4. Internal Quality Monitoring and Improvement

Internal quality assurance processes are the backbone of our continuous improvement approach. We have established a comprehensive system of internal monitoring activities to regularly evaluate our performance and identify areas for improvement. Key components of our internal QA program include:

Regular Audits: We conduct scheduled audits covering all critical aspects of care and service delivery, such as care plans, medication management, infection control, health and safety, nutrition, and record-keeping. These audits are carried out by trained staff or managers using standardised tools. Findings from audits are documented and analysed to ensure we are meeting internal standards as well as regulatory requirements. According to CQC guidance, providers must use processes like regular audits to “assess, monitor and improve the quality and safety of the service”. Our audit schedule is aligned with CQC Fundamental Standards and is reviewed periodically to remain effective. Where audits identify shortfalls or areas for improvement, remedial actions are taken promptly. Our audit tools and audit schedule are explicitly mapped to the Fundamental Standards and are baselined against Regulations 4–20A, with clear escalation routes where audits identify any risk of non-compliance or harm.

Quality Indicators and Data Monitoring: We track key performance indicators (KPIs) and outcomes (e.g., number of falls, medication errors, incidents, hospital admissions, complaints, etc.) on an ongoing basis. This data is reviewed in management meetings to spot trends or emerging risks. Information is kept up-to-date and analysed by people with the right skills so that it can drive decision-making. If indicators show any decline in performance or risk, we investigate the causes and implement improvement measures. This data-driven approach allows us to objectively measure quality and demonstrate improvements over time.

Incident Reporting and Learning: All accidents, incidents, near-misses, and safeguarding concerns are reported through our internal reporting system. Each incident is investigated and analysed to understand root causes. We share lessons learned with the staff team in a blame-free manner, focusing on problem resolution rather than blame. By learning from incidents and near-misses, we take corrective action to prevent recurrence and improve safety. Trends from incidents are reviewed (for example, through monthly governance meetings) so that systemic issues can be addressed (e.g., additional training or changes in procedure if needed).

Duty of Candour (Regulation 20) and Notifiable Safety Incidents
We comply with the statutory Duty of Candour by acting in an open and transparent way with residents and/or relevant persons whenever a notifiable safety incident occurs. Where the duty applies, we will:

notify the resident/relevant person as soon as reasonably practicable,

provide a truthful account of what is known at the time (and update as the investigation progresses),

offer an apology, and explain what further enquiries/investigation will take place,

provide reasonable support to the resident/relevant person, and

keep a full written record of all communications and actions taken.

Duty of candour compliance is reviewed through governance: any notifiable safety incident triggers a management review, a root cause analysis (where appropriate), learning dissemination, and verification that the duty of candour steps and documentation have been completed.

Complaints, Compliments and Feedback: {{org_field_name}} treats every complaint as an opportunity to improve. Our complaints procedure ensures concerns are investigated and responded to promptly. We log all complaints and compliments, analyze them for themes, and report these in quality meetings. In line with good practice, we seek and act on feedback from people using the service, their representatives, and staff to continually evaluate and improve services. We encourage residents and families to voice concerns or suggestions freely, through resident meetings, surveys, suggestion boxes, or one-to-one conversations. Positive feedback and compliments are also shared with staff to reinforce good practice. All feedback is reviewed by management and contributes to our ongoing improvement plans.

Resident and Family Involvement: We actively involve those who use our services in the quality assurance process. Residents (and their relatives or advocates) are invited to participate in care plan reviews and residents’ meetings to discuss what is working well and what could be improved. Satisfaction surveys are conducted at least annually (and more frequently for new residents) to gauge opinions on key aspects of care such as dignity, food, activities, and staff attitude. Where possible, we incorporate “I statements” (e.g., “I feel in control and safe” or “I have considerate support delivered by competent staff”) as outcome measures of quality, reflecting the personal experience of care. Their input is valued: if an issue is raised by people using the service, we take it seriously and include it in our action plans. We make a point to inform residents and families about changes or improvements made as a result of their feedback, closing the loop so they know their voice makes a difference.

