Quality and Quality Assurance Policy and Procedure

Purpose

  • To identify that which the organisation defines as “quality”. To ensure that the policies and processes which will promote that definition are in place, and to ensure that those processes are carried out in accordance with the definition.
  • To comply with statutes, regulations and quality standards.

Scope

All processes herein defined.

Policy

  • The organisation defines quality service as:
    • The provision of Care and support to Service Users and their families which is in accordance with the clearly identified individual wishes of the Service User (or their appointed advocate where it is clearly identified that the Service User is unable or unwilling to express their wishes), fully supporting their human rights, within the confines of legal and fiscal constraints.
  • The organisation believes that the management style, policies and day-to-day practices within the organisation should support the human rights of its Service Users by promoting open communications, a culture of problem resolution rather than blame, and the involvement of all participants in the services provided.
  • The organisation believes that a culture that is supportive of continuous improvement must be maintained by way of regular auditing and reviewing of the standards of performance in all aspects of the organisation and its personnel, followed by open discussion of strengths and weaknesses and action planning to resolve weaknesses.
  • The key processes which must be followed in order to provide a quality service in this organisation are identified as follows:

Admission

  • Processes to identify the physical, psychological and social needs of the Service User prior to service commencement.
  • Processes to match the Service User to The Agency, which ensure that the stated needs of the Service User are within the services that The Agency is able and willing to offer, and provide a negotiation path to an agreed compromise in situations where The Agency is unable to provide the requested service but the Service User is willing to modify their requirements.
  • Processes on service commencement to ensure that previously identified requirements of the Service User are made known to all Care staff who will be concerned with the Care of the Service User; ensure that the reception of the Service User is personalised and welcoming; encourage and support further information gathering and recording in order to guide the actions of staff.

Personal Planning

  • Processes to ensure that Care and support for each Service User is informed by a Personal Plan which records sufficient static and dynamic information to provide an individualised and planned service to each Service User.
  • Processes to ensure that the Personal Plan supports and accommodates the regular reviewing of Service Users’ needs and services, revision of the plan of care, communication of those changes to all persons concerned with the Care of the individual, review of the effect of the changes, followed by further review.
  • Individually named members of staff are identified as primarily responsible for the organisation’s interaction with each respective Service User.

Discharge

  • Processes on discharge to other Care facilities/agencies which ensure that Service Users who are transferring are accompanied by sufficient information in order to minimise the disruption caused by the move and to help the receiving organisation to begin providing quality Care services as soon as possible.
  • Processes for discharge on death are to ensure that the family and friends of the Service User, and the employees who knew the Service User, are sensitively supported through their grieving process.

Human Resources

  • Processes which identify the number and skill-level of employees that is required to deliver quality services to the specified number of Service Users.
  • Processes which recruit employees according to the identified skill specification, and whose values match those identified as important by the organisation, particularly with respect to the preservation of the human rights of Service Users.
  • Processes which inform the employee about the management framework within which they work, the standards of performance required of them, and the opportunities for development which are open to them.
  • Processes to support the personal development of the employee through induction and throughout their employment with The Agency, ensuring that the needs of the organisation and the skills of the employees are regularly reviewed and matched via the development programme.
  • Processes which ensure that employees are managed in accordance with best practice and statutes, signifying the value of the employee to the organisation.

Administration

  • Processes to ensure the financial stability of the organisation.
  • Processes which identify and accurately record all value transactions between the organisation, the Service User, and the Service User’s representatives, including any sponsoring organisations.
  • Processes to ensure the organisation’s compliance with its statutory responsibilities.
  • Communication processes to ensure that all employees are fully and accountably informed of information required to carry out their duties.
  • A complaints receipt and recording process which promotes the ability of the Service User to control their living environment.
  • Processes to control the quality of goods and services brought into the organisation.
  • Processes which inform the organisation, its employees and customers of the legal, financial and administrative framework within which they interact.
  • Processes which check that all audit and review processes are carried out as specified, action planning takes place, planned actions are carried though, and the effects of planned action are fed back into the management process.

Ancillary services

  • If appropriate, processes to ensure that Service Users’ individual and collective requirements for food are delivered.
  • If appropriate, processes to ensure that Service Users’ clothing is adequately cared for.
  • Processes to enable the Service User to maintain their normal life patterns, and their normal connections with their communities.

Procedure

  • Quality will be assured by the existence and adherence to the relevant policies and procedures.
  • See following Policies and Procedures Table.

Policies and Procedures Table (Part 1)

Quality Criteria Processes
Processes to identify the physical, psychological and social needs of the Service User prior to service commencement. Enquiry log

Pre-admission and admission P&P.

Or

Pre-service start and service start P&P.
Processes to match the Service User to The Agency to ensure that the stated needs of the Service User are within the services The Agency is able and willing to offer, and provide a negotiation path for an agreed compromise in situations whereby The Agency is unable to provide the requested service but the Service User is willing to modify their requirements. Pre-admission and admission P&P.

Or

Pre-service start and service start P&P.
Processes on service start which ensure that the previously identified requirements of the Service User are made known to all Care staff who will be concerned with the Care of the Service User; that the reception of the Service User is personalised and welcoming; that encourage and support further information gathering and recording in order to guide the actions of staff. Pre-admission and admission P&P.

Or

Pre-service start and service start P&P.
Processes to ensure that Care and support for each Service User is informed by a Personal Plan which
records sufficient static and dynamic information to provide an individualised and planned service to each Service User.		  Personal Planning P&P.

