service improvement report - whatdotheyknow

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SERVICE IMPROVEMENT REPORT

NAME OF PROVIDER:

TYPE OF SERVICE PROVIDED:

DATES OF VISIT:

CONTRACT MONITORING OFFICER:

INTRODUCTION

MONITORING METHODS

WHAT THE SERVICE DOES WELL

WHERE THE SERVICE COULD IMPROVE

FEEDBACK FROM CLIENT QUESTIONNAIRES

…… client questionnaire were sent out, and …… were returned.

Question: Yes No Other

Did the Home Care Agency visit you to discuss your care needs before your package of care started?

Did the Home Care Agency discuss the goals/outcomes you would like to achieve from receiving home care?

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Do you feel your goals / outcomes are being met by receiving home care?

Did the Home Care Agency let you know the name of the first care worker visiting you before the service started?

Do you receive a weekly rota from the Home Care Agency letting you know times of visits and names of care workers attending?

Does the Home Care Agency let you know if they are going to change the time of your visit?

Does the Home Care Agency let you know if a different care worker will be visiting to the one stated on your rota?

Home many different care workers visit you in a week?

1 and 3 = 3 and 6 = More =

Do your care workers stay the whole time?

Do your care workers arrive on time?

Do the care workers complete all tasks required to your satisfaction?

If a different care worker attends your call, do they understand what needs to be done to meet your needs?

Are the care workers pleasant and friendly?

Do you feel your care workers treat you with dignity and respect?

If you need to cancel a visit for any reason, do you know who to contact?

Has a care worker ever failed to arrive?

If you wanted to make a complaint for any reason, do you know who to contact?

Have you ever made a complaint?

Before your care started, did the Agency ask you if you would prefer a male or female care worker?

Are you happy with the care you are currently receiving?

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Summary of Client Questionnaire Results:

FEEDBACK SUMMARY OF CARE WORKER STRUCTURED INTERVIEWS

FEEDBACK SUMMARY OF MANAGER’S STRUCTURED INTERVIEW

INFORMATION HELD IN CLIENT’S OWN HOME

Evidence Criteria:

Agency folder to include Social Services Support Plan and Care Diary (Serv Spec 5.2.4v), Agency Care Plan (Serv Spec 5.2.4v) and quality of this document, is care plan person centred and outcome

focused, Agency Risk Assessment (Serv Spec 5.2.1v, 5.2.4v), Agency Manual Handling Plan and/or OT MH Plan (Serv Spec 5.2.4v), Contact details for the Agency (Serv Spec 6.1i), Service User Guide/Statement of Purpose (Serv Spec 5.2.1), Tasks recorded in full and with appropriate detail

(Serv Spec 5.2.4vii), Medication Recording (in-line with CQC requirements and Bournemouth BC, Borough of Poole and Bournemouth and Poole NHS Medicine s Policy), Financial Transaction Recording (Con B10.2.8)

Contractual Requirements: Met / Partially Met / Unmet

Remedial Action Required in order to meet criteria:

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INFECTION CONTROL / PERSONAL PROTECTIVE CLOTHING (PPE) / UNIFORM

Evidence Criteria: Use of gloves and aprons, absence of nail polish and acrylic nails, correct disposal of waste, uniform

and dress code, hand gels available, hand-washing practice witnessed, changing gloves as required, application of creams, correct administration techniques used when administering medication, appropriate footwear when moving and handling, jewellery worn by care workers . (As per Health and

Social Care Act 08, Code of Practice on the Prevention and Control of Infections and related guidance). Staff to carry ID (Con B10.2.10).


Remedial Action required in order to meet criteria:

TIME KEEPING / SCHEDULING / CONTINUITY OF CARE

Evidence Criteria:

Sufficient travel time (Serv Spec 6.2v), care workers arriving at the same time if attending a double -up call (Serv Spec 6.2vii), call time within 15mins each side of scheduled time (Serv Spec 6.1vi), continuity of care levels met (Serv Spec 6.2ii), clients informed if care work er is running late or a

different care worker will be attending the call, Electronic monitoring system in place (Serv Spec 6.2iv, Con B13.1), clients receiving a weekly rota. (Serv Spec 6.1(v), Con B7.25)


Remedial Action required in order to meet criteria:

