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SL51-Quality Assurance Policy

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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

Quality Assurance Policy

1. Introduction

Purpose of the Policy

At {{org_field_name}}, we are committed to delivering exceptional, high-quality supported living that puts our tenants at the heart of everything we do. This Quality Assurance Policy sets out our approach to ensuring that our schemes are safe, effective, compassionate, and continuously improving.

Our objective is to provide support that meets and exceeds the expectations of those we support while fully complying with all legal and regulatory requirements, including the Health and Social Care Act 2008 and Care Quality Commission (CQC) Regulations.

This policy reflects our commitment to:

By implementing this policy, we ensure that everyone within our scheme understands their role in maintaining and improving the quality of support we provide.

Scope

This policy applies to all support staff, schemes, and stakeholders within {{org_field_name}}. It covers:

This policy ensures that our entire scheme remains focused, aligned, and accountable in delivering the highest standard of support possible.

2. Mission and Values

Mission Statement

At {{org_field_name}}, our mission is to provide exceptional supported living that enables individuals to live safely, comfortably, and independently in their own homes. We are dedicated to delivering person-centred, compassionate, and high-quality support that enhances the well-being and quality of life of our tenants.

We strive to:

Our mission is not just about providing support but about empowering people to live fulfilling lives with the support they need.

Core Values

Our scheme is built on a foundation of strong values that guide our approach to support. These values shape our day-to-day practices, decision-making, and relationships with tenants, families, and support staff.

  1. Respect – We treat every individual with the utmost dignity and respect, valuing their choices, beliefs, and cultural backgrounds.
  2. Compassion – We provide support with genuine kindness, empathy, and understanding, ensuring that tenants feel valued and supported.
  3. Dignity – We protect and uphold the rights, autonomy, and self-worth of those we support for, ensuring they feel in control of their own lives.
  4. Integrity – We operate with honesty, transparency, and accountability, ensuring trust in our schemes.
  5. Excellence – We are committed to delivering the highest standard of support by continuously improving our skills, knowledge, and schemes.
  6. Collaboration – We work closely with tenants, families, support staff, and healthsupport professionals to ensure a holistic and well-coordinated approach to support.
  7. Safety – We prioritise the well-being and protection of tenants and support staff, ensuring a secure and supportive environment at all times.
  8. Innovation – We embrace new ideas, technologies, and approaches to enhance the quality of support we provide.

These values are at the heart of everything we do, guiding us to provide support that is not only effective and professional but also warm, compassionate, and truly person-centred.

3. Regulatory Compliance

Legal and Regulatory Framework

{{org_field_name}} will operate effective governance and quality assurance systems to ensure compliance with all legal and regulatory requirements applicable to the regulated activity of Personal Care delivered within Supported Living services.

Our governance arrangements are designed to support compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including all applicable requirements within Regulations 4 to 20A.

In particular, our quality assurance systems will monitor compliance with:

Regulation 17 requires {{org_field_name}} to establish and operate effective systems and processes to assess, monitor and improve the quality and safety of the regulated activity, assess and mitigate risks and maintain accurate, complete and contemporaneous records. Quality assurance arrangements will therefore monitor compliance across the organisation rather than operate as a stand-alone audit function.

In addition, {{org_field_name}} will comply with other applicable legislation and statutory requirements, including:

CQC Assessment Framework

{{org_field_name}} will maintain its quality assurance arrangements in accordance with current CQC regulatory requirements and assessment methodology.

CQC continues to assess providers against the five key questions:

Our quality assurance systems will therefore use applicable CQC quality statements and associated evidence requirements to inform monitoring and improvement activity.

Particular attention will be given to quality statements relevant to governance and quality assurance, including:

Quality assurance will include:

The Registered Manager and provider will maintain overall oversight of regulatory compliance and will take prompt action where quality assurance identifies a risk, shortfall or breach.

