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Quality Assurance and Improvement (Wales) Policy

Introduction

It has been long recognised as good commercial practice for businesses to check that their goods and services meet customer expectations and comply with industry standards.

Quality assurance is also an industry with organisations set up to assess if a business is meeting the standards expected of them and accrediting them if they do. Being awarded a benchmark or kitemark, the business can then show that it is providing quality, which should help it commercially.

In health and social care, the relevant regulators assure quality by inspecting a registered service against the relevant standards and regulations. Local service commissioners will also check that services under contract to them are achieving their quality standards and are providing value for the public monies that they are investing in them. If services are not meeting the required standards, they will be expected to make the necessary improvements and will be penalised if they fail to do so.

All forms of quality assurance require systems and processes for checking that the organisation is working correctly and effectively to achieve its goals and to take corrective actions if it is not.

Through the information obtained from the various management activities involved in monitoring, reviewing and auditing, the organisation can judge its own performance. The information will also feed into the information base of any outside assessors (inspectors or local authority quality standards sections) and contribute to their respective assessments.

This policy can apply to any adult care service registered under the Regulation and Inspection of Social Care (Wales) Act 2016 with the Care Inspectorate Wales.

Aim of Policy

This policy outlines the service provider’s approach to assuring the quality of its services in line with national and local standards. The policy should be used with the policy on Complaints and Compliments (Wales).

Service providers are expected to work continuously to meet the requirements of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 and accompanying statutory guidance.

Key regulations are:

• Regulation 8: Requirements in Relation to Monitoring and Improvement
• Regulation 12: Requirements to Provide the Service in Accordance with Policies and Procedures
• Regulation 67: Duty to Appoint a Manager
• Regulation 74: Oversight of Adequacy of Resources
• Regulation 79: Duty to Ensure Policies and Procedures are Up to Date
• Regulation 80: Quality of Care Review
• Regulation 81: Statement of Compliance with the Requirements as to Standards of Care and Support.

Local authorities (LAs), independently and in partnership with NHS Wales trusts also commission services in line with the Social Services and Well-being (Wales) Act 2014. Care providers are expected to align their policies to meet commissioning and registration standards.

The service standards require providers to ensure that they are achieving the sought outcomes for the people who use their services by having well-defined systems and procedures for monitoring and reviewing their care provision and the organisational supports required for measuring effective and efficient service delivery, particularly staffing. Local service commissioners will usually ensure that their quality standards and quality assurance methods are compatible with the national service standards.

Policy Statement

The service thinks that having the highest quality care is an absolute right of every individual. The continuing aim is to provide a professional and efficient service to meet everyone’s needs and requirements and to achieve satisfactory outcomes for each person. The long-term goal is to obtain the highest possible level of satisfaction from people who use services and relatives.

Everyone receiving a service should:

• expect the highest quality care possible
• be given a say in the running of the service
• be free to complain about any aspect of the running of the service and to have their complaints welcomed and acted upon promptly; all complaints are responded to in line with the complaints procedure
• be told about local authority care and Care Inspectorate Wales inspections and should be given unrestricted and private access to inspectors during inspections so that they can report to the inspectors directly their views on the services they are receiving.

This care provider places a strong emphasis on providing the highest quality service possible for all of the people who use its services. However, it also thinks that, no matter how good its present services, there is always room for improvement.

The service will always continue to work towards maintaining those high standards that have been achieved. It will continue to work to improve those standards where there is scope for further improvement.

The service expects all care staff and other employees to be committed to delivering a quality service and to improving in every aspect of their work.

[To reflect its commitment to the continuous improvement of its services, the service has been awarded (or is working towards) the (eg Investors in People) quality assurance accreditation. This award gives formal recognition of the quality of care given to the people who use our services]. [Include this point as and where applicable.]