POLICIES AND PROCEDURES

Evidence Criteria: In addition to Legislation, the Purchaser expects the Provider to have in place policies, procedures and practices that meet, as a minimum, those stated under Con A11.2. (Con A11.2), the Provider

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agrees to adhere to the Bournemouth and Poole and Dorset Safeguarding Policy and Procedure produced by the Purchaser (Con A11.3), the Provider must adhere to the Purchasers Managing Other People’s Money Policy (Con B10.2.8), the Provider must have a Gifts Policy approved by the

Council (Con B10.2.7)


Action Required in order to meet criteria:

CONFIDENTIALITY / DATA PROTECTION / INFORMATION GOVERNANCE

Evidence Criteria:

Staff to have signed Data Protection Slip giving permission for a Borough of Poole Officer to inspect their personnel files (Con B19.3), staff have been made aware of the Agency’s Confidentiality agreement (Serv Spec 6.1iv), key safe codes are kept confidential (Serv Spec 6.3iv), return of ID etc

when a care worker leaves the Agency (Serv Spec 6.4vii), meet the criteria within the Information Governance checklist (Data Protection Act)


Action Required in order to meet criteria:

COMPLAINTS

Evidence Criteria: SU’s and their NOK to be informed in writing of how to make a complaint including timescales (Con

B39.1), a register to be in place to record all complaints (Con B39.2), SU’s to be advised that they

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have the right to seek redress from the Complaints Manager at the Borough of Poole if not happy with the outcome from the Provider (Con B39.4), SU’s and their NOK to be informed that they have the right to complain directly to Social Services without going through the Providers Complaints Policy

(Con B39.9), Providers to maintain a log of complaints detailing name and address of SU, name and address of complainant, nature of complaint, outcome and response to complaint, level of satisfaction of the complainant, learning practices gained and any alterations made to the service provision

following the complaint (B39,6).


Action required to in order to meet criteria:

STAFF FILES

APPLICATION FORMS:

Evidence Criteria: Application form on file (Serv Spec 5.2.7ii), employment history and any gaps explored (Serv Spec

5.2.7ii), health and fitness explored (Health and Social Care Act 08, Part 3), 2 x forms of identification (Essential Standards 12a)


Action required in order to meet Criteria:

REFERENCES AND CRB CHECKS: Evidence Criteria:

2 x written references to be sought (Serv Spec 5.2.7i), 1 x reference from the last employer to be obtained (Serv Spec 5.2.7i), evidence of CRB check (Con B18.1, Serv Spec 5.2.7v)


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Action required in order to meet criteria:

SPOT CHECKS, SUPERVISIONS AND APPRAISALS: Evidence Criteria:

Regular spot checks and supervisions to be held with staff, and annual appraisals (Serv Spec 5.2.7x)



INDUCTION AND TRAINING

Evidence Criteria: Care workers to attend an Induction Programme which is in-line with the Skills for Care Common

Induction Standards 1-8 (Serv Spec 5.2.7vii), is a Staff Learning and Development Plan in place (Essential Standards 14a), care workers to achieve Level NVQ2 within 2 years of appointment (Skills for Care), who are the providers of training for the Agency, where does training take place,

mandatory training to be undertaken as stated under Serv Spec 5.2.7viii, other courses offered by the Agency, medication training as per Bournemouth, Poole and NHS Bournemouth and Poole Medicines Policy Section 4.1, Medication Competency Assessments as per Medicines Policy

Section 4.1. Evidence of current and ongoing training. Completion of required information in relation to National Minimum Data Set (NMDS) on an annual basis (Con B7.12) Contents of Safeguarding training to include 5 competencies identified in ‘National Competence Framework for Safeguarding

Adults’



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CLIENT FILES WITHIN THE OFFICE

Evidence Criteria: Involvement of client and family carers within the assessment process (Serv Spec 5.2.1vii), assessment completed prior to care commencing or within 2 days at the latest (Serv Spec 5.2.3iv),

during assessment to consider and make reasonable efforts to match culture, skills and personality of the care working with the client (Serv Spec 5.2.1ix), involvement of client and/or family carers in the Care Plan review process (Serv Spec 5.2.1vii), completed risk assessment (Serv Spec 5.2.1v), are

outcomes identified for the client being met via Care Plan Reviews.



