Policy Review Sheet. Review Date: 01/11/17 Policy Last Amended: 01/11/17. Next planned review in 12 months, or sooner as required.

Transcription

1 Category: Fundamental Standards Sub-category: SAFE Page: 1 of 8 Policy Review Sheet Review Date: 01/11/17 Policy Last Amended: 01/11/17 Next planned review in 12 months, or sooner as required. Note: The full policy change history is available in your online management system. Low Medium High Critical Business Impact: X Changes are important, but urgent implementation is not required, incorporate into your existing workflow. Reason for this review: Were changes made? Summary: Relevant Legislation: Change in Care Quality Commission framework Yes This review updates the Fundamental Standards policy and reflects the new CQC Key Lines of Enquiry. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Underpinning Knowledge - What have we used to ensure that the policy is current: Care Quality Commission, (2017), How CQC monitors, inspects and regulates adult social care services. [Online] Available from: [Accessed: 21/10/2017] Care Quality Commission, (2015), Guidance on meeting the regulations. [Online] Available from: _regulations_01.pdf [Accessed: 04/09/2017] Care Quality Commission, (2017), Key Lines of Enquiry [Online] Available from: KLOEs-prompts-and-characteristics-FINAL_2.pdf [Accessed: 04/09/2017] Suggested action: Develop training sessions for relevant staff Share Key Facts with all staff Add the policy to the planned team meeting agendas Encourage sharing the policy through the use of the QCS App

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3 1. Purpose Page: 3 of The purpose of this policy is to demonstrate how meets the Care Quality Commission (CQC) Fundamental Standards, specifically the third Key Line of Enquiry (KLOE) under the SAFE Key Question, commonly known as S It identifies the activity that the CQC states it will undertake during its inspection and how the QCS system will provide with the evidence to support any inspection activity undertaken. 1.3 This policy also identifies the evidence that could be presented to the CQC to increase the possibility of receiving a positive result from any inspection. 1.4 To support in meeting the following Key Lines of Enquiry: Key Question SAFE Key Line of Enquiry (KLOE) S3: How does the service make sure that there are sufficient numbers of suitable staff to support people to stay safe and meet their needs? 1.5 To meet the legal requirements of the regulated activities that is registered to provide: 2. Scope The Health and Social Care Act 2008 (Regulated Activities) Regulations The following roles may be affected by this policy: All staff 2.2 The following people may be affected by this policy: Service Users 2.3 The following stakeholders may be affected by this policy: Commissioners Local Authority NHS External health professionals Care Quality Commission 3. Objectives 3.1 To ensure that QCS Client Ltd has an excellent understanding of what the CQC will be looking for during the inspection process. 3.2 To ensure that the range of evidence to meet the KLOE S3 is clearly evidenced, and supports best practice. 3.3 To ensure that is fully aware of the content of the QCS management system and how it supports and meets the requirements and expectations associated with KLOE S3.