Staff Engagement and Communication: Quality improvement is everyone’s responsibility. We maintain open channels for staff to provide feedback on policies, procedures, and day-to-day issues that might affect quality. Regular staff meetings, handovers, and internal communications (newsletters, noticeboards) are used to discuss quality issues, share updates, and celebrate achievements. Staff are encouraged to raise concerns or ideas for improvement with management at any time. We believe that front-line care staff often have valuable insights into how to improve service delivery. By listening to our staff and addressing their concerns, we foster a culture of continuous improvement and teamwork in quality assurance. We promote a safe speaking-up culture. Staff can raise concerns through their line manager, senior manager, or via the organisation’s whistleblowing route without fear of victimisation. Concerns raised are logged, investigated proportionately, and outcomes/learning are fed back (as appropriate) so that staff can see concerns lead to improvement. Speaking-up themes are reviewed within governance meetings as part of our Well-led assurance.

Management Review and Internal Inspections: The Home Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}) and senior team carry out routine internal inspections or “spot checks” within the home. This might include daily walkarounds, reviewing cleanliness and safety, observing care practices, and speaking with residents about their experience. Management also convenes regular Quality Assurance meetings (e.g., monthly or quarterly) to review audit results, incidents, feedback, and progress on action plans. These reviews help us to identify where quality or safety might be compromised and respond without delay. Additionally, our organisational leadership (such as regional managers or directors, if applicable) conduct periodic oversight visits to each home to ensure standards are consistent across the group and to support the home in its quality objectives. Any significant findings from these management reviews result in documented quality improvement plans which are monitored to completion.

All these internal monitoring activities feed into our continuous quality improvement cycle. We use a “Plan-Do-Check-Act” approach: setting quality objectives and standards (Plan), implementing them in practice (Do), auditing and reviewing performance (Check), and making necessary changes (Act). There is an active internal audit process with outcomes feeding back into the quality cycle. By continuously looping through this cycle, we strive to maintain high standards and make incremental improvements in care delivery.

Staff Training, Supervision and Support

We recognize that a well-trained and supported workforce is fundamental to delivering quality care. Our policy includes strong provisions for staff training, supervision, and professional development as part of quality assurance:

Recruitment and Induction: We recruit staff who share our values of compassion and excellence. Before starting work, all staff (including agency or temporary staff) undergo a thorough induction program that covers our standards of care, policies and procedures, infection control, safeguarding, health and safety, and confidentiality. New employees are oriented to the specific needs of our resident group (for example, dementia care, frailty, or nursing tasks) so they can provide appropriate support from the outset.

Mandatory and Ongoing Training: We ensure that all care staff, nurses, and other team members complete mandatory training modules (such as moving and handling, first aid, medication management, fire safety, dementia awareness, etc.) as required by CQC and other regulators. Mandatory training and guidance updates also include any requirements arising from Fundamental Standards updates relevant to care homes, including visiting and accompanying arrangements (Reg 9A), so staff understand how to support safe visiting while protecting residents’ rights. Training is kept up-to-date with refresher courses at scheduled intervals. In addition, we provide opportunities for further learning and development, including relevant NICE guidance updates or best practice workshops, so that staff can incorporate the latest evidence-based practices into their care. Where areas for improvement are identified (e.g., an audit finds gaps in infection control technique), targeted training sessions are arranged. We maintain detailed training records and a training matrix to monitor compliance and to plan future training needs.

Supervision and Appraisals: Every staff member receives regular supervision (one-to-one meetings with a supervisor or manager) to reflect on their practice, discuss any challenges, and set goals. Supervisions are typically held every 6-8 weeks (or more frequently for new staff or if performance issues arise). We also conduct formal appraisals annually to evaluate performance over the year and identify professional development plans. Through supervision and appraisal, we ensure each staff member is clear about their role, receives feedback, and has a personal development plan. This helps maintain high performance and job satisfaction. It is our policy that personal development plans, supervision, and appraisal systems for staff are in place to ensure they have the relevant skills, knowledge and expertise required for their job roles. If any competency gaps are identified, we address them with coaching, mentoring, or additional training.

Competence and Professional Standards: We expect all staff to practice in line with their professional standards and our internal quality standards. For nursing staff, this means adhering to the Nursing and Midwifery Council (NMC) code; for care assistants, following the Skills for Care Code of Conduct; and for other professionals (e.g., therapists, chefs, cleaners), meeting industry best practices. We periodically observe staff practice (for example, medication administration rounds, moving and handling techniques) to ensure procedures are carried out safely and correctly. Any identified issues trigger further training or support. We also encourage staff to pursue vocational qualifications (such as NVQs/QCF diplomas in Health and Social Care) and provide support for continuous professional development.

