In the second part of this article, Chris Payne explains how to actually make the changes needed and more about the improvement process itself.
Making the changes
With such a formidable list of required improvements as described above, it must be difficult to know where to begin. There is, however, a common process to be followed with most requirements.
Understand how inspectors have arrived at their findings, the reasons for the judgment and how it links to the relevant regulation(s).
Identify the practices that are being carried out incorrectly, including omissions, and why they might have occurred.
Consider the implications, which will vary according to the issue, for example, for staffing, training, supervision, recording practices, record keeping or general management oversight.
Devise the most suitable and practical approach to achieve the standards required.
Set in train the actions that have been identified.
Most planned actions must be addressed systematically on several levels.
There is the required impact on the quality of care for service users (from, for example, always being moved and transferred correctly).
Staff practices must be improved by the appropriate means, eg through issuing clearer instructions and procedures, or through up-to-date manual handling training.
The regular oversight of staff practices might need to be improved, for example, by senior staff checking that service users are being moved, repositioned, and transferred in line with their care plans.
The toolbox needed by the service management to achieve the required standards, for example, the policies and procedures, audit frameworks and schedules, and record keeping on manual handling can always be improved.
Usually if inspectors find non-compliance in any practices at one level, there will be some degree of failure at other levels too, and the failures must be addressed on all levels to achieve compliance.
For example, the following should be adhered to improve medicines administration.
Service users must always receive their medicines as prescribed, including any medicines to be taken “as required”, which also involves accurate recording.
Care staff must know when and how to give the medicines in line with the prescriptions, and clear instructions will be needed, particularly if any medicine is to be taken “as required”, and how to record correctly.
Senior staff should be checking regularly that service users are taking their medicines correctly, and the designated care staff are giving them their medicines correctly.
Regular audits should be carried out to make sure that every service user is receiving their medicines correctly, as evidenced by the medicine records and the regular checking that has taken place by the designated staff.
All improvement plans should reflect actions on each of the four levels.
The improvement process to be followed
These are some points that care providers should consider when developing their improvement strategy.
Developing a culture for change. It is always important to be open and determined about the improvements that must be made. Involve and delegate improvement actions to as many people as possible to gain their commitment to change and ownership of the standards. Depending on the range and seriousness of the problems, first consider having a consultation period involving service users, staff, partners and stakeholders on how to make the required improvements. Organise meetings and invite suggestions in writing, by a letter box or through social media — whatever would be appropriate for the service situation. The action plan should not be limited to meeting the Care Quality Commission (CQC) demands, but used as an opportunity to take stock of the whole service, and decide what improvements you, as care provider or manager, also want to make. In other words, take ownership of the change process, rather than it being a chore to satisfy external demands.
Focus on people, not only systems and procedures. For example, in some reports, inspectors comment on how little care staff seemed to talk to the people they are caring for (which will affect their rating on person-centred care, dignity and consent). This is often because there are too few staff, who are always working under pressure, and, must concentrate on getting their jobs done at the expense of neglecting the person for whom they are carrying out the tasks.
Now, to improve staffing levels requires a reassessment of service users’ needs, calculations of the numbers required, a recruitment drive, and suitable appointments — more of a longer-term process. However, in the short term, a concerted “let’s talk” campaign, modelled on the idea of the “dignity campaign” might make a lot of difference, by encouraging care staff to talk through what they are expecting to do, asking for permissions, explaining what they are doing as they are going along, and generally getting to know their service users better.
The process can be sustained by asking staff to encourage and check on each other, and selecting and training “champions” so that reinforcement is not just left to senior staff, though it could feature in staff supervision and appraisals. Success of the campaign can be assessed from the feedback of service users and their relatives, and the staff in terms of any increased sense of involvement with their service users.
Make staff development and support a priority. Meeting any requirements on training should also be approached in people–centred ways, not just in terms of filling in gaps found in the service’s training matrix. Services rated as good or outstanding will tend to use a combination of training approaches, using external training providers for some purposes, in-service training led by service staff for others, all supported by open and eLearning and other available resources, and “workplace learning”, including practice-based learning and support, to reinforce and sustain the development process. However, even the more technical sounding training subjects such as “manual handling” must keep the individuals being “manually handled” in the foreground. All training must be driven by person-centred values and principles, and these must be visited and revisited in every training topic.
Learn from successful services. In their publications, the CQC has provided examples of services that were initially rated inadequate that on reinspection have climbed two places to good. In these cases, the main changes have resulted from positive leadership, adequate resourcing, and committed staff with their commitment strengthened through comprehensive development and training.
Care providers requiring change must be willing to learn from others’ experiences. They must engage in root and branch assessments of their service, to produce the radical changes that they need to make. However, they should remember that simple changes can often make a big difference. They should also be open to receiving support from their partner agencies, including the CQC.