QUALITY CONTROL AND MONITORING

Evidence Criteria: What quality control measures are in place (Serv Spec 7), monitoring to take place under

management of staff, supervision and training, service activity and outcomes, representation and complaints procedure (Con B44.6), telephone number provided to clients which is personally answered between 6am and 11pm (Con B7.27), out of hours number provided which is not an

answer-phone service (Con B12.3), Statutory Notices to be copied to the Service Improvement Team (Con B7.13)



SERVICE PROVISION

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Evidence Criteria:

The Provider shall maintain an up-to-date list of support services, advice and information services and leisure and community activities in their locality which may support older people. Information to be accessible in a range of formats (Serv Spec 5.2.5iv).

The Provider will operate a ‘Think Carer’ Policy and procedure ensuring that the needs of the carers are recognised and addressed. Providers will evidence how this objective has been achieved in relation to individual carers (Serv Spec 5.2.11iv)

Any other area which is not mentioned previously and does not comply with the Essential Standards of Quality and Safety.



GOOD PRACTICE RECOMMENDATIONS

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OUTCOMES

Community Outcomes as specified within the Care At Home Service Specification:

(See Appendix 1attached for Indicators required to meet each outcome)

Required Community Outcome

Findings by Contract Monitoring Officer Achieved / Not

Achieved

Action required by Provider

Developing self supporting communities through making best use of voluntary sector provision and prevention services.

Increasing care and treatment at home through developing integrated health and social care locality teams, increasing access to Assistive Technology and reducing the number of admissions to hospital and residential care.

Improving medicines management to ensure people are able to achieve an improved quality of life through appropriate use of their medication, and admissions to hospital as a result of misadministration of medication are reduced.

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Improving the quality of life for unpaid carers.

Ensuring that individuals are safeguarded and are able to access good quality services. There is a consistent and ongoing improvement in the quality of services available across Poole.

Promoting health and well-being through empowering people with the necessary information and skills to self care and manage their needs wherever possible.

Minimise the impact of the delivery of the service on Poole environment and evidence the commitment to ‘Making Poole Greener’ through taking all necessary steps to reduce carbon emissions.

Individual Outcomes as specified within the Care At Home Service Specification:

Required Individual Outcome

Findings by Contract Monitoring Officer Achieved / Not

Achieved

Action required by Provider

I want to be able to live the

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way that I want to live. I want to wake up in the morning feeling positive. I want services to recognise the contribution I make to my family, friends and community. As I get older I want services to recognise my fears of the unknown and give me good information and allow me to discuss those fears.

I want services to work with me and do what’s important for me.

I want my welfare to be safeguarded and to be treated with kindness, dignity, respect and honesty, do not make assumptions about what I can do on the basis of my age or disability.

I want information about choices and options to be easily available.

I want to be confident that when I need care I can get it quickly so that I feel safe about staying in my own home and not going to hospital or into residential

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care. I want the staff who care for me to be well trained and competent.

I want to know that the money being spent on my care is being spent wisely.

I don’t want to stay in hospital any longer than I need to.

I want my death to be a good death.

As a carer, I want to know that services recognise my contribution and will support me.

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UPDATE ON CQC REQUIREMENTS / ACTIONS SET FROM COMPLIANCE VISIT

Requirement / Actions set: Date: Contract Monitoring Officer Comments:

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ACTION PLAN

INFORMATION HELD IN CLIENT’S OWN HOME Action Point 1 Remedial Action required in order to meet criteria:

Agreed target completion date:

Agreed By: Date:

(Purchaser)

(Provider)

INFECTION CONTROL / PERSONAL PROTECTIVE CLOTHING (PPE) / UNIFORM

Action Point Remedial Action required in order to meet criteria:


Agreed By: Date:

(Purchaser)

(Provider)

TIME KEEPING / SCHEDULING / CONTINUITY OF CARE



Agreed By:

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Date:

(Purchaser)

(Provider)

POLICIES AND PROCEDURES



Agreed By: Date:

(Purchaser)

(Provider)

CONFIDENTIALITY / DATA PROTECTION / INFORMATION GOVERNANCE



Agreed By: Date:

(Purchaser)

(Provider)

COMPLAINTS


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Agreed By: Date:

(Purchaser)

(Provider)

STAFF FILES Action Point Remedial Action required in order to meet criteria: Agreed target completion date:

Agreed By: Date:

(Purchaser)

(Provider)

