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Quality Assurance Policy

1. Introduction

Our Home Care business is dedicated to ensuring the highest quality of care for all service users. This Quality Assurance (QA) Policy ensures that we consistently deliver person-centred, safe, and effective care in line with Care Inspectorate Wales (CIW) regulations, the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA), and the Social Services and Well-being (Wales) Act 2014. The policy outlines our commitment to continuous improvement and compliance, integrating regular monitoring, feedback, and assessment to enhance care delivery.

This policy applies to all employees, including Care Assistants, Senior Carers, Coordinators, Managers, and Directors. It provides clear guidelines for CIW inspectors on how we manage quality assurance efficiently and in accordance with regulatory standards.

2. Key Principles of Quality Assurance

• Person-Centred Care: Ensuring that care is tailored to meet each service user’s needs, preferences, and goals.
• Continuous Monitoring and Improvement: Regularly reviewing care delivery, processes, and outcomes to ensure quality and compliance.
• Service User Involvement: Actively involving service users and their families in the assessment, care planning, and review process.
• Staff Competence: Ensuring that all staff are appropriately trained, assessed, and supported to deliver high-quality care.
• Feedback and Learning: Encouraging and acting upon feedback from service users, families, and staff to identify areas for improvement.
• Compliance with Legal and Regulatory Standards: Adhering to CIW regulations, Health and Safety legislation, and best practice guidelines to ensure safe and effective care.

3. How We Manage Quality Assurance Efficiently

A. Regular Monitoring of Care Delivery

We continuously monitor and evaluate the quality of care provided to service users to ensure that it remains safe, effective, and person-centred.

For Staff:

• Step 1: Complete Routine Care Audits (RCA) for each service user, assessing the quality of care and identifying any gaps in care delivery.
• Step 2: Conduct monthly supervision meetings to review care practices, identify areas for improvement, and provide feedback to staff.
• Step 3: Implement spot checks to ensure that care standards are consistently met and that care plans are being followed.
• Step 4: Ensure that staff follow care protocols and document any deviations or incidents.

For CIW Inspectors:

• Audit logs confirm that care delivery is regularly monitored through both planned and spot-check audits.
• Care plan reviews demonstrate that care delivery is aligned with individual service users’ needs and preferences.

B. Service User and Family Involvement

We believe that service users and their families should be active participants in care planning, decision-making, and care reviews.

For Staff:

• Step 1: Ensure that service users and their families are involved in care assessments, care planning, and regular reviews.
• Step 2: Regularly communicate with families to ensure they are informed of any changes or updates in the care plan.
• Step 3: Use care review meetings to encourage feedback on care delivery, address concerns, and discuss areas for improvement.
• Step 4: Encourage service users to provide feedback through Satisfaction Surveys (SS) or informal discussions, ensuring they are heard and their concerns are addressed.

For CIW Inspectors:

• Care plan records show that service users and families are actively involved in decision-making and care delivery.
• Survey results confirm that service users and families feel their input is valued and acted upon.

C. Continuous Staff Development and Training

We ensure that all staff are appropriately trained and competent in their roles to maintain high standards of care delivery.

For Staff:

• Step 1: Provide induction training for new staff, covering all essential areas such as safeguarding, medication management, and infection control.
• Step 2: Ensure that staff complete mandatory training, including annual updates on Health & Safety, safeguarding, first aid, and moving and handling.
• Step 3: Implement ongoing professional development (PD), including specialist care training (e.g., dementia, palliative care) and leadership development.
• Step 4: Conduct annual competency assessments to ensure staff demonstrate proficiency in their roles.

For CIW Inspectors:

• Training records confirm that all staff are trained and competent in their duties.
• Competency assessments show that staff maintain up-to-date knowledge and skills in line with their roles.

D. Regular Care Plan Reviews

Care plans are reviewed regularly to ensure they reflect the current needs of service users and that the care provided is of high quality.

For Staff:

• Step 1: Conduct a review of each individual’s personal plan at least every three months, and sooner where there is a change in needs, risks, preferences, or outcomes, or where the commissioner/placing authority review requires it.
• Step 2: During the review, assess whether care goals are being met, and whether the service user’s needs are being addressed appropriately.
• Step 3: Update care plans to reflect any changes in needs, goals, or preferences.
• Step 4: Ensure that service users and their families are consulted and involved in care plan updates.

For CIW Inspectors:

• Care plan documentation demonstrates that regular reviews are conducted, ensuring that care is tailored to service users’ changing needs.
• Service user feedback confirms that they are actively involved in the review process and informed of any changes.

E. Monitoring and Acting on Feedback

Feedback from service users, families, and staff is essential in driving continuous improvement in care quality.

