Worked example PIR – Is the service well-led? (example of a good service) (care homes and nursing homes)
Suitable for care home and nursing home settings.
Note: this worked example provider information return (PIR) is for illustrative information only. It may be used by a care home or nursing home as a basis upon which to complete its own PIR but should be fully customised and adapted to the specific needs of the home concerned.
5a. What do you do to ensure the service you provide is well-led?
By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality, person-centred care, supports learning and innovation, and promotes an open and fair culture.
In residential care, this means that management and leadership encourage and deliver an open, fair, transparent, supporting and challenging culture at all levels.
Providers should consult the Provider Handbook: Residential adult social care services, CQC, March 2015. The following KLOE prompts for well-led are taken from Residential adult social care services: Appendices to the provider handbook, CQC, March 2015, and should be considered when completing the PIR (this is reproduced below).
W1 How does the service promote a positive culture that is person-centred, open, inclusive and empowering?
Prompts
- How are people and staff actively involved in developing the service?
•Is there an emphasis on support, fairness, transparency and an open culture?
•Are there strong links with the local community?
•How are staff supported to question practice and how are people who raise concerns, including whistle-blowers, protected?
•Does the service have, and keep under review, a clear vision and a set of values that includes involvement, compassion, dignity, independence, respect, equality and safety? Are they understood and promoted by all staff?
•Are managers aware of, and keep under review, the day-to-day culture in the service, including the attitudes, values and behaviour of staff?
- How does the service enable and encourage open communication with people who use the service, those that matter to them and staff?
•Are there accessible, tailored and inclusive ways of communicating with people, staff and other key stakeholders?
•Is there honesty and transparency, from all levels of staff and management, when mistakes occur?
•Do staff receive feedback from managers in a constructive and motivating way that means they know what action they need to take?
W2 How does the service demonstrate good management and leadership?
Prompts
•Is the leadership visible at all levels and does it inspire staff to provide a quality service?
•Where required, is there a registered manager in post?
•Does the registered manager understand their responsibilities, and are they supported, where appropriate, by the other managers to deliver what is required?
•Are CQC registration requirements, including the submission of notifications and any other legal obligations met?
•Are all other conditions of registration met?
•Do managers and staff have a shared understanding of the key challenges, achievements, concerns and risks?
•Are resources and support available to develop the team and drive improvement?
•How does the service make sure that staff are supported, have their rights and wellbeing protected and are motivated, caring and open?
•How does the service make sure that responsibility and accountability is understood at all levels?
•Do staff know and understand what is expected of them?
•Are there clear and transparent processes in place for staff to account for their decisions, actions, behaviours and performance?
•Where appropriate to the type of organisation, do the board and managers know about, and take responsibility for things that happen in the service?
W3 How does the service deliver high quality care?
Prompts
•How does the service make sure that their approach to quality is integral and all staff are aware of potential risks that may compromise quality?
•Are quality assurance and (where appropriate) governance and clinical governance systems effective, and are they used to drive continuous improvement?
•How does the service make sure they have robust records and data management systems?
•How is innovation recognised, encouraged and implemented in order to drive a high quality service?
•How is information from investigations and compliments used to drive quality across the service?
•How does the service measure and review the delivery of care, treatment and support against current guidance?
W4 How does the service work in partnership with other agencies?
Prompts
•How does the service work in partnership with key organisations, including the local authority, safeguarding teams and clinical commissioning groups, to support care provision, service development and joined-up care?
Residential adult social care services: Appendices to the provider handbook, CQC, March 2015
Provider Information Return worked example5a. What do you do to ensure the service you provide is well-led?
Good service provision starts with good leadership. We have invested to recruit the right leaders from the registered manager to the team leaders in charge of all aspects of our service delivery. Managers understand the need to be consistent, lead by example and be available to staff for guidance and support. This provides staff with constructive feedback and clear lines of accountability. As such managers are accountable for the actions of their staff team.