INDUCTION AND TRAINING Action Point Remedial Action required in order to meet criteria:


Agreed By: Date:

(Purchaser)

(Provider)

CLIENT FILES WITHIN THE OFFICE Action Point Remedial Action required in order to meet criteria:

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Agreed By: Date:

(Purchaser)

(Provider)

QUALITY CONTROL AND MONITORING Action Point Remedial Action required in order to meet criteria:


Agreed By: Date:

(Purchaser)

(Provider)

SERVICE PROVISION

Action Point Remedial Action required in order to meet criteria: Agreed target completion date:

Agreed By: Date:

(Purchaser)

(Provider)

GOOD PRACTICE RECOMMENDATIONS

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OUTCOMES



Agreed By: Date:

(Purchaser)

(Provider)

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PROVIDER FEEDBACK

To enable the Borough of Poole to support contract monitoring and service improvement, any feedback on the Contract Monitoring visit / process, and/or action plan would be most welcome. Name: …………………………………………………………………………………………………. Signature: ……………………………………………………………………………………………… Position within Organisation: ………………………………………………………………………... Date: …………………………………………………………………………………………………….

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APPENDIX 1: Indicators required to meet Outcomes:

Community Outcomes:

5.1.1 Developing self supporting communities through making best use of voluntary sector

provision and prevention services.

Agency having a pro-active role in the community through linking with other organisations to enable older people to become more active and engaged members of the community.

Maximising the use of trained volunteers to facilitate activities.

Enable people to self-manage all aspects of their li fe and care and pro-actively linking with health and social care professional to prevent points of crisis in an individual’s life.

Quantitative and qualitative evidence as to how the above is being achieved.

5.1.2 Increasing Care and Treatment at home through developing integrated health and social care locality teams, increasing access to Assistive Technology and reducing

the number of admissions to hospital and residential care.

Pro-actively engaging with locality teams and health professionals i.e. Hospital Discharge Team.

Providing a good quality, preventative Domiciliary Care service to enable people to remain at home, and to reduce the number of hospital admissions.

Increasing the number of people who are supported to die at home in a pain free and comfortable way which meets their expressed wishes. This will be through

excellent multi-disciplinary working with GP’s, Palliative care professionals etc.

Acting as advocates for the use of appropriate Assistive Technology equipment etc. Signposting and providing appropriate information around this area.

Providers to meet annual performance targets in this area and provide quantitative and qualitative information as to how this outcome has been achieved.

5.1.3 Improving medicines management to ensure people are able to achieve an improved

quality of life through appropriate use of their medication, and admissions to hospital as a result of misadministration of medication are reduced.

Support individuals to manage their medication appropriately and direct or assist them to access appropriate advice in the event that professional medical or

pharmaceutical intervention is needed.

Ensure all Provider staff are aware of the boundaries of their responsibilit y in relation to medication management and administration.

Feedback to the locality team and commissioners any issues or incidents that may have prevented the SU from managing their own medication appropriately.

5.1.4 Improving the quality of life for unpaid carers.

Support carers to be aware of their rights under the Carers Act i.e. right to a Carers Assessment, support services and access to GP Carers Register.

Ensure carers are aware of how to access support through National and Local Voluntary Sector support services i.e. Carer’s Helpline.

Ensure that carers are aware of how to access support, leisure or community activities in their own locality to reduce social isolation.

Ensure that carers are treated as expert partners in the delivery of services to the SU.

Support carers emotional and mental well-being through the provision of good quality, reliable, consistent and responsive support which enables them to feel confident in the service being provided.

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5.1.5 Ensuring that individuals are safeguarded and are able to access good quality services. There is a consistent and ongoing improvement in the quality of services available across Poole.

Provider to continuously achieve good practice and show ongoing continuous improvement of the services.

Providers to operate a quality assurance and improvement model using intelligence from SU’s, carers, commissioners and other good practice.

Providers to be aware of responsibilities in relation to Safeguarding and engage with the commissioners in this area when necessary.

5.1.6 Promoting health and well-being through empowering people with the necessary

information and skills to self care and manage their needs wherever possible.

The Provider will be working as part of the Locality Team to address health and well -being challenges within the community.

The Provider to work with locality teams to promote an ‘expert patient’ approach to supporting people living with Long Term Conditions.

