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Communities Directorate Adult Social Care Direct Provision

Quality Assurance

For

Older People’s Residential

And

Day Services

Author: Jillian Guild Date: August 2007 Reviewed: August 2009 Review Date: August 2010

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CONTENTS

1. Introduction 2. Annual Quality Assurance Assessment 3. Regulation 26 Visits 4. Monthly Managers’ Check 5. Improvement Questionnaire Appendix 1 www.cqc.gov.uk Appendix 2 Monthly Managers’ Report Reg 26 Appendix 3 Managers’ Checklist Appendix 4 Improvement Questionnaire

http://www.csci.gov.uk/

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1. INTRODUCTION

The National Minimum Standards (Care Standards Act 2000) apply to residential care.

The relevant quality assurance outcome in regard to the ‘National Minimum Standards for Care Homes for Older People’ requires “the home to be run in the best interests of the people who use this service.”

Lincolnshire County Council’s assurance programme for the In House Care Homes is there to help managers and staff attain the quality standards required by the Commission for Social Care Inspection.

2. ANNUAL QUALITY ASSURANCE ASSESSMENT

2.1 The Commission for Social Care Inspection introduced in April 2006 the “Annual Quality Assurance Assessment” (Appendix 1). This tool is used by managers, staff and service users to self-assess performance. This tool is completed each year and gives CSCI the evidence of what the service means to people who use the service and carers.

2.2 This is completed by the Registered Unit Managers on line at

www.cqc.gov.uk

2.3 This self-assessment tool supersedes the pre-inspection questionnaire and is used towards inspections carried out by the Commission for Social Care Inspection.

2.4 Inspections carried out by CSCI are planning to give adult

care homes a rating on the quality of the service. Inspectors will decide how well a service is doing, and will use a guide called the Key Lines Of Regulatory Assessment (KLORA). These decisions are important as they help us decide what the overall quality rating for a service should be. The KLORA guidelines can be found by visiting [email protected]

2.5 Action Plans are used as part of the quality assurance cycle

and are compiled from outstanding inspection requirements, recommendations, further inputs and outcomes as required.


http://[email protected]/

Quality circle

AQAA

Improvement CSCI Questionnaire Inspection

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Stakeholder Action Feedback Plan Staff Supervision/ Reg 26 Appraisal Visit/Report

Managers’ Checklist

3. REGULATION 26 VISITS

3.1 Regulation 26 (Appendix 2) requires an individual, but not in day to day charge of the care home to visit the Lincolnshire County Councils’ Residential Units.

3.2 The visiting person for the Lincolnshire County Council Units

will be the role and responsibility of the Service Manager.

3.3 Visits are mandatory and unannounced and shall take place at least once a month.

3.4 The purpose of the visit will be to measure the success in

meeting the aims, objectives and statement of purpose of the units. This process is designed to support the manager and staff to achieve the standards laid down by the Care Standards Act.

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3.5 The Service Manager must ensure that they speak with

managers, staff and evaluate satisfaction with people who use the service and others to ensure that outcomes meet expectations.

4. MONTHLY MANAGERS’ CHECK

4.1 The ‘Monthly Manager’s Check’ (Appendix 3) is a detailed description of activities carried out by the unit manager.

4.2 The checklist is an appraisal of the National Minimum Care

Standard’s inspection report, examination of buildings, fixtures, fittings, equipment, policies, procedures, records and reports.

5. SERVICE USER IMPROVEMENT QUESTIONNAIRES

5.1 The improvement questionnaires (Appendix 4) are a consultative tool and focus on individual views from individuals who have used the service.

5.2 The questionnaires and pre-paid envelopes are given to each

individual in a written format. Other formats are available upon request from the unit manager.

5.3 Information is then collated and this then forms further

evidence to show how Lincolnshire County Council is placing emphasis on the views of people who use the service, on quality and how we improve future services.

6. POLICIES, PROCEDURES AND PRACTICES

Registered unit managers must ensure that policies, procedures and practices are regularly reviewed in light of changing legislation and of good practice advice from the Department of Health/local Health Authorities and specialist/professional organisations.