Staff Support and Wellbeing: Quality care can only be delivered by staff who feel valued and supported. We promote a positive working environment where staff well-being is taken seriously. This includes ensuring safe staffing levels so employees are not overburdened, providing access to mental health or occupational health support if needed, and recognizing good performance. We have zero tolerance for bullying or discrimination; an open-door policy allows staff to report any workplace concerns. By supporting our staff and maintaining open communication, we enable them to focus on providing excellent care. A culture of support and learning (rather than blame) means staff are more likely to report errors or near-misses, which in turn helps us improve practices. Ultimately, competent and confident staff lead to better quality outcomes for residents.

External Quality Assurance and Compliance

In addition to our internal processes, we engage in external quality monitoring to validate our performance and remain accountable. We embrace external inspections and reviews as opportunities to demonstrate our quality and to learn how we can improve further. Key external QA mechanisms include:

CQC Inspections: As a CQC-registered service, we are subject to periodic inspections by the Care Quality Commission. We fully cooperate with CQC inspectors, providing them access to our premises, records, staff, and residents as required. Our goal is to achieve and maintain at least a “Good” rating (or “Outstanding”) in all five key questions (Safe, Effective, Caring, Responsive, Well-led). The CQC assessment framework and quality statements serve as a benchmark for our care. After any inspection, we closely review the CQC report and ratings. If any regulatory breaches or improvement recommendations are identified, we develop a clear action plan to address them. We then implement those actions promptly and monitor their completion. Likewise, positive feedback from CQC (areas of good practice) is celebrated and shared across our homes. Compliance with CQC requirements is non-negotiable; failure to meet fundamental standards triggers immediate corrective action and could jeopardize our registration. Thus, aligning with CQC expectations is a core component of this policy. We comply with Regulation 20A by displaying our current CQC rating in the required formats and locations (including where applicable at the premises and on any provider website). This is checked through routine governance audits and immediately updated following any change to our CQC rating.

Local Authority and Commissioning Reviews: Many of our residents are placed or funded by local authorities or NHS commissioners. These bodies often have their own contract monitoring processes or quality assurance frameworks. We ensure full compliance with all clauses in our contracts related to quality of care, safeguarding, record-keeping, and outcomes. We welcome quality monitoring visits or reviews by commissioning teams (for example, a local authority quality monitoring officer may visit to check on care quality or review records). During such visits, we provide any requested data or documents (such as training records, policies, audit results) and facilitate private feedback sessions with residents or staff if the reviewers wish. If a local authority uses a Quality Assessment Framework (QAF) with specific criteria, we self-assess against those criteria in preparation and work to meet the required standards. Any findings from external contract monitoring are taken seriously: we will promptly address any noted shortfalls and report back on improvements made. Maintaining positive relationships with commissioners and meeting their quality expectations is important, as reflected in our commitment to meet all legal, regulatory, and contractual compliance requirements.

External Audits and Accreditation: Where appropriate, we may engage independent audits or pursue accreditation schemes to validate our quality. For instance, we might use an external auditor or consultant to conduct an annual mock inspection or health and safety audit, providing an objective perspective on our services. We consider recommendations from these external audits to enhance our practices. Additionally, if industry-recognised quality award programs or accreditation (e.g., Gold Standards Framework for end-of-life care, or hospitality awards for catering) are available, we may participate to benchmark ourselves against best practice. While such accreditations are voluntary, they demonstrate our commitment to going above and beyond minimum standards. Any external accolades or certifications will be maintained through continuous adherence to those higher standards.

Collaboration and Transparency: We work collaboratively with external bodies, such as healthcare professionals (GPs, community nurses, therapists), social workers, safeguarding teams, and others who have input into our residents’ care. Their feedback on our service quality is welcomed. If any external professional or organization raises a concern about quality, we investigate it fully and openly. We also share relevant information with external agencies when needed to safeguard residents or improve care (for example, notifying the local safeguarding board of incidents, or cooperating with infection control teams during public health outbreaks). By being transparent and responsive with external partners, we ensure that our quality assurance is not insular but part of the wider health and social care system’s efforts to uphold high standards.

Statutory Notifications and Information to CQC
In addition to inspection activity, we meet our legal duty to provide statutory notifications and information to the CQC in line with the Care Quality Commission (Registration) Regulations 2009 (as amended). We maintain a notification log and audit it routinely to confirm that:

notifications are submitted within required timescales,

information is accurate, consistent with internal incident/complaints records, and appropriately investigated, and

any themes/trends are reviewed through governance with action plans created and completed.
Where a notifiable event also meets the threshold for safeguarding referral, police involvement, coronial processes, or duty of candour, the notification process is coordinated to ensure all parallel duties are met and evidenced.

