Quality Assessment Guidance
Revision: 1.2
Date: July 2012 /

Care Homes Module

Guidance on the operation of Performance Measures and Quality Standards

For

Directorate for Adults, Health and Wellbeing

Introduction

The Directorate for Adults, Health and Wellbeing Quality Standards (DfAHW QS) for contracts with all sectors of care has been introduced to set out the standards expected in the delivery of Directorate for Adults, Health and Wellbeing services.

The DfAHW QS will become an essential part of Manchester City Council’s means of ensuring that providers deliver services to an acceptable standard and in accordance with contractual expectations.

The overarching objective of this review programme is to ensure that commissioned services are safe and effective, providing good quality, efficient and cost effective services to Manchester residents.

The quality standards enable the Council to monitor the contract to:

  • Determine whether services are meeting the strategic objectives for all care placements at a local level.
  • Evaluate the quality and performance of services
  • Assess the extent to which continuous improvement is taking place
  • Engage with users of the service and to get their feedback on the service.

Guide to the approach

The review process will be conducted in two steps which will consist of:

Step 1 – Bi-annual Self Assessment Questionnaire

Step 2 - Quality monitoring visit (Annual)

Step 1 – Bi-annual Self Assessment Questionnaire

This will largely consist of a self assessment review, amongst the information considered within the questions, there will be a focus on a number of key areas and risk factors including:

  • Strategic Fit
  • Service User Involvement & Empowerment
  • Staff and Training
  • Security, Health and Safety
  • Safeguarding and Protection from Abuse

There are three levels of standard which will be assigned to the outcome of the self assessment. Bronze Award must be reached to meet the minimum requirement, services at Silver level have examples of good practice and are committed to continuous improvement, and Gold level denote that services are providing excellent services and are innovative in their approach to delivering services.

Service providers will use the DfAHW QS to self-assess their services. The self-assessments are to be completed by the service provider and sent to Manchester City Council at

You will receive an email notification that your submission has been received.

Bronze Award means that the service meets, and is able to evidence the required minimum standard but there is scope for improvement. Bronze Award requires that the service:

  • complies with any statutory requirements
  • has policies and procedures in place, and that these are followed
  • has staff that understand and can explain the policies and procedures
  • has clients who understand the nature of the service they are receiving
  • engages in partnership working at a client level to better meet the needs of the individual
  • is working towards the achievement of individual client outcomes
  • demonstrates a commitment to continuous improvement

Silver Award means the service can evidence good practice. In addition to meeting minimum standards, Silver Award requires that the service:

  • has policies and procedures in place that go beyond statutory requirements to embrace good practice, and that these are followed
  • has staff that are confident to take the initiative, and work effectively with other agencies
  • has service users meaningfully engaged at a service level
  • engages in partnership working at a service level to better meet the needs of service users and the service
  • is working towards the achievement of shared outcomes at a service level
  • challenges its own performance with internal auditing and the setting and monitoring of targets
  • demonstrates a commitment to continuous improvement

Gold Award means excellence and is associated with providers striving to be leaders in their field. In addition to meeting minimum standards and evidencing good practice, Gold Award requires that the service:

  • is flexible and responsive, and able to adapt the service to best meet service users needs
  • is a learning organisation that reflects on its work and uses this information to challenge its own performance
  • effectively engages service users and staff in this shared learning
  • engages in partnership working at a strategic level to better meet the needs of service users, the service/organisation and commissioners
  • demonstrates the achievement of shared outcomes as a result of effective partnership working
  • demonstrates vision, leadership and creativity that influences practice beyond the boundaries of the service

Step 2 – Quality Monitoring visit

Most homes will be visited twice a year, once by Quality Team and once by their Contracts Officer. However, during the year, some homes will be visited more often as deemed necessary by the Council to ensure contractual compliance or to resolve identified problems. During the assessment the contracts and quality teams will focus their engagement with the prioritised providers to validate initial findings. It is likely that staff will visit services, conduct interviews with management, front line staff and look at a range of service related documentation. Service user feedback on their experience of the service will also be collected.

Note: Monitoring visits may be either announced or unannounced

Service providers will use the DfAHW QS to self-assess their services. The Quality Team visit will be to validate the provider’s self assessment score.

Scoring Criteria

The assessment tables are intended for self-assessment by service providers and may be used in two ways:

  • to facilitate objective quality assessment of a service which is then subject to external validation by the Council; and
  • as a tool to assist providers in the delivery of continuous improvement.

Failure to meet Bronze Award means that the service is failing to meet the minimum quality standard. In some instances immediate action will be required to meet legal, statutory or health and safety standards. Services in receipt of Directorate for Adults, Health and Wellbeing funding should not be below the minimum requirements and service providers should prioritise achieving Bronze Award immediately.

