Policy Statement
This organisation has in place a range of policies and procedures that are annually reviewed and updated. These provide the core operational standards set by the business, and reflect the regulatory requirements set by the Care Quality Commission in the Fundamental Standards Regulations 2014, The audit processes set out below, ensures that day-to-day services meet the required standards and provides a tool that can identify any shortfalls in the assessment and monitoring of the quality of our service provision.
The Policy
It sets out how a robust self-aware improvement system for the business, which introduces a critical analysis framework of continuous improvement and learning that will engage staff, service users, and multi-agency partners in the process. It will link into the business plan, which will ensure audit findings are actioned and Implemented regularly.
Audit Roles
Only those job holders identified below will undertake the audit function.
Process
The audit function has to be a planned and systematic process of evaluating and validating the monitoring mechanisms set out in the company policies and procedures. It ensures that the monitoring role within the business is in place, timely, fit for purpose, proportionate to the service, and enables the implementation of any actions required from the cycle of improvement. Therefore, although two different functions, monitoring and audit are inextricably linked and one often follows the other.
Monitor means to check or observe identified tasks or performance.
Audit means to evaluate, examine, and critically analyse conformance to set standards by reviewing the objective evidence from statements, records, files, and any formal monitoring systems in place.
In health and social care, the standards are those set by the Care Quality Commission in the Health and Social Care Act (Regulated Activities) Regulations 2014. These standards apply to all registered providers of health and social care.
All providers need to evidence their compliance. Audits are a way of identifying, within a range of indicators, whether the business is meeting its regulatory requirements.
It also provides a mechanism for good practice to be shared, whilst dealing with any practice that does not meet the expected standard of regulatory requirements.
Audit Structure
For ease of use, the audit is set up to follow the regulations of the Care Quality Commission.
Different regulations require different frequencies of audit; therefore, each audit record needs to have the code identified. Audit frequency coding is as follows:
A = annually
M = monthly
Q = quarterly
R = randomly
W = weekly
Our audit frequency codes reflect the activity of the establishment and are proportionate to our service delivery.
Each audit record must be completed, signed, and dated by the designated post holder, who is named below, within the frequency coding timescales. Where this is not possible, a written record should be available detailing why the timescale lapsed. [IDENTIFY HERE NAME OR POST HOLDERS RESPONSIBLE FOR INDIVIDUAL AUDITS]
Planning Audits
A schedule must be compiled of the planned audit activity for the coming year. The schedule should be reviewed monthly or changed as the business needs change or if there is an incident that requires additional auditing to resolve.
The audit schedule must contain:
The subject matter – i.e.Medication
The frequency
Who is responsible for carrying out the audit
Indicate completion of audits – i.e change the font colour of completed audits on the schedule.
At least one across the business quality audit is conducted annually. This audit will cover all the business operations and will include auditing the Quality Systems to ensure they are fit for purpose.
The data collected from these audits are reviewed by the Quality Lead and Board of Directors to identify trends or emerging themes.
The Quality Group will identify all areas of non-compliance and compile Quality Improvement Action Plans to resolve the issues. These action plans will be co-produced with service users where possible and will be agreed upon and discussed with all staff members to ensure there is a consistent management approach. Action plans will be:
Written down
Shared with all staff and service users
Routinely reviewed
Updated and revised for project slippage
Signed off as complete
Reviewed at 6 months to ensure changes are being applied
Customer Surveys/Feedback
Gaining feedback from customers is essential for maintaining responsive services. Gaining feedbacking must be embedded in day-to-day practice but there must also be more formalised methods of gaining feedback from service users and the wider stakeholder group – such as family members and informal carers.
Methods include:
Monthly Satisfaction Questionnaires (Service users and Staff)
Detailed 6 monthly Satisfaction Questionnaires.
Monthly analysis of complaints and compliments
Monthly analysis of incidents (Safeguarding, Accidents etc.)
Annual Stakeholder Questionnaires (Local Authority, GP’s etc.)
Service user Forums
Staff Meetings
[AMEND TO REFLECT YOUR PRACTICE]
Getting feedback is has little merit unless the information is collated and analysed to identify trends or emerging themes. The Quality Lead is responsible for communicating any issues of non-compliance to the board so that robust action plans can be put in place to rectify them.
Thematic Internal Audits
Our Quality Management System requires us to carry out regular internal audits of key activities and functions to ensure our service continually monitors its performance and where deficiencies are identified clear and robust action plans are implemented. This ensures that this organisation is a Learning Organisation that embraces the principles of Continuous Improvement.
Audits will include:
Medication Management
Information Governance
Infection Control
Adult Safeguarding
Training and Workforce Development
Equality and Diversity
Health & Safety
Regulatory Compliance
Complaints & Compliments
MCA/Dols
Internal Systems and Processes i.e. Staff Rotas or Scheduling Systems
Recruitment and Selection
Effective Communication (Accessible Information)
Care Plans and Risk Assessments
Staff Wellbeing
Customer Satisfaction
Management Performance – including the board of directors
The Quality Management System
Social Value and Environmental issues
Partnership working
The frequency of audits will depend upon the subject matter. For example, medication audits should be carried out monthly by the designated medication lead. The Quality lead will produce an audit schedule that details all the planned audits for the year and their frequency.
Data Interrogation
The audit itself is the start of the process but, to complete the cycle, from the date of the audit, the record must be scrutinised, findings reported, and actions implemented to remedy any identified non-conformance with the standards.
The senior management team will have responsibility for scrutinising all such data, including the written report, and lead the implementation of any action planning and delivery.
Related Policies
Good Governance
Quality Assurance
Related Guidance
CQC Regulation 17: Good Governance:
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance
Dignity Audit Tools:
https://www.dignityincare.org.uk/
Training Statement
All staff, during induction, are made aware of the organisation’s policies and procedures, all of which are used for training updates. All policies and procedures are reviewed and amended where necessary, and staff are made aware of any changes. Observations are undertaken to check skills and competencies. Various methods of training are used, including one to one, online, workbook, group meetings, and individual supervisions. External courses are sourced as required.
Date Reviewed: October 2022
Person responsible for updating this policy:
Next Review Date: October 2023
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