4. Governance and Leadership

Organisational Structure

At {{org_field_name}}, we have a clear and robust governance structure in place to ensure that all aspects of our supported living schemes are effectively managed and continuously improved. Our leadership team is responsible for maintaining the highest standards of quality, safety, and compliance while fostering a culture of excellence and accountability.

The key roles within our schemeal structure include:

This structured approach to governance allows us to effectively manage resources, uphold quality standards, and ensure accountability at all levels of scheme delivery.

Leadership Commitment

Our leadership team is fully committed to fostering a culture of continuous improvement, open communication, and transparency across all levels of our scheme. This commitment is demonstrated through:

By embedding strong governance and leadership principles, {{org_field_name}} ensures that high-quality, person-centred support is consistently delivered, regulatory standards are met, and tenants receive the best possible support tailored to their needs.

5. Person-Centred Care

Individualised Care Planning

At {{org_field_name}}, we recognise that every scheme user is unique, with individual needs, preferences, and aspirations. Our approach to support planning is built on personalisation, ensuring that each person receives the right level of support that reflects their lifestyle, choices, and well-being goals.

To achieve this, we implement a comprehensive support planning process, which includes:

By providing individualised support plans, we empower our tenants to live with greater independence, dignity, and confidence, knowing that their needs are at the centre of the support we provide.

Service User Involvement

People using the service will be active participants in the assessment, planning, delivery and review of their care and support.

Our approach includes:

Quality assurance activity will monitor whether people are meaningfully involved in their care and whether consent, capacity and representative involvement are appropriately recorded.

6. Quality Assurance Framework

Quality Objectives

At {{org_field_name}}, we are committed to maintaining the highest standards of support through a structured Quality Assurance Framework. Our quality objectives are designed using the SMART criteria (Specific, Measurable, Achievable, Relevant, and Time-bound) to ensure a continuous focus on improving scheme delivery, safety, and overall user satisfaction.

Our key quality objectives include:

By setting clear and measurable objectives, we create an environment of accountability, continuous improvement, and high-quality support delivery.

Performance Indicators

To evaluate the effectiveness of our support schemes, we monitor key performance indicators (KPIs) that help us assess quality, efficiency, and compliance. These indicators include:

These performance indicators allow us to proactively identify strengths and areas needing improvement, ensuring we provide safe, effective, and person-centred support.

Audit and Monitoring

A robust audit and monitoring system is in place to ensure compliance with regulatory standards and internal policies. We conduct:

7. Risk Management

Risk Assessment

{{org_field_name}} is committed to ensuring the safety, well-being, and protection of both our tenants and support staff. A proactive approach to risk management is embedded in our daily operations, ensuring that risks are identified, assessed, and mitigated effectively.

Our risk assessment process includes:

By systematically assessing and managing risks, we ensure a safe, effective, and person-centred approach to support delivery.

Incident Reporting

A transparent and structured incident reporting system is essential to learning from mistakes, improving safety measures, and preventing recurrence. We have a clear, step-by-step process for reporting, investigating, and acting on incidents.

Our incident reporting procedure includes:

  1. Immediate Action and Reporting:
    • Staff must report any incident or near miss immediately to their line manager.
    • If the incident involves serious harm or a safeguarding concern, it must be escalated without delay to senior management and external authorities if required.
  2. Incident Documentation:
    • All incidents are recorded in the Incident Log, detailing the nature of the incident, time, location, persons involved, and any immediate actions taken.
    • If applicable, scheme user records and support plans are updated to reflect necessary changes following an incident.
  3. Investigation and Root Cause Analysis:
    • A thorough investigation is conducted for all reported incidents to identify underlying causes and contributing factors.
    • In cases of serious incidents, a formal review panel may be convened to assess the findings and recommend action.
  4. Corrective and Preventative Actions:
    • Where failures or gaps are identified, immediate corrective actions are taken to address risks.
    • Preventative strategies are developed, such as additional support staff training, policy updates, or procedural improvements.
  5. Communication and Learning:
    • Incident reports and investigation findings are shared with relevant support staff, tenants, and families where appropriate, ensuring transparency and accountability.
    • Key learnings from incidents are used to inform support staff training, policy revisions, and risk management improvements.
  6. Regulatory Compliance and External Reporting:

Following an incident, the Registered Manager or another authorised person will determine whether any statutory notification, safeguarding referral or external report is required.