4 4. Policy 4.1 will use the structures, processes, procedures and approaches detailed within this policy to support the delivery of a Safe service in accordance with requirements and best practice. 4.2 The policy includes details of how systems, processes and practices evidence that there are sufficient numbers of suitable staff to meet Service User needs as detailed within KLOE S There is additional information in the online management system that details what policies and procedures support the delivery of the CQC KLOE S3: 'How does the service make sure that there are sufficient numbers of suitable staff to support people to stay safe and meet their needs?'. 4.4 These policies and procedures should be read in conjunction with this policy to provide you with the understanding, knowledge and evidence that you require to provide services that are Safe. 5. Procedure Page: 4 of The potential ways that the CQC will assess your service against KLOE S3 will include assessing information received by them before the inspection from stakeholders, talking to people, observing practice, talking to staff and reviewing records. The CQC may also undertake other activity during an inspection dependent upon their findings during the site visit. 5.2 Planning The CQC will review all notifications they have received from regarding concerns, complaints, incidents and safeguarding issues before the actual inspection in order to develop an opinion about the quality of your service, and the areas that they may wish to focus on during the site visit. The CQC will liaise with other stakeholders, review the content of your Provider Information Return (PIR) and look for possible areas of concern to be investigated. Records of late visits, missed visits and short visits will inform opinions as to whether the staffing levels are sufficient for a safe service. In addition, views on adequacy may be interpreted from indirect evidence such as complaints and compliments. The recording of the outcomes from any surveys undertaken that focus on staffing will also be informative. Complaints are inevitable, and are in fact, excellent opportunities to learn, improve the service and demonstrate caring responsiveness. Staff need exposure to the complaints procedure to bolster their understanding of this. Managers also need to demonstrate by their actions and attitudes that complaints are welcome. Very effective tracking and responses to complaints relating to staffing levels, recording that the complainant is satisfied with the outcome, and the timescales. To balance complaints, and the reality that a very open and effective organisation may well have more complaints recorded than a closed, poor service, compliments need to be generated and recorded. All staff need to be aware from the Policy that they need to record compliments for review, with a view to improve the service further and disseminate best practice, and to balance and put the complaints record into proper perspective 5.3 Gathering Feedback From any visiting nursing staff, doctors, social workers, the local safeguarding team or people and their relatives or friends who have commented previously. If you have made use of the Professional Advisors' surveys and taken action on them, it is likely that you will have prepared the ground for a more positive response There should be clear evidence that opinions, advice and feedback from professionals track through to individual Care Plans in the case of individual Service User data, and action plans or supervisions in the case of service or employee related data Rotas or staffing schedules should be reviewed and updated based upon feedback from external

5 professionals Remember that professional advisors should be positioned and regarded as customers and treated as such in order to foster a mutually respectful relationship 5.4 Talking to People The inspector will ask Services Users how staffing levels affect their day to day lives, their safety and care management, in both a positive or negative way. They may also talk to their relatives and/or friends, advocates and any visiting professionals on the day. Staff attitudes are notoriously difficult to predict, especially in the area of staffing levels. A key factor is accumulated staff expertise. Focus on reduction of staff turnover, as per the QCS Staff Retention Policy and Procedure, which will reduce the level of inexperience and promote the overall competence of the team, which in turn reduces stress. An effective management approach is the reduction of frustrations through fairness, good discipline and planning. This will defuse complaints about the management of staffing levels, which often boil over into complaints about overall staffing levels. Effective scheduling, planned well in advance as recommended by the QCS Staff Rota Policy and Procedure, can defuse staff complaints about fairness between staff. A full review of the scheduling every time a member of staff leaves and is to be replaced, or there is a reorganisation, is an opportunity to review requests from individual staff for changes to their work pattern, again defusing frustrations. Effective management of absences, as in the QCS Sickness Absence Policy and Procedure, including return to work interviews, can help defuse staff complaints about staffing levels. Careful consideration and sympathetic response to requests for flexibility to meet family commitments helps foster a positive staff attitude. Open discussion of staffing concerns can improve attitudes. Research and comparison with other services' staffing approaches may assist agreement over acceptable levels, timings and allocations Evidence of staff meeting discussions which focus attention on fairness of the allocation of the current staff to achieve the best result with the available resource. 5.5 Observation The inspector will spend time observing whether people have their needs met and are safe, and whether requests for support are answered promptly, or the times allocated for certain support activities are sufficient and whether they are predicted appropriately by staff. Another area to be observed will be the staff reaction to situations which could cause harm or compromise safety. Effective planning of staff activity, and allocation to area, is essential to improve Service Users' confidence in having attention when they need it. Effective scheduling and providing appropriate time to undertake required activities, but maintaining a person-centred approach to care and promoting the person's dignity and human rights. How person-centred care approaches have been employed and embedded will be evident to the inspector Use of Key Worker systems, as per the QCS Key Worker Policy and Procedure, will improve staff knowledge of the needs of the Service Users they are primarily attached to. A planned approach to responding to need is essential; ensure that there is a clear and well understood local policy. Good outcomes in this area will depend heavily on your investment in training on risk recognition and management. 5.6 Talking to Staff The inspector will talk to a range of staff to hear their views on the staffing at the service, including how scheduled calls are covered, particularly at weekends and at night. They will ask how staffing needs are maintained or increased at busy times and about the deployment of staff across the service to meet the dependency of the people for whom they care and support. They may ask how agencies are used and what recruitment processes are followed. Page: 5 of 8

