2.12 Quality Audits |
Contents
- Overview
- Regulation 33 Visits
- Regulation 34 Monitoring
- Key Performance Indicators (KPI)
- Regulation 30 Notifications
- Children’s Accident/Injury Reports
- Managers Weekly Reports
- Complaints Monitoring
- Specific Quality Audits
- Non- Conformance
- Annual Development Plans
- Reports to the Regulatory Authority
- ContactPoint Audits
- Management Review Meetings
- Re-auditing
- Closure of Audits
1. Overview
Objective
The aim of the Quality & Audit Department is to ensure the continued suitability of the Quality System to meet the business objectives of the Company, and to ensure that Procedures are implemented correctly and effectively.
The Group Quality & Audit Manager is responsible for the implementation of the quality procedure.
Internal audits are carried out in accordance with the Quality Audit Planner (QAP 11/01) the contents of which will be agreed by way of an Annual Management Review Meeting.
Whenever a new procedure is generated, or an existing procedure is substantially amended, the Audit Team will modify the Quality Audit Planner and identify the relevant sections and subsections of ISO 9000 which control the activities involved.
Wherever possible electronic reporting and storage facilities will be utilised.
2. Regulation 33 Visits
For the purpose of this manual any reference to Regulation 33 visits will also be taken to mean, any other visits that are statutory requirements for other services, but may be numbered differently. For example, Regulation 25 in Family Assessment Centres. For our services in Wales the equivalent Welsh Standards will apply.
The main auditing tool used by the Quality & Audit Department to monitor the quality of care and systems implemented are the monthly Regulation 33 visits.
Regulation 33 visits will normally be carried out by the Quality & Audit Department or by visiting officers designated by the department to conduct the visit.
The visiting officers will use the approved Regulation 33 reporting format to record the results of the audit. The report must clearly show what items were checked and the results of those checks. In addition the Quality and Audit Department may request specific additional items or themes are included in any or all of the visits. This may be as a result of a Regulatory Authority inspection report, a particular incident occurring, or as a response to emerging trends and patterns etc.
The visiting officer will also comment on the actions taken to remedy the previous month’s recommendations and where necessary detail any recommendations arising from the current visit.
The home Manager will add their response to the report, including an action plan detailing how they propose to resolve issues. The report will then be sent to the Quality and Audit Department who will be responsible for the centralised storage and distribution of the reports.
Whenever possible, upon completion of the audit, any recommendations or non-conformances should be discussed with the person who has day to day responsibility for their implementation.
3. Regulation 34 Monitoring
| 3.1 | On a monthly basis each service Manager, where required, will complete the appropriate monthly monitoring form. Each service is responsible for ensuring that a copy of this report is sent to the Regulatory Authority and to the Quality and Audit Department. Children’s Homes are expected to have systems in place to monitor the performance of the home against its Statement of Purpose, and for regular reviewing of the Statement. The Registered Provider must ensure that performance is monitored in accordance with the Children’s Homes Regulations 2001. The Registered Person of the home (home Manager) must monitor and sign the home’s records at least once a month to identify any patterns or issues requiring action, she/he must then take steps to improve or adjust provisions where necessary |
| 3.2 | On a monthly basis, Home/Service Managers should complete a Regulation 34 Monitoring Form, or its equivalent, for each home/service for which they have responsibility. Once completed copies should be distributed by the home/service to the following:
Those with senior line management responsibility for the above should ensure that issues raised are monitored and signed off. |
4. Key Performance Indicators (KPI)
On a monthly basis each service Manager (or their designate) where required, will complete the appropriate KPI monitoring tool. The completed return should be forwarded to the Quality and Audit Department, or their designate, by the given deadline.
Key performance targets will be set for each KPI.
The Quality and Audit Department, or their designate, will then analyse the returns and prepare a summary report for the Board of Directors.