Personal Plan.

Personal Planning notes.
Processes to ensure that the Personal Plan supports and accommodates the processes of regular review of Service User needs and services, revision of the plan of care, communication of those changes to all persons concerned with the Care of the individual, review of the effect of the changes, followed by further review.  Care and daily living P&P.

Care communications and information P&P.

Changes in health state P&P.

Continence review.

Review of Care P&P.
 An individual member of staff is identified as primarily responsible for the organisation’s interaction with the Service User. Choice of Carer sex P&P.

Key worker P&P
 Processes on discharge to other Care facilities/agencies which ensure that Service Users transferring are accompanied by sufficient information to minimise the disruption caused by the move and help the receiving organisation to begin providing quality service as soon as possible.  Discharge P&P.
 Processes for discharge on death to ensure that the family and friends of the Service User, and the employees who knew the Service User, are sensitively supported through their grieving process.  Death and dying P&P.

Discharge P&P.
Processes which identify the number and skill level of
employees required to deliver a quality service to the
specified number of Service Users.		 Business plan.
Training Plan.

Policies and Procedures Table (Part 2)

Quality Criteria Processes
 Processes which recruit employees according to the identified skill specification, and whose values match those identified as important by the organisation, particularly with respect to the preservation of the human rights of Service Users. Principles of customer care/Philosophy of Care.

Recruitment P&P.
 Processes to inform the employee about the management framework within which they work, the standards of performance required of them, and the opportunities for development which are open to them.  Absenteeism P&P record.
Agency staff P&P.
Alcohol and drugs P&P.
Annual holidays P&P.
Carer supervision.
Casual workers P&P.
Discipline P&P.
Disciplinary appeals P&P.
Employee’s handbook.
Family leave P&P.
General management protocol.
Grievance P&P.
Moonlighting P&P.
Notice periods P&P.
Part-time employees P&P.
Performance appraisal P&P.
Poor performance P&P.
Public holidays P&P.
Harassment P&P.
Sickness absence P&P.
Staff rota P&P.
Statement of main terms and conditions of employment.
Statutory time off work P&P.
Temporary workers P&P.
Organisation chart.
Principles of customer care/Philosophy of Care.
Processes which support the personal development of the employee through induction and throughout their employment with The Agency, ensuring that the needs of the organisation and the skills of the employees are regularly reviewed and matched via the development
programme.		  Induction P&P.
Induction training materials.
Training P&P.
 Processes which ensure that employees are managed in accordance with best practices and statutes, signifying the value of the employee to the organisation.  Employee appearance P&P.
Employee termination P&P.
Equal opportunities P&P.
Maternity P&P
Monitoring of Business Communication P&P.
Working time regulations P&P.

Policies and Procedures Table (Part 3)

Quality Criteria Process Processes
 Processes to ensure the financial stability of the organisation.  Business Plan.
Financial Administration P&P.
 Processes which identify and accurately record all value transactions between the organisation, the Service User, and the Service User’s representatives, including any sponsoring organisations.  Financial Administration P&P.
Service Users’ finances P&P.
 Processes which ensure the organisation’s compliance with its statutory responsibilities.  Access to employees’ information P&P.
Accident reporting P&P.
Accommodation Standards P&P.
Archiving and storage of records P&P.
Disabled workers P&P.
First aid box checklist.
Health and safety P&P.
Manual handling P&P.
Commission for Social Care.
Inspection Notification P&P.
 Communication processes which ensure that all employees are fully and accountably informed of information required in order to carry out their duties.  Action Planning Pro Forma.
Administration P&P.
Communication P&P.
Daily communications meetings P&P.
Document publication P&P.
Personnel communication form.
Quality meetings P&P.
 A complaints receipt and recording process which promotes the ability of the Service User to control their living environment.  Advocacy P&P.
Complaints P&P.
Service User’s communication with organisation P&P.
Service User’s satisfaction survey.
 Processes to control the quality of goods and services brought into the organisation.  Purchasing P&P.
Receipt of goods delivered P&P.
Stock control P&P.
 Processes which inform the organisation, its employees and customers of the legal, financial and administrative framework within which they interact.  Service User’s finances P&P.
Service Users’ handbook.Statement of account P&P.
 Processes which check that all audit and review processes are carried out as specified, action planning takes place, planned actions are carried though, and the effects of planned action fed back into the management process.  Administration audit and action form.
Care audit and action form.
Catering audit and action form.
Management meeting P&P.
Housekeeping audit and action form. Maintenance audit
and action form.
Management Meetings Policy and Procedure.
Personnel audit and action form.

Policies and Procedures Table (Part 4)

Quality Criteria Process Processes
 Processes to enable the Service User to maintain their normal life patterns, and their normal connections with their communities.  Personal Plan
Promotion of recreational activities P&P.

Auditing

  • Audits.
  • Each area to be audited will be supported by a full policy statement (purpose/scope/policy/procedure).
  • The purpose of audit is to verify the implementation of stated and documented policy, procedure and standards.
  • Audit reports will identify action required to achieve compliance.
  • Employees will be involved in the audit process, and results will be reported to them.
  • Specific communication strategies will be implemented to support audit and the carrying out of remedial action and improvements, such as Quality Meetings, Team Meetings, Staff meetings and Management Meetings.

Quality Assurance System Schematic


Note: All QCS Policies are reviewed annually, more frequently, or as necessary.