This may result in enforcement action, including breach of contract, notice or suspension of service contracts, depending on the nature of the failing. If this happens, we will work with the provider to rectify the shortfalls, and will produce an action plan with agreed timescales. The aim is to rectify any shortfall as quickly as possible.

Scoring Matrix

Table 1 illustrates the scoring principles which are applied against the Self Assessment Questionnaire. Each factor within these is assessed to produce an overall score of between 0 and 10 for each criterion.

Manchester City Council will use the following scoring system for evaluating responses of the questionnaire and the outcomes of monitoring review visits.

Table 1.0
Score / Scoring Principles
0 / Unanswered – Question not been answered or has been answered but there is a failure to properly address any issues.
1-4 / Poor – The response and evidence is deficient in certain areas where the lack of detail or information requires the reviewer to make assumptions.
5-6 / Satisfactory –The response and evidence is acceptable, but with some minor reservations.
7-8 / Good – The response and evidence meets requirements with some evidence provided.
9-10 / Excellent – Comprehensively meet requirements with high quality and substantial amounts of evidence and information provided.

Scoring Criteria

The self assessment questionnaire scores will be calculated by multiplying the score for each criterion by its weighting. The weighted scores will be totalled providing the total score for the self assessment questionnaire. Each of the five sections will be equally weighted.

The indicative quality score for your service will be based on your response to the questionnaire. This is not your final score, and it is our intention to discuss these results with you on the date of our visit at which point you will have the opportunity to provide evidence so that your award level can be validated. You will be awarded a final score following the visit.

This methodology will seek to capture the quality, performance, outcomes and strategic fit of each service provider.

A simple scoring matrix will be developed and prioritised by colour coding similar to that of a risk register as follow:

Scale / Impact
0 to 49 / Fail / Fail
50 to 59 / Bronze Standard / Bronze
60 to 89 / Silver Standard / Sliver
90 to 100 / Gold Standard / Gold

In addition to the overall score of providers must also meet the minimum standards that the City Council expects of its services. Failure to meet any of the minimum standards will result in a fail, regardless of the overall score.

The minimum standards that must be met are listed below as pass/fail questions.