6 See under Planning above. The use of agency staff is one cause of complaints. Agency staff should only be used when totally unexpected staff absences happen. Even then, if the staff team is well-managed, balanced and not overstretched, it should be easier, and certainly a lot more effective, to ask for additional hours from the staff team to undertake additional visits or other duties Holidays are not unexpected; neither is a normal level of sickness. The QCS Staff Rota and Staff Levels Policies and Procedures show how to create an overall staff team, consisting of full-time, part-time, and bank/casual staff, which will be able to cover all but the most unusual of circumstances, such as an outbreak of illness. The maintenance of an effective bank/casual team will also aid in dealing with spikes in work caused by temporary illness, or additional support requirements Regular supervision and team meetings to discuss issues and resolve any concerns will assist in promoting an environment conducive to positive relationships and effective care delivery. 5.7 Reviewing Records If the inspector has concerns that there may be breach of regulations, they may also wish to look at Service Users' risk assessments/individual care files, staffing level assessment systems, staff handover records, staff scheduling records, agency records, minutes of meetings, internal quality assurance feedback, quality assurance records on patterns/timings of accidents and incidents, staff files for recruitment and disciplinary procedures and, should you need to corroborate evidence, policies and procedures. Diligent following of the QCS policies on care planning and staff scheduling management. Discussions regarding staffing levels in management meetings, hand-overs, management meetings rolling action plans and audits. When action does not automatically lead to records, such as management meeting action plans, consider keeping a daily management diary, where a quick note can be made of day-to-day actions, such as problem-solving discussions, quick informal coaching sessions, etc. Fully use the QCS recruitment packs, particularly the oft-overlooked Recruit Specification Pack which promotes an analytical approach to staffing levels and recruitment. 6. Definitions 6.1 Fundamental Standards The term used to explain the overarching structure and content of the requirements that services must meet in order to provide a regulated activity 6.2 KLOE Key Line of Enquiry, which is a level of questions that the CQC asks of providers to support whether services are Safe, Effective, Caring, Responsive or Well-led 6.3 Evidence Material information that can be shared to support a claim Specifically, for your service to support any activity that takes place within your service Key Facts - Professionals Page: 6 of 8 Professionals providing this service should be aware of the following: This policy supports the use of the QCS system, and indicates specific practice, procedures and policies that support KLOE S3 This policy identifies what the CQC will be focusing on under KLOE S3 Identifies the evidence you could have to support inspection action Identifies and explains in practical terms what is meant by KLOE S3 and the implications for the management of staffing levels and suitability of staff

7 Further Reading Page: 7 of 8 There is no further reading for this policy, but we recommend the 'Underpinning Knowledge' section of the review sheet to increase your knowledge and understanding. Outstanding Practice To be Outstanding in this policy area you could provide evidence that: All evidence is easily accessible and well ordered All staff are highly aware of the staffing requirements at the service, and they are consistently complementary about staffing levels and how the service responds to changes in need and personal circumstances The evidence that you provide in this area demonstrates innovation and best practice You are fully using the QCS management system, and that staff are all engaged in delivering best practice and using the QCS system to consistently deliver services that support effective staffing levels All records regarding staffing, including rotas and scheduling are clear, well ordered, transparent and any actions are robustly followed through and completed Service Users report that staff are consistently available for them and that the service is proactive in anticipating their needs There is excellent communication at all levels of the service in the area of staffing, with everyone taking responsibility and able to input into decision-making within the service The wide understanding of the policy is enabled by proactive use of the QCS App Policies that support this Key Lines of Enquiry (KLOE) The policies in your QCS management system that support the delivery of the CQC KLOE S3: 'How does the service make sure that there are sufficient numbers of suitable staff to support people to stay safe and meet their needs?'. Can be found in your online management system in the Fundamental Standards section. These policies and procedures should be read in conjunction with this policy to provide you with the understanding, knowledge and evidence that you require to provide services that are SAFE.

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