Purpose: To inform all stakeholders about the aspirations for quality care and services delivered at Leuchie House and facilitate stakeholders’ evaluation of their experiences in order to make ongoing improvements and deliver on regulatory requirements.
Outcome: People using the short break care service at Leuchie House benefit from safe quality support and care due to effective systems in place to monitor, assess and improve the service.
- Quality Statement
Leuchie House aims to provide care and services of a consistent quality for all customers including guests and their carers, staff, volunteers, supporters and donors. Leuchie strives to offer a truly exceptional respite/short break experience underpinned by high quality nursing care and therapeutic intervention.
Leuchie House aims to achieve the best results for its customers through clear policies and systems and appropriately trained and competent team members. Practice and performance is evaluated on a regular basis through guest, carer and staff feedback and audits.
- Quality Assurance Framework
2.1 Leuchie House provides holiday respite care services within a number of externally imposed frameworks that define specific standards. The most important of these include:
- National Care Standards set by Social Care Social Work Improvement Scotland (known as the Care Inspectorate). The Care Inspectorate is the independent scrutiny and improvement body for social care and social work services across Scotland. The Care Inspectorate has a significant part to play in improving social care and social work services for adults and children across Scotland.
- Other regulatory standards e.g. fire safety, health and safety, environmental health, food hygiene.
- Contracts compliance in terms of standards set by respite guests’ placing authorities and agencies e.g. social work departments, MS Society, NHS etc.
In general, these external quality frameworks all aim to ensure that quality is built into services through setting and implementation of standards, through processes for review, and through monitoring to ensure that services meet the needs of guests at Leuchie House and other stakeholders where relevant.
- Quality Assurance Programme
Leuchie House adheres to the principle that quality is everyone’s business. All staff and volunteers are encouraged to look out for examples of good practice as well as areas for development, and to feed this information into the quality monitoring system.
3.1 This document describes the systematic method to assess, monitor, evaluate and improve the short break holiday and respite care service at Leuchie House. It explains the following:
- what areas will be monitored
- how often monitoring will take place
- what evidence will be produced
- how monitoring results will be documented, and
- how areas identified for improvement will be addressed.
3.2 The Leuchie House quality assurance programme includes the following key areas:
3.2.1 Systems and regulations – elaborated at 4.1 and 4.2
- reviews and updates of policies and procedures
- accidents, incidents and near miss monitoring and reporting
- workplace risk assessments
- health and safety audits
- fire safety monitoring
- clinically related audits – records, infection control, medications
- food hygiene standards monitoring, and
- staff recruitment process monitoring.
3.2.2 Guest, carer and staff satisfaction – elaborated at 4.3 and 4.4
- Guest evaluations
- Relative/carer evaluations
- Staff survey
- Complaints monitoring
- Floor standards and training issues
- Senior nurse audits
- Social media and website feedback
- KEY AREAS OF THE QUALITY ASSURANCE PROGRAMME
4.1 SYSTEMS AND REGULATIONS
4.1.1 Policies and procedures
Leuchie House has a comprehensive range of policies and procedures to support the short break respite service. It is important that these policies are in date and have a planned future review date, we work to ensure via training and induction staff awareness of the policies and ensure they are available in a readily accessible place for staff to review as needed.
The policies and procedures are due to be reviewed every three years but at Leuchie House we find it best practice is to review them on an annual basis.
4.1.2 Accidents, incidents and near miss monitoring
Accidents, incidents and near misses can happen in Leuchie House at any time.
Accidents, incidents and near miss monitoring will be done on an ongoing basis. An accident, incident and near miss update will be provided on a monthly basis in terms of accidents which have occurred and action taken.
4.1.3 Workplace risk assessments
It is important that any actual or potential harm is identified in Leuchie House in terms of controlling and minimising risks that may affect guests, relatives, carers, staff and visitors.
Risk assessments will be carried out in areas that have the potential to cause harm. These will be done on an as required basis and reviewed every six months.
4.1.4 Health and safety audits
It is important that Leuchie House is maintained in a safe condition at all times for the benefit of guests, relatives, carers, staff and visitors.
A health and safety audit will be carried out at least once per year and more often if any issues arise that have the potential to affect the health and safety of persons using the Leuchie House service.