Where required, {{org_field_name}} will:

An incident will not be reported to CQC solely because it is described internally as “serious”. The Registered Manager will determine whether it meets the relevant statutory notification criteria.

Quality assurance audits will monitor whether required notifications and referrals have been made accurately and without delay.

8. Staff Recruitment, Training, and Development

Recruitment Policies

{{org_field_name}} will operate safe and effective recruitment procedures in accordance with Regulation 19 – Fit and proper persons employed, Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safeguarding requirements and applicable employment legislation.

Before a person is permitted to undertake duties for which recruitment checks are required, the organisation will complete and record checks appropriate to the role.

These will include, as applicable:

A criminal record or other information disclosed through recruitment checks will not automatically result in exclusion unless employment is prohibited by law. Information will be considered fairly and proportionately in relation to the duties and risks of the role.

No person will be permitted to work unsupervised in a role requiring completed suitability checks until {{org_field_name}} is satisfied that the required checks have been completed and the person is suitable for employment.

Recruitment records will be maintained securely and will be subject to periodic audit as part of the organisation’s Regulation 17 governance arrangements.

Training Programs

We are committed to continuous professional development (CPD) and ensuring all support staff are fully equipped with the knowledge and skills required to provide safe, high-quality support. Our training programs comply with CQC training requirements and national standards for supported living.

Our training framework includes:

By investing in comprehensive and ongoing training, we ensure that our team remains highly skilled, knowledgeable, and capable of delivering the best possible support.

Supervision and Appraisal

Regular support staff supervision and performance appraisals are essential to maintaining high standards of support, supporting professional growth, and ensuring support staff well-being. Our approach to support staff development and oversight includes:

Through structured supervision and appraisal processes, we ensure that our support staff are supported, valued, and continuously developing, which in turn enhances the quality of support provided to tenants.

9. Feedback and Complaints Management

Feedback Mechanisms

Feedback is an essential tool for continuous improvement and scheme excellence. We actively encourage tenants, families, and support staff to share their experiences, concerns, and suggestions to enhance the quality of support we provide.

To facilitate open and effective communication, we have implemented multiple feedback channels, including:

All feedback is reviewed by senior management, and necessary action plans are implemented to address concerns and improve scheme quality.

Complaints Procedure

We are committed to handling complaints fairly, transparently, and efficiently, ensuring that all concerns raised are thoroughly investigated and resolved in a timely manner. Our complaints procedure aligns with Regulation 16: Receiving and Acting on Complaints of the Health and Social Care Act 2008.

The complaints process follows these key steps:

  1. Receiving the Complaint
    • Complaints can be submitted verbally, in writing, by email, or through an online platform.
    • All complaints are acknowledged within two working days of receipt.
    • If a complaint is raised verbally, support staff will record and confirm the details to ensure accuracy.
  2. Investigation and Resolution
    • A designated complaints officer or senior manager will conduct a thorough investigation, gathering relevant information from all involved parties.
    • If necessary, tenants and their families will be consulted to ensure their perspectives are fully considered.
    • A formal response outlining findings and proposed resolutions will be provided within 14 working days. If further investigation is required, the complainant will be informed of the expected timeline.
  3. Appeal and Escalation

If the complainant remains dissatisfied following the organisation’s response, they may request a review in accordance with {{org_field_name}}’s Complaints Policy.

Where the organisation’s complaints procedure has been completed and the complainant remains dissatisfied, they will be provided with information about any appropriate external route.

