Kettlewell House / POLICY NO: P-07
Date: 03/02/16 / Version 01
Page 1 of 4
QUALITY ASSURANCE

The Home has been established with a quality orientated approach with the aim of it being run in the best interests of the residents. To this end, a pro-active approach is taken to introduce quality systems that incorporate audits and feedback so that every part of the home and its services can be evaluated to ensure improvements are continuous.

  1. Daily E-mails

a)An external contractor sends an email each working day to the Duty Manager (with a copy to the respective Home Manager) covering:

(1)Staff due to have a supervision/appraisal that day

(2)Care plan(s) to be reviewed that day

b)An external contractor sends an email each working day to the Home Manager containing:

(1)Details of any policies which have been checked for regulatory compliance and which the Home Manager now needs to check and approve for factual accuracy.

(2)Review of documentation of all new staff members and advice on anything outstanding.

(3)Review of End of Shift Reports since the previous email.

(4)Review of all charts which have been scanned into the server since the last email.

(5)Comments on the Staff supervision(s)/appraisal(s) done since the previous email.

(6)PDF attachments of the Care plan(s) reviewed since the previous email, together with comments on:

End of Life:
NOW
  • DNAR must be signed by resident if able and current GP. If resident lacks capacity to make that decision, document needs to say it is best interest decision.
PRESCRIPTION
  • Delete Liverpool care pathway – not used now
  • If end of life care/ after death care not known, needs to state resident/family asked on (date) still no decision made. This needs to be documented every month until details accurate.

Hygiene:
NOW
  • State if MCA & BID in place for resident if they cannot give consent. (Paper doc held in file)
PRESCRIPTION
  • Ensure day of shower/bath etc is chosen by resident not prescribed by us. Provide evidence for this – if not make comments general not being specific.

Medication:
NOW
  • State if MCA & BID in place if resident cannot consent. (Paper docs held in file)
  • State if COVERT medication regime used and WHY and add See file for paper documents (risk assessment, BID meeting evidence, BID, pharmacy advice document re suitable food & drink for each medication)

Mobility:
NOW
  • Check that Mobility RA is reviewed every month
  • If falls are occurring mention to follow Falls Protocol (on website)

Nutrition:
NOW
  • MUST score must detail numbers for all steps to explain final score.
  • MUST score must be re-calculated every month
  • Any history of choking must give details of action taken and RA
  • Detail if person needs feeding – how long does it take

Pressure Care/Skin Integrity:
NOW
  • Ensure Waterlow score checked and re-calculated monthly
  • Ensure paper documents are reviewed every month as minimum

Sleeping:
NOW
  • State if bedrails & bumpers in place MCA & BID must be completed.

N.B. Manager to review and sign-off each Care Plan when completed satisfactorily by writing "Care Plan read and approved" in the Residata Care Notes.

  1. Monthly Site Audit

Each month,an external consultant visits the Home to audit all areas of care delivery. Based on quantitative data from the previous month and interviews with a sample of residents, relatives and staff, the consultant produces a report covering each of the following areas:

1.Residents

1.1Care Outcomesincluding any complaints/compliments

1.2Care Plan Reviews

1.3Night-time monitoring of residents

1.4Social Programme

1.5Food Menus

1.6Unplanned Hospital Transfers

1.7Weights

1.8Accidents & Falls

1.9Pressure Ulcers

1.10Infections

1.11Medications

2.Staff

2.1Welfare

2.2Practice

2.3Shift handovers and staff allocations

2.4Staff Daily Routine

2.5Appraisals & Supervisions

  1. Quarterly Clinical Supervision

An external supervisor meets quarterly with each Home Manager to review their clinical performance and agree a development plan for the forthcoming period.

  1. Bi-annual Resident Satisfaction Survey

A Resident Satisfaction Survey is carried out twice a year by Philip McAuley of Care Home Satisfaction Surveys, a specialist independent research organization, using CHSS’s standard resident satisfaction questionnaire. This survey (formerly of Laing & Buisson) has been used to measure quality at hundreds of UK care homes over the past 18 years. The questionnaire comprises 37 questions for nursing homes and a Likert scale is used to rate each attribute. Respondents are invited to make comments at the end of the questionnaire.

Residents (or their advocates if they lack capacity) are emailed a link to the CHSS web based customer satisfaction survey. The web based survey guarantees complete independence.

Residents (or their advocates if they lack capacity) without an email address are sent a postal survey. Completed surveys are returned to CHSS. The care home is not involved in the processing of the postal survey at all so complete independence is guaranteed.

With many years of data from many thousands of respondents CHSS are able to measure a homes performance against all the other homes surveyed by CHSS. This enables a care home to judge its performance for each attribute against hundreds of other homes. A CHSS report clearly shows strengths and weaknesses, effort can then be directed to improve aspects of the home that do not perform as well as other homes.

Response rates are high compared with postal survey norms; the range is typically 40% to 80% averaging around 54%. The high response rates mean that the data is robust.

The results are discussed with each Home Manager as part of the Monthly Care Audit and an appropriate action plan is devised to address any issues which come up.

  1. Annual Staff & Stakeholder Surveys

Satisfaction surveys are sent to both staff and stakeholders every year. The responses are analysed by an external consultant and the results are discussed with the Home Manager as part of the Monthly Care Audit. An appropriate action plan is devised to address any issues which come up.

  1. Staff Training

At all times when staff have been identified for training they must attend the training at the agreed date and time. Where staff are unable to attend they must inform the Registered Manager as soon as possible. Staff who are unable to attend due to illness should also inform the Registered Manager.

All Mandatory Training Packs should all be undertaken within the agreed timescales, failure to do so may result in disciplinary action.

All staff undertaking accredited courses should be committed to and actively demonstrate that they are undertaking and will complete their course within the agreed timescale.

  1. ISO Quality Accreditation

ISO 9001:2008 – To assist us with our continual improvement programme, we have been awarded the International Standard ISO 9001:2008.

  1. Health & Safety Management

A contract is in place with an external company to inspect and advise on all aspects of Health and Safety.

  1. Complaints Procedure

Our complaints procedure is clearly shown in the Home's website and an “open door” policy is held by the Manager.