CHW51-Quality Assurance Policy
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{{org_field_name}}
Registration Number: {{org_field_registration_no}}
Quality Assurance Policy
1. Purpose
The purpose of this policy is to ensure that {{org_field_name}} provides the highest standards of care by implementing a robust quality assurance framework. This policy outlines how we continuously monitor, evaluate, and improve our services in compliance with Care Inspectorate Wales (CIW) regulations, ensuring service users receive safe, effective, and person-centred care.
This policy aligns with:
- The Regulation and Inspection of Social Care (Wales) Act 2016, which mandates service providers to assess and improve service quality.
- The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, which require service providers to implement quality assurance measures.
- CIW Quality of Care Review Guidance, which outlines expectations for self-assessment and continuous improvement.
- The Social Services and Well-being (Wales) Act 2014, which promotes person-centred care and well-being.
- The Health and Social Care (Quality and Engagement) (Wales) Act 2020, which reinforces the duty of quality across healthcare and social care services.
2. Scope
This policy applies to:
- All staff members, including care workers, managers, and administrative personnel.
- Service users and their families, ensuring they have a voice in quality assurance processes.
- External professionals and regulatory bodies, including CIW, local authorities, and healthcare partners.
The policy covers:
- Internal and external quality assurance measures.
- Service user feedback and engagement.
- Auditing, inspections, and compliance monitoring.
- Continuous improvement and staff development.
3. Principles of Quality Assurance
3.1. Commitment to High Standards and Continuous Improvement
At {{org_field_name}}, we are committed to:
- Delivering person-centred, safe, and effective care that meets regulatory standards.
- A culture of learning, where feedback and incidents drive improvement.
- Transparency and accountability, ensuring that quality assurance is embedded in all aspects of service delivery.
We actively encourage staff, service users, and families to contribute to ongoing improvements.
3.2. Monitoring and Evaluating Service Quality
To ensure the highest standards of care, we conduct regular quality monitoring through:
- Monthly internal audits, reviewing care plans, medication management, infection control, and safeguarding.
- Annual Quality of Care Reviews, as required by CIW, assessing service impact and improvement areas.
- Incident and complaint analysis, identifying trends and root causes to prevent recurrence.
- Regular feedback sessions with service users and their families to assess satisfaction and care outcomes.
All findings are reviewed by the Registered Manager, and action plans are developed to address any concerns.
3.3. Service User Involvement and Feedback
Service user and family involvement is at the heart of our quality assurance framework. We gather feedback through:
- Quarterly satisfaction surveys, ensuring service users can voice their experiences.
- Regular residents’ meetings, where service users discuss their care experience.
- Open-door policy, allowing service users and families to raise concerns or suggestions at any time.
- Complaints and compliments log, ensuring all feedback is documented and responded to.
Feedback is used to shape service improvements and staff training.
3.4. Compliance with CIW Regulations and Inspections
We ensure compliance with CIW regulations and inspections by:
- Preparing for unannounced inspections, ensuring standards are upheld at all times.
- Conducting mock inspections, identifying potential areas for improvement before CIW visits.
- Responding promptly to inspection feedback, implementing required actions immediately.
- Submitting regulatory reports, including the Annual Quality of Care Review, to CIW.
Our Registered Manager and Responsible Individual oversee regulatory compliance and quality assurance activities.
3.5. Risk Management and Safeguarding
Quality assurance includes proactive risk management to safeguard service users and staff. This is achieved through:
- Regular risk assessments, ensuring service users’ safety and well-being.
- Incident reporting and investigation, identifying trends and implementing preventative measures.
- Staff training in safeguarding and risk management, ensuring all team members can identify and address potential risks.
- Health and safety audits, ensuring compliance with workplace safety standards.
3.6. Staff Development and Performance Monitoring
Our staff play a critical role in maintaining quality standards. We support them by:
- Regular supervision and appraisals, ensuring staff receive feedback and development opportunities.
- Mandatory and ongoing training, keeping staff updated on best practices and regulations.
- Encouraging reflective practice, where staff review their work and identify improvement areas.
- Rewarding excellence, recognising and celebrating staff contributions to quality care.
All training and supervision records are documented and reviewed as part of our quality assurance framework.
3.7. Incident Reporting and Learning from Mistakes
Mistakes and incidents are learning opportunities, and we manage them through:
- A structured incident reporting system, ensuring transparency and accountability.
- Root cause analysis, identifying underlying causes of incidents.
- Action plans for improvement, ensuring changes are implemented to prevent recurrence.
- Sharing lessons learned with staff, creating a culture of continuous learning.
All incidents are reported to the Registered Manager and, where required, to CIW or external safeguarding authorities.
3.8. Partnership Working and External Quality Monitoring
We work closely with external partners and professionals to maintain high-quality care, including:
- Healthcare professionals, ensuring service users receive integrated care.
- Local authorities, supporting best practices in social care.
- Pharmacists and medical practitioners, ensuring safe medication management.
- CIW and external auditors, ensuring independent quality assurance oversight.
We welcome external feedback and reviews as part of our commitment to transparency and improvement.
4. Managing Quality Assurance Efficiently
4.1. Leadership and Accountability
- The Registered Manager oversees all quality assurance activities.
- The Responsible Individual ensures strategic quality management and regulatory compliance.
- Team leaders and senior staff support frontline quality monitoring.
4.2. Staff Training and Engagement
- Mandatory quality assurance training ensures all staff understand their role in maintaining standards.
- Regular team meetings and workshops promote shared responsibility for quality.
- Encouraging staff to report concerns, ensuring proactive identification of issues.
4.3. Monitoring and Continuous Improvement
- Monthly quality audits track compliance with policies and regulations.
- Quarterly performance reviews assess progress on improvement actions.
- Annual quality strategy review, ensuring our approach remains effective and aligned with best practices.
5. Related Policies
This policy is supported by:
- CHW04 – Good Governance Policy
- CHW11 – Safe Care and Treatment Policy
- CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
- CHW16 – Health and Safety at Work Policy
- CHW18 – Risk Management and Assessment Policy
- CHW24 – Management of Accidents, Incidents, and Near Misses Policy
- CHW27 – Staff Supervision, Training, and Development Policy
6. Policy Review
This policy is reviewed annually, or sooner if there are changes in legislation, CIW guidance, or best practice standards. Updates are communicated to all staff, and additional training is provided as necessary.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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