4.1.5 Fire safety monitoring
It is important that Leuchie House is maintained in a fire safe condition at all times for the comfort of guests, relatives, carers, staff and visitors.
A fire safety check is carried out by the fire and rescue service. Any issues identified in the issued report will be addressed without delay.
4.1.6 Food hygiene/Environmental health checks
Leuchie House is subject to unannounced environmental health officer (EHO) visits. Any issues identified in the resulting report will be addressed without delay.
4.1.7 Staff recruitment audits
It is important that staff appointed at Leuchie House are recruited in a consistent manner following recognised employment practices. Staff personnel files will be kept securely and contain the necessary pre-employment information.
Staff recruitment audits will be carried out every six months.
4.1.8 Clinically related audits:
- Care plan record keeping audits
Guests’ care plans and healthcare records are a key part of providing a degree of assurance that healthcare risks have been assessed, identified and documented, key areas of individual care have been planned for and care measures identified to support a guest whilst they are in Leuchie House. Care plans guide the ongoing provision of care and in the evaluation of that care.
The following full audits will be carried out every fortnight:
Bed audits
Cream charts
Body Maps
Wound charts
Care plans/PCS
- Guest Medication audits
The majority of guests who use the services at Leuchie House bring their own medicines with them for the duration of their short break. Leuchie House has arrangements in place with an external pharmacy to supplement guests’ medicines on an as required basis. All medicines in Leuchie House require to be prescribed, stored, administered and where applicable, disposed of safely. Medicines management audits will identify any areas for improvement to ensure that guests receive their medicines safely.
Full Guest Medication audits will be carried out every fortnight.
- Infection control monitoring
Leuchie House requires to be kept safe and clean at all times to prevent guests, relatives, carers, staff and visitors from potentially picking up a healthcare acquired infection (HAI). Robust infection control practices needs to be in place to minimise the risk of spreading infection.
4.2 Summary of quality audit programme – systems and regulations
| Audit or review | Frequency | Evidence | By whom |
| Policies and procedures | Annually | Review and updating of policies | Chief ExecutiveExternal Reviewer |
| Complaints Monitoring | Ongoing | Evidence of upheld/not upheld complaints. Evidence of improved areas | Head of CareChief Executive |
| Accidents, incidents, near misses | Ongoing with monthly update | Incidence reporting and areas for improvement | Head of Services |
| Fire Safety assessment | Annually | Report with areas identified for improvement | Head of Services |
| Food and Environmental Health | As required | Report with areas for improvement | Catering ManagerExternal Review |
| Care Plan and record keeping audits | Fortnightly audits | Report with areas for improvement. | Registered NursesHead of Care |
| Guest Medication Audit | Fortnightly audits | Report with areas for improvement
Capability Matrix |
Registered NursesHead of Care |
| Infection Control audits | Six monthly | Report with areas identified for improvement | Registered Nurses |
4.3 GUEST, CARER AND STAFF SATISFACTION
Each two consecutive holidays serve as a ‘monitoring period.’ Information is
collected from the sources listed here and collated into a Summary Quality
Report for each monitoring period.
4.3.1 Quality Champions meetings
Quality Champions are members of the staff and volunteer teams who have undergone specific training to look for evidence of good practice as described by the Five Star Philosophy, as well as identifying areas for development and suggestions for improving practice/systems. Quality Champions conduct ‘Caring Walks’ on a regular basis and record evidence relating to the quality framework. Their records are summarised and discussed at monthly meetings where ‘bottom-up’ action is planned and then implemented, with managers’ support. The notes of these meetings are circulated to everyone at Leuchie and are incorporated into the Summary Quality Report for each monitoring period.
4.3.2 Guest evaluations
Guests will be given the opportunity to say what they think about the holiday and respite service provided at Leuchie House. This is done using a guest evaluation questionnaire which is offered to all guests at the end of their holiday/respite short break. This information is confidential but an anonymous, collated summary of the results will be made available and offered to all guests, relatives/carers, the Care Inspectorate (on request) and any stakeholders. The monthly summary quality report will be made available on request.
The guest evaluations are carried out at the end of each holiday/respite break and information included in the Summary Quality Report for each monitoring period.