We make sure via our service user management committee that people, their family and friends are regularly involved with the service in a meaningful way. Committee meetings are held on the first Tuesday of each month and the aim is to drive continuous improvement.
At our most recent survey 92.5% of people described the quality of how well our service is well-led as good or excellent. The other 7.5% made comments which we are acting upon.
Our mission statement was developed with staff, people who use our service and their families and it is underpinned by a set of values which include:honesty, involvement, compassion, dignity, independence, respect, equality and safety. These form part of staff induction (linking to the Care Certificate), supervision and our internal quality assurance procedures to ensure that they are understood and consistently put into practice. Our ethos is one of empowerment, inclusion and person centred care. Key to this is that everybody understands the principles of equality, diversity and human rights and is able to put these into practice. We provide training for staff in these areas and instil in them the responsivity to question practice and report concerns about the care offered by colleagues, carers and other professionals. When this happens they are supported and their concerns are thoroughly investigated in accordance with our feedback procedure.
Via supervision and day to day observations we are confident that staff understand their role, appreciate what is expected of them, are happy in their work, are motivated and have confidence in the way the service is managed. Our recent staff survey bears this out.
We make sure that our team are adequately supported and resourced to deliver continuous improvement. We define a good service as one which the people who use our service would describe as good. So, we asked them what makes a well-led service. They said “visible management, leading by example, consistent care and action being seen to be taken to address concerns”.
We use a PIR bases quality assurance tool to assess our service and identify improvements. This is a live document but it is crystallised once every three months to provide evidence of compliance.
We regard the establishment and maintaining of partnerships with key organisations to support care provision, service development and joined-up care as vital in ensuring that we deliver a good standard of care and also meet our legal obligations, including conditions of registration from CQC. We have submitted 100% of the required safeguarding referrals, Reg 18 notifications, RIDDOR reports in the last 12 months.
Provider Information Return worked example
5b. What improvements do you plan to introduce that will make your service better led, and when will this be done by?
We will invite about 20 local providers to meet at our setting once to share experiences and good practice. Our agenda will also include new and innovative ideas from the wider social care sector. We plan to hold the first of these meetings within 3 months
We have recently changed our complaints form to a feedback form, and we plan to build upon this to sustain a positive culture in the service encouraging staff and people to raise issues of concern, which we will always act upon.
We plan to continue our PIR based audits to identify areas for improvement. The commitment of leaders and managers is key to this and we will allocate a budget of 1% of turnover for the identification and development of new ideas for the improvement of our service. We aim to have one new initiative per month implemented within 6 months.
We will explore the suitability of recognisedquality accreditation schemes such as ISO9000. We have tasked a small team comprising: the registered manager, a team leader, 2 care staff, cook and head of housekeeping to look into this and report within 3 months.
We are talking to suitable providers to set up smart TV’s for use by people who use our service. The aim is to enable them voice their opinions about our service. We hope to have the smart TV’s installed in communal areas within 6 months and if this pilot is successful, to roll this out to the bedrooms of service users who wish to be involved within 18 months. We have commissioned a report from dementia care experts to identify ways in which people who use our service can express their views regardless of their communication needs. We expect the report within 2 months.
We wish to build upon our ethos that without the people who use our service we have no service. Even though we have made good progress in embedding this we recognise that it is always going to be a work in progress. Our plans are to build upon the work so far (training, supervision) and embed person centred care into every aspect of our service delivery. We are developing a PERSON (Preferences, Empowerment, Respect, Support, Outcome, Needs) test for every: policy, procedure, form etc. The PERSON test was developed by our staff and service users and we will apply this all aspects of our work within the next 6 months.
We are designing anewsletter for key stakeholders, this will be communicated via: paper, email, website, web app and via the smart TV’s. We aim to have this up and running within 2 months.
We have contacted three leading researchers in the fields of dementia, gerontology and falls prevention. We have asked them to work with us to identify and explore some of our ideas for service improvements. We aim to have 6 student projects (undergraduate and post graduate) in place for the next academic year. We will involve other local providers via our manager’s networks.
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