For Staff:

• Step 1: Regularly collect feedback from service users and families using satisfaction surveys, feedback forms, and informal discussions.
• Step 2: Encourage open communication during care reviews, staff meetings, and through direct engagement with service users.
• Step 3: Where people receive commissioned care, we proactively gather feedback from service commissioners and relevant professionals (e.g., community nursing/therapy teams) and include this within our service improvement actions and RI quality of care review evidence.
• Step 4: Implement changes and improvements based on feedback, ensuring that issues raised are addressed promptly.
• Step 5: Monitor outcomes of any changes to ensure that they have led to improvements in care quality.

For CIW Inspectors:

• Feedback logs and survey results show that feedback is actively sought and acted upon.
• Action plans are in place to address any concerns raised and demonstrate continuous improvement.
• All feedback themes, actions, and outcomes are collated and form part of the evidence set considered in the Responsible Individual’s Quality of Care Review.

F. Incident Reporting and Analysis

We have a clear procedure for reporting, investigating, and learning from incidents that affect care quality.

For Staff:

• Step 1: Report any incidents, near-misses, or complaints immediately using the Incident Reporting System (IRS).
• Step 2: Participate in investigations and root cause analysis (RCA) to determine the cause of the incident and identify corrective actions.
• Step 3: Ensure that corrective actions are taken to prevent similar incidents from occurring in the future.
• Step 4: Review incident trends regularly to identify potential systemic issues and implement improvements.
• Step 5: Where an event meets the CIW notification requirements, we ensure the appropriate notification is made without delay and recorded, alongside safeguarding referrals where applicable.
• Step 6: Concerns raised (including via whistleblowing) are logged, investigated proportionately, outcomes recorded, and learning shared with staff to prevent recurrence.
• Step 7: We act in an open and transparent way with individuals receiving care and support and/or their representatives when things go wrong, ensuring appropriate communication, apology where appropriate, and clear documentation of actions and learning.

For CIW Inspectors:

• Incident logs demonstrate that all incidents are reported and addressed in accordance with our incident management procedure.
• Audit records show that lessons are learned from incidents and improvements are made to prevent recurrence.

4. Governance and Continuous Improvement

We are committed to maintaining a robust governance structure to oversee the implementation and effectiveness of our quality assurance processes.

What We Do:

• Conduct Quarterly Quality Audits (QQA) to assess the effectiveness of care delivery and compliance with policies.
• Hold Annual Quality Review Meetings (AQRM) to review overall care standards, identify areas for improvement, and plan for the future.
• Implement an annual service user and family feedback cycle to identify areas for continuous improvement.

For CIW Inspectors:

• Audit logs confirm that regular quality audits are conducted and reviewed.
• Action plans show continuous improvements based on feedback, audits, and incident reports.

4.1 Responsible Individual (RI) Quality of Care Review (Regulation 80)

The Responsible Individual (RI) will maintain a system for monitoring, reviewing, and improving the quality and safety of the service. The quality of care and support will be reviewed as often as required but at least every six months.

Each RI review will include:

• consideration of engagement/feedback from people using the service, their representatives, service commissioners, and staff;
• analysis of aggregated data on incidents, notifiable incidents, safeguarding matters, whistleblowing, concerns, and complaints, including actions taken; and
• review of the outcome of audits of the accuracy and completeness of records, including audits of personal plans.

Following each review, the RI will produce a Quality of Care Review Report to the service provider, including:

• (a) an assessment of the standard of care and support provided; and
• (b) recommendations for improvement.

Actions arising will be logged, assigned to a responsible lead, and tracked to completion, with impact reviewed.

4.2 Statement of Compliance and Annual Return (Regulation 81 / RISCA 2016 s.10)

The Responsible Individual will prepare the Statement of Compliance required for the Annual Return, having regard to the assessment contained in the most recent Quality of Care Review Report.

The service provider will submit the Annual Return within 56 days of the end of the financial year (by 26 May), ensuring the information is complete, accurate, and consistent with the RI’s quality review evidence.

Failure to submit within the required timescales may lead to enforcement action and a penalty notice.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to assess care quality, training compliance, and incident management.
• Annual Reviews: Full compliance check against CIW standards, NICE guidelines, and Social Services and Well-being (Wales) Act 2014.
• Staff Supervisions & Appraisals: Supervision is provided at least monthly (or more frequently where risk/performance indicates). Formal appraisal is completed at least annually (with additional review where role changes, capability issues, or development needs are identified).

6. CIW Inspection Ratings Readiness and Display Requirements

From April 2025, CIW applies published inspection ratings for care homes and domiciliary support services. We maintain a ratings-readiness evidence file mapped to the CIW inspection themes (including Well-being, Care and Support, and Leadership and Management) and keep this under continuous review through audits, feedback, supervision findings, and RI quality of care reviews.

Where required, we will display our current CIW ratings on our website (where we have one) and at the service location in the manner CIW specifies, and we will keep the displayed information up to date following publication of inspection reports.

7. Conclusion

We are dedicated to ensuring the highest standards of care through continuous monitoring, feedback, and improvement. This policy outlines how we manage quality assurance efficiently, ensuring that we comply with CIW regulations, promote person-centred care, and foster an environment of continuous learning and improvement.

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