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7. STAKEHOLDERS

The views of family and friends and of stakeholders in the community (eg GPs, chiropodist, voluntary organisations) must be sought on how the unit is achieving goals for those people who use its services. The above planned activities together with further consultation mechanisms such as meetings with people who use the service can help to provide adequate confidence that the services that Lincolnshire County Council provides in the Care Homes satisfy user and stakeholder expectations.

Appendix 1 www.CQC.gov.uk

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Appendix 2

MONTHLY MANAGERS’ REPORT Reg. 26

Name of Home: Month: Occupancy Number of Beds Beds Occupied Long Term Care Respite Care Intermediate Care Dementia Unit Day Care Number of Places Number of Attendees High Dependency ESMI Date: Regulatory Visit

Supervision with Unit Manager

Staff Meeting Attended

Meeting with Individual/Carers :

Very positive comments re kitchen , food, staff and service received.

Ideas for activities and outings were suggested by SU and programme

for the Summer discussed.

Equity and Diversity (issues and /or consultation re: services and

policies):

E&D questionnaire for consulting with individuals and the wider public

discussed- and questionnaire amended accordingly.

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Health and Safety: Infection Control: Maintenance of Premises and Grounds: Notifiable Events: (Reg. 37) Record of Satisfactions: Record of Complaints:

Record of Social Activities: Staffing Issues: Care Practice Issues: Medication Issues: Financial Issues: General Comments/Actions to be Taken:

Service Manager Signature: _____________________________ Date: _________________ Unit Manager Signature: _____________________________ Date: _________________

Appendix 3

Monthly Managers’ Checklist

RECORD OF CHECKS CARRIED OUT BY UNIT MANAGER

UNIT NAME: ........................................................................ UNIT MANAGER’S NAME: ............................................….. MONTH/YEAR: .................................................................... Contents:-

Subject Page No Administration/Registered manager 2, 3, 4 Health & Safety 5, 6 Environment 7, 8 Staffing 9, 10 Budgets 11 Service Users 12, 13 Training 14, 15 Registered Manager 16 Contracts and service details/requirements

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Additional Comments 18

* The monthly management record of checks will take place as soon as possible after the allocated month i.e. April will be completed early May*

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INFORMATION CSCI REF

COMMENTS ACTION/OUTCOME SIGNATURE

1.

ADMINISTRATION

1.1. Major Incidents record - check process (Part 7 section 37)

1.2. Check SAP Print Out Staff/Other/SAP Order - spot check process

1.3. Monthly Imprest Check/sign to validate process

1.4. Banking Check If correct sign off:- Receipt book/Paying In book/Cheque book

1.5. Check Retained Monies/Safe Property

1.6. Amenities Fund - Check Cross Reference Records

Administration continued

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INFORMATION

CSCI REF


1.7. Pensions/Debtor Account Systems sign to validate process

1.8. Short Term/Intermediate Care - Accommodation charges monitoring

1.9. Admission/Discharge Book - up to date Spot Check

1.10. Occupancy Statistics/EMT Report

1.11. Security of Keys

1.12. Complaints/Satisfaction Monthly returns to complaints department

1.13. Meals on Wheels Return (SS/116)

1.14. Visitors Book in place and being used (schedule 4.17 regulation 17)

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1.15.

1.16.

1.17

1.18.

1.19.

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2. HEALTH & SAFETY

2.1. Four Weekly Maintenance Checks completed and requirements actioned

2.2. Kitchen Stock control/probes in date tested/ menu alternatives/fridge temperatures/ general cleanliness/risk assessment/hazard control (cooking transportation)

2.3. Fire Systems weekly break glass bell test/ staff fire drills/emergency lighting/ risk assessments

2.4. Medication spot check x2 Individual records admission to discharge

2.5. Health and Safety Audit up to date

2.6. Legionella Tests Temperature of taps/water flushing/ capped off Shower - not in use flush weekly - risk assessment

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Health and Safety continued INFORMATION

CSCI REF


2.7.