Roles and Responsibilities

Quality assurance is embedded in every role within our organization. The following outlines key responsibilities:

Registered Manager: The Registered Manager holds overall responsibility for implementing this Quality Assurance Policy at the home level. They ensure that compliance with regulatory and contractual requirements is maintained and that all internal quality processes (audits, supervisions, etc.) are carried out effectively. The manager reviews outcomes from audits and incidents, seeks feedback from residents, relatives, and staff, and takes action on any identified issues. They are responsible for developing and updating home-level Quality Improvement Plans and reporting on quality performance to senior management. The Registered Manager also ensures there are sufficient numbers of suitably trained staff to deliver safe, high-quality care at all times. If the Manager is absent, a designated competent deputy will assume these responsibilities.

All Staff: Every staff member, from care assistants and nurses to ancillary and administrative staff, has a duty to contribute to quality assurance. Staff are expected to follow all policies and procedures, deliver care to the required standards, and report any concerns about quality or safety to management. They should participate openly in audits, inspections, and training. Staff are also encouraged to suggest ideas for improvement. By carrying out their roles diligently and embracing a culture of quality, staff ensure that daily practices reflect the high standards we aim for. We emphasize that quality is everyone’s business – even small actions (like prompt reporting of a maintenance issue or spending extra time to comfort a resident) add up to the overall quality of service.

Senior Management / Quality Team: At the organizational level, senior managers or a dedicated Quality Assurance Team (if in place) provide oversight and support. They set the overall quality strategy and objectives, ensuring this policy is implemented uniformly across all homes. Senior management allocates resources (budget, training, personnel) to support quality initiatives. They also stay updated on regulatory changes and best practices, updating policies and guidance accordingly. Regular reports on each home’s quality metrics, incidents, and improvements are reviewed at senior level (e.g., in governance meetings or board reports). The organization’s leadership fosters a culture where quality improvement is prioritised and supports home managers in tackling any quality challenges. They also may conduct unannounced visits or quality audits to verify standards first-hand. Ultimately, the owners/board have a responsibility to ensure that effective governance systems (as required by Reg 17) are in place and that this policy is not just a document but a living process driving improvement.

Residents and Families: While not “responsible” in the same way as staff, we view residents and their loved ones as partners in quality assurance. Their role is to provide honest feedback about their experience and to engage with us in making the service better. We encourage residents and families to attend meetings, fill in surveys, and speak up about any concerns or suggestions. Their participation helps keep us aligned with what matters most to those we care for. We commit to listening and responding to this input as part of our responsibility.

External Stakeholders: Other stakeholders such as healthcare professionals, regulators, and commissioners also play a role in our quality ecosystem. We expect our team to cooperate professionally with these stakeholders. For example, when a CQC inspector or contract officer visits, staff should be courteous, transparent, and helpful. If a visiting health professional advises on improving a resident’s care, staff should take that advice on board as part of quality improvement. By respecting the insights and requirements of external stakeholders, we strengthen our overall quality governance.

Review and Audit of this Policy

This Quality Assurance Policy is not a static document – it will be reviewed regularly and updated as needed. At a minimum, the policy will undergo a formal review annually to ensure it remains aligned with current regulations, CQC guidance, and best practices. Reviews may be conducted sooner if there are significant changes in legislation, CQC’s assessment framework, or internal organizational changes that affect quality management. Any updates to the policy will be approved by senior management and communicated to all staff (with training or briefing provided on new expectations).

We will also audit compliance with this policy itself. This means periodically checking that the quality assurance activities described (audits, supervisions, meetings, etc.) are happening as scheduled and are effective. Internal or external auditors may review our quality governance against this policy to ensure we “practice what we preach.” If we find gaps in how the policy is implemented, we will take corrective action.

By regularly reviewing the policy and our adherence to it, we make sure that our approach to quality assurance stays current, effective, and genuinely embedded in our day-to-day operations. Our ultimate goal is to foster a culture of excellence where continuous improvement is second nature, ensuring the people in our care receive the safe, high-quality, and compassionate service they deserve.

Sources:

Care Quality Commission (CQC) – Assessment framework (5 key questions and quality statements)

CQC – Regulations for service providers and managers (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended)

CQC – Regulation 17: Good governance guidance

CQC – Regulation 20: Duty of candour guidance

Care Quality Commission (Registration) Regulations 2009 (as amended) – notifications and provider information duties

NICE guidance and quality standards relevant to care home settings

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