What is a quality check?
Inspection reports often refer to “quality checking” or “checks” to discuss how a care service is carrying out its quality assurance, which is required by the regulations. But checking takes different forms, all of which need to be present in an effective quality assurance system.
The different types of checks
1. Continuous checking
This is another way of describing “monitoring”, which means “being alert to warning signals”. Everyone in a care service should be expected to use their eyes, ears and other senses as well as to ask questions to keep a continuous check on what they are doing and what is happening around them. People then need opportunities to communicate their observations, positive and negative, and to formally record and report any concerns as they arise.
2. Regular checking or looking over
This corresponds to the idea of “reviewing” ie “to look again or reconsider”. Whereas everyone should be always checking on what they are doing, reviewing is more likely to be part of the job descriptions of those in supervisory and management roles responsible for checking on a group of people or area of work.
3. Scheduled systematic checking, ie auditing
This means “making an official systematic examination of (usually accounts)”. It follows that if the first two forms of checking are embedded in the working practices of the care service, and appropriate actions have been taken in response to those activities, systematic auditing should not only be easier in that it will complement rather than duplicate previous efforts, and be a more effective driver of service improvements.
Reviewing and auditing shade into one another and what term is used is often irrelevant. But whatever name is given, by definition an audit (or formal review) is a systematic procedure that must be carefully planned and carried out, using appropriate resources and tools. Some audits can be narrowly focused, for example, on service users’ risk assessments and management plans, or comprehensive, involving the scrutiny of all service users’ complete care records, or of the care service as a whole.
Why are quality checks important?
Regulation 17 “Good Governance” of the 2014 “Regulated Activities” Regulations requires care providers to have effective methods for assessing their service against all the other fundamental standards (regulations 4 – 20a). As regulation 17 is also one of the fundamental standards, the service cannot be compliant without engaging in these activities and cannot know if it is achieving the required standards. There is an emphasis on controlling the risks to service users’ health, safety and welfare, and on improving service quality.
The statutory guidance refers to the need for “systems and processes” (for assessing quality, etc.) such as “audits — that should be “baselined” against the fundamental standards 4 – 20A. Auditing methods should always be fit for purpose so that they identify any weaknesses in the care provision with sufficient information to trigger the appropriate remedial action.
How should providers meet these requirements?
The answer is reflected in this inspection report of a “good” service. “There were effective auditing systems in place to drive and improve high-quality and person-centred care. Records showed audits and checks were carried out for care plans, risk assessments, medicines administration records, healthcare appointments, staff training, safeguarding, complaints, accidents, and finances. Where required, action plans were developed to address any issues or concerns raised”.
Where do providers go wrong?
Services that fall short of the requirements and are rated as “requires improvement” or “inadequate” under “Well-Led” typically reflect one or more of these failings:
the lack of a comprehensive system of auditing and audit schedules so that all risks and quality issues are not being identified in timely ways
a failure to identify risks and quality issues requiring attention within the auditing system even though audits are being carried out
a failure to follow through the audit outcomes so that identified improvements are not being made
the service’s quality system does not drive quality improvements
lack of recording, failure to communicate and joining up of information from the audits so that there was no “audit trail” or clarity about who should be doing what with the audit findings
auditors’ lack of understanding and skills of auditing methods and need for further training, coupled with the lack of suitable or use of inadequate auditing tools.
What are the benchmarks against which the quality checks should be carried out?
The key areas identifiable from fundamental standards 4 – 20A are:
The current registration conditions to ensure that all are being met and are in line with the current operations of the business (ie regulations 4 – 8, which are not strictly speaking the “fundamental standards” but are included in regulation 17 requirements) – auditing here will be the provider’s or responsible individual’s task. See the Registered Provider and Registered Manager topic.
The rest will fall on the registered manager with oversight from the registered provider or representative.
An overview of the requirements and the recommended checks can be found in our “Audit: A Protocol For Checking Compliance With The Fundamental Standards, Preparing An Auditing Schedule And Summary Recording Framework”. This framework suggests how to check:
Care practice records, including risk assessments (including for nutrition and hydration) and management plans, and other records relating to daily care provision eg log sheets. (Regulations 9 – 11 & 14).