2.8.

2.9.

2.10.

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INFORMATION

CSCI REF


3. ENVIRONMENT

3.1. Energy Conservation - monitor gas and electricity input/output

3.2. People’s rooms - spot check for: Equipment Cleanliness Comfort * with their agreement*

3.3. Spot check Unit small kitchen area: Equipment Cleanliness

3.4. Outside building spot check: Gardens, tidy and well maintained Outside buildings such as garages,

boiler house Bins/refuse area free from

clutter/pest control

3.5. Inside Unit general spot check: Odours Cleanliness Décor

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Environment continued INFORMATION

CSCI REF


3.6.

3.7.

3.8.

3.9.

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INFORMATION

CSCI REF


4. 4.1.

STAFFING Last staff meeting date or newsletter issued

4.2. Supervision taken place during the month

4.3. Appraisals taken place during the month

4.4. Long term sickness up to date

4.5. Special leave taken during the month

4.6. New staff starting during the month Staff details/information sheet completed Induction Photo Birth certificate (other proof) Police check Copy references x2 Medical clearance form Supervisor allocated

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4.7.

4.8.

4.9.

4.10.

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5. 5.1.

BUDGETS Print off SAP staffing budget sheet Complete staff monitoring forms

5.2. Print off SAP general budget information all budgets

5.3. Check SAP sheets against manual sheet to gain financial position

5.4. Check time sheet calculation x reference to Sap print off. Refer issues to Finance Manager and Service/Intermediate Care Manager for consultation

5.5. Assess and review new purchases required

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6. 6.1.

INDIVIDUALS Talk to people to gather views and comments relating to the service provision - use the service questionnaire format

6.2. Spot check Individual files at least x4

6.3. Check people who use the service guide information for accuracy/updates (schedule 4.2 regulation 17(2)

6.4. Check general information file (schedule 4.4 regulation 17(2)

6.5. Monitor complaints and satisfactions

6.6. Monitor and review aims and objectives

6.7. Leisure activities completed within the Unit during the month (regulation 16.1, 2M)

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INFORMATION

CSCI REF


6.8. Reviews taken place during the month

6.9. Review contents of statement of purpose and update as required (schedule 4.1 regulation 17(2)

6.10. Activate call alarm to monitor response times

6.11.

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7. TRAINING

7.1. Moving & Handling - All Staff (yearly)

7.2. Nominated First Aider - date

7.3. COSHH

7.4. Nominated People - Legionella

7.5. Fire Awareness/Equipment

8.6. Essential Food Hygiene - (7 years) - date

8.7. NVQ Monitoring

Training continued

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7.8. Equipment Training Rotunda/Hoist/Bath/ Carpet Shampooer/Kitchen Equipment

7.9. Monthly Training Cover Forms

7.10 Training Profile Matrix - monitor and action and submit training nominations as required

7.11.

7.12.

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8. 8.1.

REGISTERED MANAGER Service/Intermediate Care Manager report completed (Part 5 regulation 26.1, 2, 3, 4, 5)

8.2.

8.3.

8.4.

9.

CONTRACTS AND SERVICES FOR THIS MONTH

9.1.

9.2.

9.3.

9.4

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ADDITIONAL COMMENTS/CHANGES

Appendix 4

SERVICE IMPROVEMENT QUESTIONNAIRE

CARE HOME

Admission Date

Your name (optional)

Discharge Date

PLEASE PUT TICK IN RELEVANT BOX

Were you aware of the purpose of your admission?

YES NO Additional Comments: When you arrived, did a member of staff talk with you to plan your care? YES NO Additional Comments: When you arrived, did a member of staff explain the emergency call system and layout of the building to you? YES NO Additional Comments:

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Do you have any comments to make about the meals? Excellent Good Average Poor Additional Comments:

Was the home comfortable? YES NO Additional Comments: Were the staff helpful? YES NO Additional Comments: Please suggest how we could have improved your stay.

We value your comments to help us improve our service.

Thank you for taking the time to complete this form.

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