4.3.3 Relative/carer evaluations
Guests’ relatives and carers will be given the opportunity to say what they think about the holiday and respite service provided at Leuchie House. This is done using a relatives and carers’ evaluation questionnaire which is offered to all relatives and carers at the end of the guest’s holiday/respite short break. This information is confidential but an anonymous, collated summary of the results will be made available and offered to all guests, relatives/carers, the Care Inspectorate (on request) and any stakeholders.
4.3.4 Other guest and relative/carer involvement
- One-off guests’ meetings
Where there are specific important issues or changes on which guests should be consulted, one-off meetings will be organised. Any one-off meetings will be recorded, minutes produced and action taken where appropriate.
- Relative/carer meetings
These meetings will be held as required to enable relatives/carers to work in partnership with staff and guests and to raise any issues concerning the holiday and respite care service provided.
- Care plan meetings
Meetings will be held during each respite holiday with guests on an individual basis in relation to planning and agreeing specific care planning issues. These meetings will focus on care plan goals, objectives and risk assessments. The meeting is for the individual guest and careful attention should be paid to the language used to enable the guest to be as comfortable as possible.
4.3.6 Staff surveys
Approximately 80 members of staff are employed or engaged by Leuchie House to provide the short break respite care service to guests. This is the most valuable resource that Leuchie House has and it is important that staff have an opportunity to influence the future direction of the service as their views, observations, opinions and suggestions are important.
4.3.8 Complaints monitoring
Focusing on guests’, relatives’ and carers’ dissatisfaction issues is one of the most important things that Leuchie House can do if it is to resolve complaints. Leuchie House’s complaints policy and procedure allows for the tracking, organising and eventual resolution of complaints issues. Monitoring guests’ complaints on a regular basis is crucial to developing successful long-term Leuchie House – guest relationship.
Complaints monitoring will be done on an ongoing basis. A complaints update will be provided on a monthly basis in terms of complaints received and whether upheld or not upheld. Information from this process is included in the Summary Quality Report for each monitoring period.
4.3.9 Floor standards and training issues
The Senior Care assistants conduct a review of floor standards during each holiday and identify any areas requiring training or development. Key points are added to the Summary Quality Report for each monitoring period.
4.3.10 Charge Nurse audits
These are conducted by the Charge Nurses once during each holiday.
- Summary of quality audit programme – Guest, carer and staff satisfaction
| Audit or review | Frequency | Evidence | By whom |
| Guest Evaluations | Two weekly – pre-departure | Collated survey results and areas identified for improvement | Collected by volunteers through forms on the IPad |
| Relative / Carer Evaluations | Two weekly –
post-departure |
Collated survey results and areas identified for improvement | |
| Staff Survey | Twice yearly | Collated survey results and areas identified for improvement | Responded to, and actioned overseen by Chief Executive |
| Complaints Monitoring | Ongoing with monthly update | Evidence of upheld/not upheld complaints. Evidence of improved areas | Head of CareChief Executive |
| Floor standards and training issues | Two weekly | Results collated and areas identified for improvement | Reported in Summary Quality Report. Actioned by Named Manager |
| Charge Nurse audits | Two-weekly | Charge Nurses |
- OUTLINE OF THE QUALITY MONITORING PROCESS
At the end of each holiday/respite break, the Guest Evaluation spreadsheet is completed and posted on the S-drive. Named Managers (see 5.2) are alerted to its presence and are responsible for recording action and outcome monitoring on that spreadsheet. Information collected from the Carer Evaluation forms is also recorded on this Evaluation spreadsheet.
Information about quality is collected from the other sources identified at 3.2.2.
5.2 NAMED MANAGERS
The Care Inspectorate looks at four different areas of an organisation: quality of care, the environment, leadership, and staffing. Responsibility for ensuring action is implemented, monitored and progress followed up lies with Named Managers. In addition, guest engagement is crucial to achieving the quality aspirations of Leuchie House. There is, therefore, a Named Manager for this issue.
- Jade Clarke, HR manager: leadership and staffing
- Emma Jenson, Director of Care and Health: quality of care
- Victoria Shields, Guest engagement manager: guest engagement
- Nicola Collin, Head of Services: setting
6.1 THE CREATION OF THE MONTHLY QUALITY REPORT.
On the shared S-drive in the Quality Assurance folder, there are folders named for each of the quality monitoring periods. Staff and volunteers who collect information about different aspects of the quality process are asked to place a copy of that information into the relevant monitoring period file at the end of each holiday.