Minimum Standard
Key
Marked / Response to questions are marked
Not Marked / Response to questions is required but not marked
Pass/Fail / Response is marked against minimum standards - % indicates the required score
Strategic Fit
1.1 / How often through one to one and group meetings with the service users do you discuss individual outcomes? / Marked
1.2 / How often through one to one and group meetings with the staff do you share the aims and objectives of the service? / Marked
1.3 / Do you link the service aims and objectives to the outcomes in the support plans of the service users? / Marked
1.4 / How many places does your service have? / Not Marked
1.5 / How many bed vacancies do you currently have? / Not Marked
1.6 / How many service users have been referred by Manchester City Council? / Not Marked
1.7 / How many service users have been referred by other Local Authorities? / Not Marked
1.8 / How many service users in your home are self funders? / Not Marked
Service User Involvement & Empowerment
2.1 / How often do service users engage in their chosen social or leisure activities? (in the local community where appropriate) / Marked
2.2 / How many service users participate in chosen social, leisure or cultural informal learning activities? / 50% / Pass/Fail
2.3 / People may be over or under weight and may have health conditions that affect their needs. How often is the service user given support and guidance about a balanced diet? / Marked
2.4 / Please indicate how many service users have been weighed in the last 3 months. / 50% / Pass/Fail
2.5 / How often are the service users consulted on all significant proposals which affect their service, and their views taken into account? / Marked
2.6 / Before accepting an offer are prospective service users given information and access to the proposed service? This should include information and activities available to meet their needs to make an informed decision, and be available in accessible formats. / Marked
2.7 / Maximising the income of the service user, which includes receipt of the right benefits, contributes to their economic wellbeing. How often are service users given support and guidance about their financial position, or signposted to appropriate services? / Marked
2.8 linked / Do you have any service users who suffer from dementia?
Are there any social or leisure activities provided that are specifically designed to meet the needs of the service users with dementia? / Marked
2.9 / How many days a week do most service users engage in their chosen social or leisure activities? (in the local community where appropriate) / Marked
2.10 / How many different activities have been introduced during the last 3 months? / Marked
2.11 / How many service user rooms have an en suite bathroom? / Marked
2.12 / How many service user rooms are provided with television aerial outlets? / Marked
2.13 / Have service users who are eligible (i.e. not excluded by support plan), been consulted and offered a key to their own room? / Marked
2.14 / Do you provide service users with free access to computers? / Marked
2.15 / How many service users are provided with free internet access? / Marked
2.16 / Are service users or their carers able to engage with the process for recruiting staff in the service? / Marked
Do you have any service users who suffer from dementia? / Not marked
2.17 / Are staff able to communicate with service users with dementia which includes how they view their quality of life? / Marked
2.18 / Has the service environment been specifically designed to meet the needs of service users with dementia? / Marked
2.19 / Are you flexible about when meal facilities are available to service users? / Marked
2.20 / Are you flexible about where service users eat their meals? / Marked
Staff & Training
3.1 / Please indicate the number of Care Staff (Including agency) / Not Marked
3.2 / Please indicate the number of Nursing Staff (Including agency) / Not Marked
Please indicate in questions (3.3 - 3.14) whether staff have been trained in the following areas:
- Safeguarding and protection from abuse
- Deprivation of Liberty
- Mental Capacity Act 2005
- Infection control
- Handling medicines
- Continence management
- Person centred care
- End of life care
3.3 / Care Workers who have attained a relevant NVQ2 in care and support (or QCF) / 45% / Pass/Fail
3.4 / Care Workers who have attained a relevant NVQ3 (or QCF) in care and support (combined total with 3.3) / Pass/Fail
3.5 / All staff who have received training in Safeguarding during the past 24 months / 45% / Pass/Fail
3.6 / Care staff who have attended training in Infection Control as part of their induction / 45% / Pass/Fail
3.7 / Care staff who have attended refreshed or further training in Infection Control within the past 24 months / Marked
3.8 / Care staff who have received training in continence management / 45% / Pass/Fail
3.9 / Care staff who handle medicines that have received relevant training in medicines management within 24 months. / 45% / Pass/Fail
3.10 / Staff who have received training on the Business Continuity Plan over the last 12 months. / 1 / Pass/Fail
3.11 / Care staff who have undertaken training in End of Life care / 45% / Pass/Fail
3.12 / Care staff who have undertaken Mental Capacity Act training within the last 24 months. / 45% / Pass/Fail
3.13 / Has the Registered Manager undertaken Deprivation of Liberty training within the last 24 months? / Marked
3.14 / Number of care staff who have received training in person-centred care in the past 24 months. / Marked
3.15 / Number of all staff who have received training in areas other than the above or statutory training? / Marked
Security, Health & Safety
4.1 / Is there a health and safety policy which has been reviewed in the last two years which is in accordance with current legislation? / Marked
4.2 / Does the service have a co-ordinated approach to assessing and managing security and health and safety risks that could potentially affect the service users, staff and the wider community? / Marked
4.3 / Are there appropriate arrangements to enable the service users to access help in crisis or emergency? / Marked
4.4 / Is there an emergency alarm equipment installed which is appropriate to the service, maintained to a satisfactory standard and which takes account of the need to ensure privacy, security health and safety? / Marked
4.5 / Have you achieved the Dignity in Care Daisy Award? / Marked
4.6 / Are you working towards achieving the Dignity in Care Daisy Award? / Marked
4.7 / Have you achieved the Investors in People Award? / Marked
4.8 / Are you working towards Investors in People Award? / Marked
4.9 / Have you achieved the Gold Standard in the End of Life Pathway? / Marked
4.10 / Are you working towards achieving the Gold Standard in the End of Life Pathway? / Marked
4.11 / Is the service working towards an award similar to Dignity in Care or Investors in People? / Marked
Safeguarding & Protection from Abuse
5.1 / Are there robust policies and procedures for safeguarding and protecting adults and children that are less than two years old and in accordance with current legislation? / Marked
5.2 / Do all staff work to policies and procedures that safeguard service users and children and promote an understanding of abuse? / Marked
5.3 / How often are staff made aware of the importance of professional boundaries and whistle blowing and does their practice reflect this? / Marked
5.4 / Do you have a safeguarding log which details allegations and cases of abuse which shows the appropriate action is taken, including reporting to the appropriate authorities, together with eventual outcomes? / Marked
5.5 / During one to ones and group meetings how often are service users made aware of and understand what abuse is and know how to report any incident? / Marked
5.6 / Does the service practise a multi-agency approach to safeguarding vulnerable adults and children? / Marked

Guide to the Self Assessment Questionnaire

Should you experience problems opening Excel Macros

Move your mouse and click on to Tools on the standard tool bar as shown.

From the drop down menu click on Macro a new drop down menu will appear. Click on to the Security tab. A Security Level option window will open as detailed below:


Please select “Medium. You can choose whether or not to run potentially unsafe macros”. Then press OK.

Answering the Questions

The questionnaire consists of two steps. Please complete each section: General Information and Questions. We have shown two examples of how best to fill in your questionnaire