MPM SOCIAL CARE CONSULTANCY SERVICES

KEY LINES OF ENQUIRY COMPREHENSIVE AUDIT

This comprehensive Audit of your Service includes the Key Lines of Enquiry and fundamental Standards, mapped to the CQC Regulated Requirements. (Health and Social Care Act 2008 (Regulated Activities) 2014). It covers in detail the 5

 KLOE domains, safe, effective, caring, effective and well led; RAG rated to determine level of compliance. Staff interviews will ascertain knowledge and to what extent the team feels valued. Observing interaction with Service Users will demonstrate how privacy and dignity is respected and promoted.

A report will be presented with a set of recommendations and actions, depending on your rating. This extensive appraisal takes up to five working days to complete.

CLINICAL GOVERNANCE AUDITING

This audit involves a Quality Improvement (QI) audit examining 25 governance requirements. It examines the effectiveness of service delivery against agreed and proven standards that ensure continued and sustained high quality. Significant events are analysed and evaluated. An action plan is created to guide your team to bring service delivery into compliance where failings are discovered.

This audit gives a snapshot of your compliance rating and any actions required. When performed monthly as part of your clinical auditing it highlights a month on month trend that helps to resolve problems and ensure effective internal governance.

COVID ASSURED INFECTION PREVENTION CONTROL AUDIT (IPC)

This is a specific IPC audit in line with KLOE 5, looking for assurance that good infection management protects staff and service users. It identifies any gaps or concerns about infection prevention and control. A full report will be generated stating if your Service IPC is -‘assured’ ‘somewhat assured’ or ‘not assured’. An action plan will be produced with recommendations on how to improve any concerns or failings. This is a unique audit focusing on Covid requirements only. The more comprehensive infection management audit is more general and elaborate.

INFECTION CONTROL AUDIT

This audit reviews the effectiveness of your service in relation to infection control management from safe handwashing to cleanliness of all areas of the service and includes reviewing training records and staff knowledge. This is RAG rated to establish if your service is compliant or where actions are required in line Local and National standards and Public Health England’s guidance on infection control.

COMPREHENSIVE MEDICATION AUDIT

We can complete a medication audit in line with statutory Duty of Candour (promoting openness and transparency). It reviews, for example, policies, administration, errors, ordering, record keeping, use of topical applications, as required and homely remedy medication usage. storage, management of controlled medication, disposal of medication, and hygiene.  It questions the long-term use of non-essential medications, if other means of wellbeing can be utilised, eg, diet instead of laxatives. It comes with relevant guidance from several official pharmaceutical sources. It also advises on the Nursing and Midwifery Council (NMC) Standards for Medication Management.

SUPPORT WITH PROVIDER INFORMATION RETURN (PIR)

This is a snapshot of your Service requested by the CQC prior to inspection. It must be submitted within 4 weeks from the date requested. Each question aligns with the Key Lines of Enquiry (KLOEs). The information helps CQC inspectors decide when, where and what to inspect. (The activities regulated are listed in Regulation 17(3) of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014). Regulation 17 refers to good governance. CQC can prosecute for a breach of part of this regulation (17(3), if a provider fails to submit their PIR when requested because this could prevent the provider taking appropriate, timely action. This is a lengthy but important exercise. We can support with completing this process and any remedial actions in time for submission.

CHANGE MANAGEMENT

Change is inevitable for progression and is a process of transformation, which can often meet resistance. We can support with cultural change management and team building where morale is low or there are institutional norms affecting the quality output expected of the team. This involves meeting team members, including night team members to listen to their views and initiate positive thinking.  Change management training is available to managers who would prefer to deliver this internally and control the change process.

STAFF FILE AUDIT

A common problem often overlooked is maintaining staff files and can lead to inadequate inspection reports. Failings around recruitment screening are common, where there is absence of essential records. From application to employment and beyond, we will support you by auditing your staff files, identifying any breaches and creating an action plan to remedy the gaps. We will also audit mandatory training records.

1-2-1 SUPPORT AND EFFECTIVE SUPERVISION

‘Planning and implementing effective supervision supports good working relationships, helps you to address any issues and celebrate achievements and gives you the opportunity to discuss learning and development. if you’re a regulated provider, the Care Quality Commission (CQC) expects you to offer staff regular supervision to ensure that they are competent and confident to do their role’.  (Skills for Care 2020). We can provide 121 sessions with your staff in a formal and private location to ensure the supervisee feels valued. Sessions are confidential. Objectives are negotiated in an environment where both parties are equal. Sometimes, it might be necessary to do a group supervision session, to discuss any changes or concerns or to provide an update. This can ensure good practice is shared and followed by the group.

SURVEYS

We can support with quality surveys for residents, staff, families and external professionals. This is aligned to good governance and collaboration. Gleaning feedback from any service provider influences how a business operates. We can devise appropriate feedback templates, analyse results, and recommend remedial actions. Results can enable the provider to incorporate the opinions and suggestions of those surveyed. In addition, it gives the provider the opportunity to provide explanations about how the service operates.

ESSENTIAL DOCUMENTATION

We can review the quality of your risk assessments and compliance audits and check the action plans against the audits are being completed timely to ensure sustained quality care provision. We will include a snapshot audit of up to 10 careplans to identify gaps as well as to appraise the strengths and weaknesses of documentation. Ideally, you will have an annual calendar of quality audits in place ensuring the continuous monitoring of essential requirements and fundamental standards. A full report of findings is provided with recommendations for improvement where required.

PRE-ADMISSION ASSESSMENT TO ADMISSION

A common theme that leads to poor compliance is the heavy focus on occupancy and client group over client quality care intervention and can put service users at risk of harm. This is an emotional time for prospective service users and their loved ones, which needs to be treated with sensitivity. We can support with the process by assessing prospective service users. Your preadmission and care plan documentation will take full account of the person’s individuality, choice/preference as well as their physical and psychological needs. Where accepted, we will discuss the preadmission assessment with your team so they can then ensure a person centred care plan is prepared. We will also liaise with your wellbeing coordinator to ensure the ‘This is Me’ and Personal Biography is in place in a timely manner.