5. Regulation 30 Notifications
The recording of significant events as detailed in Regulation 30, Schedule 5, is to be completed by each service as appropriate. A copy of each notification should be sent to both the Regulatory Authority and the Quality and Audit Department.
6. Children’s Accident/Injury Reports
A copy of each report detailing any accident or injury concerning a child/service user should be copied to the Quality and Audit Department. Reports detailing accidents or injury to members of Staff should be copied directly to the appropriate HR department.
7. Managers Weekly Reports
On a weekly basis each service head/home Manager, or their designate, should complete the appropriate Manager’s weekly report. This report should provide an overview of the homes activity. A copy of this report should be sent to the Quality and Audit department.
8. Complaints Monitoring
A copy of all complaints (not Grumbles Book) made to the company should be copied to the Quality and Audit Department. Depending on circumstances the Quality and Audit Department may conduct an enquiry into the complaint itself. Normally the Quality and Audit Department will monitor complaints for compliance with procedures and timescales.
9. Specific Quality Audits
At any time the Quality and Audit Department may of its own volition or at the request of the Board of Directors, or other regulatory agency, conduct any such inspection, audit or review that is deemed to be necessary.
10. Non-conformance
Serious breaches of Regulations, Statutory Guidance, Registration Requirements, Child Protection or Financial procedures may dependant on the circumstances result in the completion of a non-conformance report. This report will be given to the respective Service Manager, their direct Line Manager and the Managing Director. Timescales will be imposed by the Audit Team and/or Managing Director for corrective action – failure to meet these timescales could lead to disciplinary action and will be reported at Board level.
Less serious breaches but those which remain uncorrected, despite notification in Regulation 33 reports or elsewhere may also be the subject of non-conformance reporting. Failure to action work set out in a non-conformance report is liable to invoke disciplinary procedures and will inevitably be reported to the Board, at the earliest opportunity.
11. Annual Development Plans
In accordance with Standard 33.5 of the National Care Standards, the registered person is required to provide a written development plan, which is to be reviewed on an annual basis. The Annual Development Plan should outline the future of the home, detailing and identifying any planned changes in the operation or resources of the home, or confirming that the home will continue with its current operation and level of resourcing. On an annual basis each children’s home is required to produce an Annual Development Plan. Copies of all Annual Development Plans should be forwarded to the Quality and Audit Department.
12. Reports to the Regulatory Authority
The Quality and Audit department will monitor, log and retain a copy of all inspection reports from Regulatory Authority. Copies of responses to the Regulatory Authority and action plans for corrective action should also be sent to the Quality and Audit Department.
13. ContactPoint
ContactPoint Audits will take place on an annual basis that will ensure Continuum Care and Education remains compliant to the Organisational Accreditation document.
14. Management Review Meetings
At least annually, or when the need arises due to an event of significance. The Quality and Audit Department will call a Management Review and will meet with the Managing Director, senior service Managers, including administration services, or their appropriate designate to agree the content of the Quality Audit Planner (QAP)
The QAP will record the proposed scope and frequency of the audit activity which will be agreed or amended and approved by the meeting. The effectiveness of the QAP will be reviewed at subsequent Management Reviews.
15. Re-auditing
Any audit failures must be action planned with an agreed timescale. Audit failures will be re-audited within an agreed period of time.
Typically the re-audit is conducted at the subsequent auditing session, although some action plans may have identified a longer period of time. In this case, the Auditor will check the progress of planned actions and will record this. If timescales are short due to the urgency of the action needed then the Auditor may telephone for confirmation, or ask another member of Staff to confirm progress during a visit they are making.
If any further problems are reported, it will be necessary to re-audit until the problems are resolved.
Any re-audit must be conducted in the same manner as the original audit, as far as possible, so that like is compared with like. The results of the re-audit must be recorded and any ongoing issues dealt with as above.
16. Closure of Audits
Issues subject to re-audit must be action planned until such time as the auditor is satisfied they have been addressed.
When the auditor is satisfied that the action plan has been completed the audit may be closed.
End