At the end of a Quality Monitoring Period, this information, and that from the Guest Evaluation spreadsheet, Carer Evaluation spreadsheet and Master Evaluation and Complaints spreadsheet is collated into the Monthly Quality report by the Chair of the Quality Champions group or designated colleague.
The processes through which specific information is collected, reported, addressed and outcomes monitored is given in the flowcharts at Appendix 3.
This report is prepared for the four-weekly Quality Champions meeting and published on the S-drive, and Senior and Named Managers notified. Action and progress monitoring is recorded on the S-drive copy of the report.
- LEUCHIE GOVERNANCE
The service is led by the Board of trustees. The Board meets quarterly to ensure the safe delivery of the service within budget. The Quality Monthly reports are shared with the Board on a quarterly basis. There are sub-group meetings in Fundraising, Governance, Operations and Building fabric and any Quality issues in relation to these subgroups are shared as appropriate. The Trustees have a recognised presence in the House with guests and staff. They attend in-house events, training week and celebrations. They all have discussions with guests and staff when in-house to ensure a high level of service is being delivered.
- INSPECTIONS BY THE CARE INSPECTORATE
8.1 Leuchie House is subject to announced and unannounced inspections carried out by Care Inspectorate inspectors.
8.2 If guests are within Leuchie House at the time of any inspection, they will have an opportunity to speak to an inspector in private about any aspect of the holiday and respite short break service provided by Leuchie House.
8.3 A copy of the most recent Care Inspectorate inspection will be available with Leuchie for guests, relatives, carers, staff and others to access. Any requirements and recommendations in inspection reports will be actioned and the necessary improvements made within set timescales.
- CONTINUOUS QUALITY IMPROVEMENT PLAN
9.1 Leuchie House will have a continuous development plan for quality improvement, based upon feedback from guests, relatives, carers, staff and external stakeholders.
9.2 The quality improvement plan will become part of an agreed ‘live’ ongoing commitment to continuous improvement. The plan will be ‘live’ because it will be regularly reviewed and amended. The definition of ‘regularly’ in this context means:
- weekly
- monthly
- quarterly
- six monthly
- annually, or
- some other agreed frequency depending on circumstances.
9.3 Documentation and records will be place for continuous improvement. These records will include:
- Policies and procedures
- Guest satisfaction surveys
- Relative/carer satisfaction surveys
- Staff surveys
- Minutes of staff meetings
- Staff training and learning events
- Complaints
- Suggestions
- Accidents, incidents and near misses
- Workplace risk assessments
- Health and safety audits
- Infection control assessments
- Fire safety records
- Records and record keeping audits
- Food hygiene audits
- Staff recruitment audits, and
- Care Inspectorate inspection reports.
The above list of records is not exhaustive.
9.4 A key responsibility of the Chief Executive and Head of Care of Leuchie House is to ensure that any agreed improvements are carried out. In implementing the quality improvement programme, the following key activities will be included:
- Discussion with Leuchie House staff to ensure everyone is clear about improvements that are required.
- Discussion with guests to ensure everyone is clear and happy with any proposed changes that will be made.
- Discussion with relatives and carers to provide an opportunity to ask questions about any proposed changes and how they may affect the guests’ holiday and respite care service.
- Ensuring that where a member of staff is given a specific improvement task, that the person:
- Is clear what the task is
- The standard required and expected, and
- The level of authority and responsibility they have in achieving the task.
- Ensuring that a method is in place for checking progress on the improvements that have been made, e.g. guests’ meetings, relatives/carers’ meetings, staff meetings, audits and assessments.
- Promoting among guests, relatives/carers and staff the concept of a team approach and commitment to service improvement at Leuchie House.
9.5 An important element of the quality improvement process at Leuchie House is management follow-up. The Chief Executive and Head of Care’s role is to confirm that the identified improvements have been carried out and that they meet an acceptable standard. When following up, consideration will be given to ensuring that:
- A written timetable is established, in order to review progress and to give a clear signal to guests, relatives/carers and staff that management is committed to improvement.
- The best possible forums for promoting achievement and commitment to improvement are used.
- All the improvement tasks are reviewed regularly, and
- Help is given to resolve any problems that are being encountered in achieving any improvement.