See the Care and Support Plans: Audit Tool.
Administration of medicines to ensure that no aspect and at any stage in the process harms or puts users at risk of being harmed by incorrect handling (Regulation 12).
All health and safety measures that fall within the scope of the corresponding regulations, including infection control, manual handling, COSSH, equipment and devices to ensure all aspects keep people safe from any risks in their application, accidents and near misses. (Regulation 12). Each aspect might be audited separately eg infection control or comprehensively.
See, for example Health and Social Care Act 2008 Code of Practice for Health and Adult Social Care on the Prevention and Control of Infections: Checklist for Care Homes and Domiciliary Care Services respectively), and Audit: Premises — General Risk Assessment Form among many other audit tools found under the general heading of Audit: Premises covering various health and safety issues).
Safeguarding reports and incidents to check that safeguarding policies and procedures have been followed and nothing has been missed. The audit should include the checking of restraint and restrictive practices including mental incapacity and deprivation of liberty. (Regulation 13, and 20A “Duty of Candour”).
See, for example, Safeguarding: Manager’s Audit Checklist.
In care homes, the environment needs to be audited regularly not just in terms of safety as with fire safety, but for its fitness for purpose and contribution to people’s quality of life (Regulation 15).
See under the general heading of Audit: Premises a wide range of audit tools and checklists to examine quality of environment and safety issues).
Concerns and complaints, including their incidence and patterns so that the results are analysed and used to improve services (Regulation 16).
Ensuring feedback is sought from users and stakeholders about the quality of service experienced. The audit should include what has been carried out and if the findings have been used to effect improvements (Regulation 17).
For tools, see range of feedback questionnaires found in the Quality Assurance topic, including Self-audits Well-led 3: Engagement and Involvement, and Well-led 4: Continuous Learning and Improvement.
Staffing in terms of “fitness” (as defined in regulation 19), complement and levels in relation to needs, and competences and qualifications to meet needs, and the support staff require in terms of supervision and training, including the keeping of the corresponding records (Regulations 12, 18 & 19).
See, for example, the Staffing: General Recruitment, Selection And Appointment Checklist, which can be converted for auditing purposes.
General record keeping, manual or electronic, including security and compliance with data protection laws (Regulation 17).
This is certainly a formidable list of activities to be systematically quality checked and careful planning is required.
How often should systematic checking (auditing) be carried out?
It is difficult to be prescriptive about how often different audits should be carried out. As a general principle, frequency might be decided by the levels of risk to which service users are exposed in any given care service. High-risk areas include medication, all areas of risk, and safety and safeguarding. These need to be kept under constant scrutiny. Other aspects might need less frequent auditing.
Who are the auditors?
Some providers might prefer to employ outside consultants to carry out their quality assurance audits to obtain objective, independent opinions. There are advantages and disadvantages to this approach. Outside consultants can also be used to help in the setting up and implementation of an internal auditing system so there is no single way of proceeding.
Auditing responsibilities can be delegated to appropriate individuals and working groups with each reporting to one person, usually the registered manager, who can then obtain an overview of the findings and incorporate them into their improvement plans.
The manager in turn can be expected to report regularly to their directors or nominated individual, who also needs to be assured as part of their oversight function that the auditing is being carried out satisfactorily and the system is fit for purpose. The provider will also need to authorise any improvements that are recommended and the expenditure. So they must be kept closely informed.
What resources and tools are needed?
In addition to the audit frameworks cited above and the many others that are available in Forms, it will be helpful to build into the service’s quality checking strategy a systematic self-assessment procedure benchmarked against the Key Lines of Enquiry (and corresponding regulations for Scotland and Wales), completion of which will function as a form of internal inspection. The KLOE self-audit frameworks can be found in the Self-audit menu, as individual Worked Examples against corresponding topics, or collectively (with self-audits for Wales and Scotland) as Worked Examples in the Inspection Procedures topic.
The frameworks can be worked through a section or so at a time within say an annual plan, or comprehensively over as set period. The process will serve as an overarching framework that complements the work carried out on individual areas as described above, and should result in the service providing its own self-rating and improvement plans.