This Policy summarises the procedures used for periodic monitoring and auditing of the Organisation’s Quality Management Systems by the Organisation’s staff to ensure continued compliance to declared standards. This is designed to meet the requirements of the appropriate Regulations, Standards and Outcomes for Domiciliary Care for England, Scotland and Wales.
Auditing the Quality System is a structured process and is designed to check to ensure that documented Policies are being followed in practice. The auditing process uses a comprehensive set of specialised Self-Assessment Checklists designed to allow the auditor to assess and measure the quality of care delivered to service users. The auditing process can be approached from two angles with the over-riding objective that ensures compliance with the latest Domiciliary Care Standards and Regulations.
1. The VistaPoint™ Self-Assessment System is structured into 4 modules, each sub-divided into sections as appropriate:
Module 1 - Business Management
Module 2 - Continuous Quality Improvement
Module 3 - Looking After the Service User
Module 4 - Health & Safety Management
Each section identifies the overall Outcomes to be achieved for the Care Service, and the check-lists are designed as “Stand-alone” systems.
2. A Plan or Schedule of the sections of the Quality System to be audited through a calendar year will be prepared by the Domiciliary Care Services Manager using one of the following Record Forms, according to the Standards or Outcomes being audited:
FOR A GENERIC AUDIT - use Form No 2-000- Annual Plan of Quality Self Assessments - VistaPoint™ Quality Management System.
FOR ENGLAND - use the check-lists and KLOE references contained in the VistaPoint™ Quality Self-Assessment Manual, reference clause 1. above.
FOR SCOTLAND - use Form No 2-001 - Annual Plan of Quality Self-Assessments - National Care Standards for Care at Home - Scottish Executive
FOR WALES - use Form No 2-002 - Annual Plan of Quality Self-Assessments - National Minimum Standards for Domiciliary Care Agencies in Wales - Standard 27.
FOR NORTHERN IRELAND - use Form No 2-003, Annual Plan of Quality Self-Assessments - Minimum Standards for Domiciliary Care Agencies - Northern Ireland
3. Audits may be carried out either by designated staff, or by using an approved outside Management Consultancy service:
4. All designated staff shall be trained in Quality Audit techniques, and such training included in appropriate staff training records. Such staff are the “internal quality auditors”.
5. Outside Consultants shall be included on the list of Preferred Suppliers of Services, ref. Policy No 1102.
6. Wherever practical an auditor should not be permitted to audit his / her own area of responsibility.
7. The VistaPoint™ Quality Self-Assessment System Manual can be used as a working document and contains a comprehensive set of Checklist points. The auditor is invited to address a series of Performance Indicators (PIs), each geared to a specific Policy where relevant, and to award a Score relating to each PI. The system offers the flexibility for the user to interpret the scores achieved according to his / her system of choice. For each PI a facility is provided for the auditor to record where the evidence supporting the audit findings may be found in the Organisation’s Quality System.
8. Where audit findings show a deviation from declared standards or Policies, these will be known as “non-compliances”. These non-compliances, together with any observations noted by the auditor, will be reviewed for action required at the Quality Management Review meetings.
9. A summary of findings for each Standard will be made on the relevant year planner, reference clause 2 of this Policy. Where the Standards being evaluated are the C.Q.C. Essential Standards of Quality and Safety - C.Q.C. Outcomes, 2010, a special Record Form No 2-005 can be used to build a compliance record.
10. Following completion of the remedial action required, any action taken will be re-audited to verify its effectiveness in the space provided on the Non-Compliance Report. If acceptable, the Report will be closed off by the auditor.
Form No: 2-000 Annual Plan of Quality Self-Assessments - VistaPoint™ Quality Management System
Form No: 2-001 Annual Plan of Quality Self-Assessments - National Care Standards for Care at Home - Scottish Executive
Form No: 2-002 Annual Plan of Quality Self-Assessments - National Minimum Standards for Domiciliary Care Agencies in Wales - Standard 27
Form No: 2-003 Annual Plan of Quality Self-Assessments - Minimum Standards for Domiciliary Care Agencies - Northern Ireland