For adult social care complaints, this may include the Local Government and Social Care Ombudsman (LGSCO) where the complaint falls within its jurisdiction.

Where care has been commissioned or arranged by a Local Authority or another commissioning body, the complainant will also be informed of any relevant commissioning complaints arrangements where applicable.

The Care Quality Commission regulates {{org_field_name}} and may receive information or concerns about the quality or safety of the service. However, CQC does not normally investigate individual complaints on behalf of complainants or provide an individual complaints appeal service.

Where a complaint raises a safeguarding concern, the safeguarding procedure will be commenced without delay and a referral will be made to the relevant Local Authority Safeguarding Adults Team where required.

  1. Learning and Improvement
    • All complaints are logged and reviewed to identify trends and areas for improvement.
    • Staff training and policy updates are implemented where necessary to prevent recurrence of issues.
    • Regular reports on complaints and resolutions are presented to senior management to drive scheme enhancements.

10. Continuous Improvement

Quality Improvement Plan

At {{org_field_name}}, we are committed to continuous improvement to ensure that our support schemes remain effective, responsive, and aligned with the evolving needs of tenants. Our Quality Improvement Plan (QIP) serves as a structured framework for identifying areas of improvement, setting clear objectives, and implementing changes that enhance scheme delivery.

The key components of our Quality Improvement Plan include:

By proactively identifying opportunities for growth and development, we ensure that our schemes continuously evolve to provide the best possible support and support.

Stakeholder Engagement

We believe that meaningful engagement with tenants, support staff, families, and external partners is essential for effective continuous improvement. Involving stakeholders in our quality assurance processes ensures that our schemes reflect real needs and expectations.

Key approaches to stakeholder engagement include:

Through active participation, open communication, and shared responsibility, we create a culture of continuous learning and enhancement, ensuring that {{org_field_name}} remains at the forefront of high-quality supported living.

11. Documentation and Record-Keeping

Accurate Records

Comprehensive and accurate record-keeping is essential for delivering high-quality support, ensuring regulatory compliance, and maintaining accountability. Our documentation practices align with CQC requirements, the Health and Social Care Act 2008, and best practice guidelines to ensure that all records are clear, detailed, and securely maintained.

Our approach to accurate record-keeping includes:

All records are maintained accurately, securely, and in a structured format, ensuring they are accessible when needed while preserving confidentiality and integrity.

Data Protection

{{org_field_name}} will process personal information in accordance with the UK General Data Protection Regulation (UK GDPR), the Data Protection Act 2018 and applicable confidentiality and information-governance requirements.

Personal information will be:

{{org_field_name}} will identify and record the appropriate lawful basis for processing personal information. Where special-category information, including health information, is processed, an appropriate condition under UK GDPR and the Data Protection Act 2018 will also be identified where required.

Consent will be obtained where consent is the appropriate lawful basis or where consent is otherwise required for the proposed activity. However, consent is not the only lawful basis for processing or sharing personal information.

Information may be shared without consent where there is another appropriate lawful basis, including where necessary for safeguarding, protection of vital interests, compliance with a legal obligation, provision or management of health or social care, or another lawful purpose.

Information sharing will be:

Where information is shared with family members, friends or other representatives, staff will consider the person’s wishes, capacity, confidentiality rights and any legal authority held by the representative.

Care and support records will be accurate, complete, contemporaneous and securely maintained in accordance with Regulation 17.

The organisation will maintain appropriate arrangements for:

Quality assurance activity will include appropriate audits of record quality, information security and compliance with data-protection requirements.

Regulation 17 specifically requires secure, accurate, complete and contemporaneous service-user records, as well as effective governance of information and risk.

12. Related Policies

SL04-Good Governance Policy

SL13-Safeguarding Adults from Abuse and Improper Treatment Policy

SL26-Recruitment, Selection, and Retention Policy

SL14-Receiving and Acting on Complaints Policy

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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