5.1.7 Minimise the impact of the delivery of the service on Poole environment and evidence the commitment to ‘Making Poole Greener’ through taking all necessary steps to

reduce carbon emissions.

Car travel minimised through appropriate mapping of service delivery times whilst meeting the needs of the SU.

Recycling initiatives and energy saving devices used by the Provider.

Individual Outcomes:

I want to be able to live the way I want to live. I want to wake up in the morning feeling positive.

I want services to recognise the contribution I make to my family, friends and community.

Provider’s Statement of Purpose in place.

Person centred practices, and choice and control are embedded in all aspects of service

delivery.

Quality of risk assessments and how this ties in with SU’s making their own choices.

SU tastes, interests, abilities and aspirations to be considered, and evidenced in the Provider assessment.

SU’s and their carers to be active participants in the assessment, care planning, care planning review and monitoring activity.

Provider staff to support SU’s to maintain connections with family, friends and community

through advice and information.

Provider to make efforts to match culture, skills and personality of the care worker with the SU.

As I get older, I want services to recognise my fears of the unknown and give me good

information and allow me to discuss those fears.

SU to feel comfortable to discuss their fears and anxieties with Provider staff.

Provider staff to have access to a range of information and advice in formats accessible to the SU.

Provider staff to have appropriate training to meet this outcome.

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I want services to work with me and do what’s important for me.

Provider to carry out own care needs assessment and produce person centred plan of care,

prior to provision of the care package (or within 2 working days in exceptional circumstances.

Assessment and Care plan to be sensitive of the age, gender, racial, ethnic and cultural needs of the SU and carers.

Evidence of ‘flexibility’ through a range of methods , including the ability to ‘bank’ and use

hours in a planned way.

I want my welfare to be safeguarded and to be treated with kindness, dignity, respect and honesty, do not make assumptions about what I can so on the basis of my age or disability.

Staff to have undertaken appropriate training.

Provider to work with the Commissioner to ensure a timely resolution to safeguarding issues.

Records kept in the home including Purchaser’s Support Plan, Provider’s Support Plan, risk

assessments, record of each visit.

Quality of records kept within the home.

Provider to monitor the use of records kept within the home as part of quality assurance processes.

I want information about choices and options to be easily available.

The Provider to maintain an up-to-date list of support services, advice and information

services and leisure and community activities in their locality which may support older people. Information will be accessible in a range of formats which reflect the SU’s needs.

Care workers to actively demonstrate an awareness of the above.

I want to be confident that when I need care I can get it quickly so that I feel safe about staying

in my own home and not going to hospital or into residential care.

The Provider to respond to Brokerage re availability to accept referrals/or not within 2 hours.

Provider to commence services within 2 days of the referral unless a longer lead in time is

specified.

Providers to recommence packages of care for individuals who ha ve been in hospital on the day of discharge or prior to this if preparation work is needed within the client’s home.

(Feedback from Brokerage Team)

I want the staff who care for me to be well trained and competent.

Provider’s recruitment process.

Provider’s Induction process.

Provider’s Training Programme and evidence of training care workers have undertaken.

Staff to have CRB checks.

Manager qualifications.

Supervision programme in place.

I want to know that the money being spent on my care is being spent wisely.

Operating costs to be made available to the Purchaser and/or SU on request.

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I don’t want to stay in hospital any longer than I need to.

Provider to work with Re-ablement Teams as necessary following hospital discharge.

Delayed discharges due to lack of Provider staff availability to be kept at zero. Any exception to this will be subject to exemption reporting. (Check with Brokerage).

Where appropriate, support to continue to be provided whilst the client is in Hospital – in liaison with Hospital teams etc.

I want my death to be a good death.

Staff are appropriately trained in this area.

Provider to have a Policy to ensure that wherever possible SU’s are supported to stay at home to die if this is their express wish.

Provider to have knowledge of National studies taking place i.e. Gold Standard Framework (GSF).

As a carer I want to know that services recognise my contribution and will support me.

Provider to operate a ‘Think Carer’ Policy and procedure ensuring that the needs of carers

are recognised and addressed.

Staff are appropriately trained in the above area.

Care workers demonstrate an active knowledge of this area of service.

Provider staff to evidence how objectives identified in 5.1.4 have been achieved in relation to

individual carers they come into contact with.

service improvement report - whatdotheyknow

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