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HCS03-Quality Assurance and Continuous Improvement

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Registration Number: {{org_field_registration_no}}

Quality Assurance and Continuous Improvement Policy

1. Purpose

The purpose of this policy is to outline how {{org_field_name}} maintains high standards of care and support through a structured and evidence-based approach to quality assurance and continuous improvement. We are committed to delivering a consistently high-quality service that is person-led, safe, compassionate and outcome-focused, in accordance with the Health and Social Care Standards (in use across Scotland since 1 April 2018), the Care Inspectorate Quality Framework for Support Services (care at home, including supported living models of support) (May 2022), relevant care service legislation and regulations, and the SSSC Codes of Practice.

Our quality assurance framework ensures we remain accountable to the people we support, their families, regulatory bodies, and our wider community. We aim to demonstrate through practice, documentation, and outcomes that the care we provide is not only compliant but continually improving.

2. Scope

This policy applies to all staff and stakeholders of {{org_field_name}}, including:

The policy covers all aspects of care delivery, governance, communication, leadership, compliance, service development, and engagement with the people we support.

3. Related Policies

This policy works alongside and complements the following:

4. Policy Statement: Our Commitment to Quality

At {{org_field_name}}, we believe that quality is everyone’s responsibility. Quality assurance is embedded at every level of the organisation – from the day-to-day interactions between care workers and the people we support, to the strategic decisions made by the Registered Manager and Company Director.

We strive to meet the following principles:

5. How We Manage Quality and Improvement Efficiently

5.1. Using the Health and Social Care Standards as a Foundation

We use the HSCS principles of dignity, compassion, inclusion, responsive care, and wellbeing as the benchmark for all care planning and delivery. Every staff member is trained to understand the standards, and these are used in:

Our care plans reflect personal outcomes aligned with HSCS Standard 1.15 and 2.17, and are reviewed regularly with the person and/or their representative.

5.2. Ongoing Self-Evaluation and Quality Frameworks

In line with Care Inspectorate quality frameworks, we ask ourselves three core questions:

For care at home, our primary self-evaluation tool is the Care Inspectorate Quality Framework for Support Services (care at home, including supported living models of support) (May 2022). Our audits, KPIs and evidence folders are mapped to the framework’s quality indicators to ensure we can demonstrate outcomes and impact in the same way inspections evaluate our service.

To answer these, we:

We also utilise the Care Inspectorate’s self-evaluation resources and quality indicators to benchmark our performance.

5.3. Feedback-Driven Culture

We actively seek feedback from:

Feedback is gathered via:

All feedback is logged, monitored, and actioned in our service improvement tracker.

5.4. Learning from Incidents and Complaints

When something goes wrong—or almost goes wrong—we treat it as an opportunity to learn and improve. Our robust procedures ensure:

This aligns with the SSSC Code 3.7 and 5.12, promoting openness, reflection, and action.

5.5. Duty of Candour (Organisational)

Where an unexpected or unintended incident occurs during the provision of care and results in harm as defined by the Duty of Candour Procedure (Scotland) Regulations 2018, {{org_field_name}} will follow the statutory duty of candour procedure. This includes: notifying the relevant person, offering an apology, offering the opportunity for a meeting/discussion, carrying out a review of the incident, sharing learning and improvement actions, and keeping a written record of the procedure and all correspondence.

The Registered Manager is responsible for ensuring duty of candour actions are completed within required timescales and that learning is incorporated into the Service Improvement Plan and staff learning. A Duty of Candour report will be prepared and published annually in line with national guidance and Care Inspectorate expectations.

5.6. Monitoring Staff Competence and Practice

Staff quality is continuously monitored through:

Supervision includes reflective conversations about how staff apply the Health and Social Care Standards and the SSSC Codes of Practice in daily work.

5.7. Audit and Reporting Framework

Our Registered Manager is responsible for ensuring that monthly and quarterly audits are carried out across all service areas. This includes:

Audit outcomes are used to develop our Service Improvement Plan (SIP) which outlines actions, responsible persons, timescales, and measures of success. The SIP is reviewed quarterly and updated accordingly.

5.8. Staff Involvement in Quality Improvement

We recognise that frontline staff often have the most valuable insight into what is working well and what needs to change. We foster a culture where staff:

We hold regular team learning sessions that encourage open dialogue and collaborative thinking, aligned with the SSSC Employer Code 2.5 and 2.6.

5.9. Compliance and Continuous Learning

We ensure all aspects of our service are in full compliance with, and are informed by:

5.10. Records, Notifications and Reporting to the Care Inspectorate

We maintain the records required for registered adult support services and submit statutory notifications using the Care Inspectorate digital portal/eForms, in line with current Care Inspectorate guidance for adult services.

The Registered Manager (or delegated authorised person) will ensure notifications are submitted within required timescales, including (where applicable) notifications relating to: deaths, serious injury/serious illness, outbreaks and significant infectious disease events, medication incidents, significant service disruption, staffing issues, and protection concerns.

From 7 April 2025, we will use the Care Inspectorate ‘protection concern’ notification route (replacing the previous ‘allegation of abuse’ notification process) and will ensure staff are briefed and procedures updated accordingly.

5.11. Communication and Transparency

Quality assurance findings and improvement plans are shared with:

Our quality reports are retained as part of our governance records and are made available upon request.

6. Roles and Responsibilities

7. Policy Review

This policy is reviewed annually or earlier if there are:

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

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