Procedures (adapt as appropriate)

• The responsible individual and care manager are responsible for establishing, maintaining and implementing a quality assurance and improvement system for the service. They do this with the help of all members of the management and staff teams, and the full involvement of the people receiving our services.
• The service provider will seek the views of the people who use its services, relatives and others involved in a person’s care continuously and through regular meetings to discuss and address any concerns or complaints that they might have about the service.
• It will also carry out regular surveys, at least annually, of the views of the people who use its services. It uses a standard questionnaire and follow-up interviews with a random sample of the people who use its services, representatives and stakeholders. [This last procedure might vary in line with the methods used.]
• The findings are analysed and incorporated into its development plan. The survey is confidential with the overall results published and distributed to all people who use services and others in formats suitable for their communication needs. The provider always positively encourages comment and feedback from people who use services, relatives and other stakeholders.
• The service always encourages comment and feedback from people who use the services, relatives and other stakeholders. If a person decides to stop using the service, we will seek their views on the reasons and on their satisfaction with what they have experienced so that we can learn from them and make improvements.
• The service bases its approach on continuous self-assessment and regular monitoring, reviewing and auditing of its practices and procedures. It aims to be responsive to all forms of external feedback from inspectors and (where involved) local quality assurance assessors. In these ways, it measures its achievements against the required standards and make changes where needed to make improvements.
• The service provider always responds promptly and fully to CIW requests for information and reports and that its returns reflect the service’s true achievements.
• It seeks to make every employee responsible for the quality of their work and provides all the training they require to perform their duties to the specified quality standards.
• It ensures that any contractors employed for specific functions meet our specified standards.
• Its annual development plan for quality improvement, which is drawn up as part of its business plan, always considers the contributions of the people receiving our services and their views on how the services might be improved.
• Annual development plans are fully costed. They identify specific measurable goals, the actions and resources allocated to achieve them. All plans are rigorously monitored and reviewed..
• There is a named person responsible for assuring and managing quality matters. [Describe as appropriate.] The responsible person has available quality team comprising nominated staff members, people who use services, relatives and other stakeholders who are invited to contribute.

Auditing Procedures

• The service has in place a programme for auditing all the service standards and key procedures, including the seeking and obtaining of people who use services’ views and others involved in their care. An auditing schedule might include any or all of the following if applicable to {{org_field_name}}.
  • Care practices, including nursing and clinical practices.
  • Catering, meals and mealtimes (including nutrition and hydration risk checking).
  • Administration of medicines.
  • Use of equipment and devices, including safety checks.
  • Checking of premises and facilities (care homes)/location premises (domiciliary care).
  • Checking of infection control and hygiene measures.
  • Health and safety and fire safety checks (care homes and domiciliary care premises).
  • Current safeguarding and complaints’ issues, including any alerts to the local safeguarding authority.
  • Staffing, including provision of supervision, support and training.
  • Continuity of care: travel and care time monitoring (domiciliary care).
  • Recording practices and record keeping, including data protection.
  • Checking that quality assurance schedules are being carried out, eg feedback from people who use services is being obtained.
  • Checking that policies and procedures are being reviewed in line with reviewing schedules and are up to date.
  • Other checks needed to achieve compliance with the relevant quality standards, eg notifications to the care regulator.
  • Checking that emergency plans are available and up to date.
• Where applicable, {{org_field_name}} continues to receive regular visits from the responsible individual, the feedback from which makes an important contribution to the service’s quality information. Reports are sent to the CIW in line with the requirements.
• The service will also conduct at least an annual self-evaluation of the service’s performance against the service standards using suitable professional tools, which include obtaining systematised feedback from people who use services and stakeholders.

Training

To provide a quality service, the provider requires high-quality staff who are suitably trained, supervised and supported. The service carries out the following activities.

1. As part of its induction programme, all new staff receive training in this policy. They receive a copy of the quality policy and procedures, and are expected to read, understand and apply them. They can expect to update their training on quality matters as part of their further development and training programme.
2. {{org_field_name}} is committed to providing its staff with as many opportunities as possible for training to improve the quality of its service.
3. The provider has strategies to meet its registration requirements for staff qualifications and training.

The management team undertake to ensure through instruction, practical example supervision and training that quality is the aim of all members of staff and that each employee has a proper understanding of the importance of the quality system and its direct relevance to the success of the business.

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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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