Providing professional care in the home environment.








Pride in care (North Wales)


Annual Quality

 Assurance report.


April 2013- April 2014




To monitor all aspects of the service being provided including the day to day running of the office, team leader management, call time monitoring and the level of care being provided. To be as honest and open as possible to ensure that people using our service and their loved ones know not only our strong points but our weaker points and what we intend to do to address them.




To identify aspects of the service that can be improved, systems that work well.


Care planning (including):

Initial reviews, care plans, time allocation, travel time allowances and service user preferences.

Records of care provided.

Hazard and risk management.

Joint working.

Provision of care.

Risk management.

Staffing quality.


Care management.


The person completing this Quality assurance report must utilise all monitoring reports and gather information to be able to build a picture on the quality of the service being provided. Evidence is to be sort to ensure the following is taking place this is then to be compiled to allow the report to be completed.


Information available prior to the service starting, this is to include the information gathered in the initial review process, time scale given from referral to start date.


Level of information gathered during the initial review and whether this enabled the administration staff to complete a detailed care plan prior to the care package beginning.


Details held in the care plan ensuring they are personalised and outcome focused, outcomes are agreed for carers to achieve and for the service user to achieve. Instructions are clear and precise enough that the person reading the care plan understands exactly what tasks are required and how to carry them out.

Risk assessments and care plans identify hazards and relate to each other.

Service user day books are relevant to the care being provided and are used as a control measure to minimise risk and are there for included in risk assessments.

Evidence of joint working in the best interest of service users and any referrals.

Service user feedback with regards to their service provision.

Evidence how service users are centre their care provision and how they are involved in the planning and continued development of the care.


Evidence that staff receive the appropriate training that their records are up to date and in line with current legislation including regular supervision, annual appraisals spot checks and induction/probation training periods.

Team leaders are managed and have sufficient time to carry out their duties and the quality they are carried out in. Managers carry out their duties and the documentation is as required.


Quality assurance report April 2013 -April 2014



Information gathered with regards to acceptance of a service user:


Last report stated:


Prior to a care package starting we receive a care plan from the social worker that outlines the duties we are  required to carry out, although this document is detailed it does not go into the required depth of how the service is to be provided.

 Prior to starting the package of care we carry out an initial assessment.  During the initial assessment review the information gathered is of a good standard and detailed enough to allow the administration staff to complete a detailed care plan. The initial review details likes, dislikes, preferences and is person centred allowing the service user to give details on how they want their care package run. The review also gathers personal history of the service user which assists in conversation making and seeing the person as an individual. The review does show evidence that the service user has been involved by requiring a signature. It is also split in to two parts one being a routine that  the service user wants to rebuild/ set up or maintain and the other part being what is required by who and how.


Once complete the form is taken back to the office and used to construct a careplan this is then returned back to the service user for approval and signing. Two copies are taken one stays with the service user and one is returned to the office for the office service users file.

NEW for 2014

There has only been a slight development in this, now the two review books have been altered to contain slightly more information, they have been amalgamated in to one single book. During our 2014 CSSIW inspection we was informed that even though there were details on how to contact the office in and out of working hours on the front of the care pack file, contact details in the statement of purpose and details on how to make a complaint within the file some service users did not know how to contact the office. We have therefore added a section to the review that requires the team leader to discuss and show the service users how to do this.



What works well:

 The reviewing form is very detailed and has lots of prompts for the team leader to follow when carrying out the review. There is also room on the backs of the forms for further information. There is clear evidence that the service users and relatives input to the care plan and the plan of care is based around them.



Recommendations for improvement:


Further improvements need to be made with regards to introducing the main carers for days and nights prior to the package starting.  Some team leaders need to incorporate more information and ensure the signature forms are signed.

All parts of the review form/book needs to be completed.

Reasons they cannot be implemented:

Sometimes it is not possible to introduce the planned carer as the review maybe carried out while the planned carer is carrying out a service to other service users and may not be free.




Service user file:


The quality of service user’s files is of a high standard they are easy to follow and all relevant information is easy to find due to an index in the front. There is an electronic file as well as a hard copy. The electronic copy has a list of all concerns over the whole time of the service being provided and list all phone call and a complete list of every call and the carer who called.

There are details on the service user and their NOK, DR and District Nurses, their living circumstances and mobility amongst other details.


Service user files have the most recent care plan as well as the previous care plan, this evidences that reviews are taking place and care planning changes are implemented. There are copies of social services care plans and agreements such as IPO's or purchase agreements. There are copies of reviews and planned review dates in the hard copy as well as the electronic copy. Risk assessments are present and are well detailed,

  NEW for 2014

We are now rolling out our new format care plans, day books and risk assessments, the aim is that the careplan give much more detail on the tasks to be completed and the day book acts as a prompt and a risk management tool to prevent mistakes in key areas of support, it also assists in the reviewing of the service being provided and can be used to monitor service users and carers. We believe this is a large step forward in the monitoring, reviewing and management of service being provided.



What works well:

The files are easy to access and to follow, the index is accurate and also the cssiw check list in the front assists the person completing the file. The file also has a section to state who completed it and who checked it. The monthly reviews of care work well to identify changes in care. Client concern sheets also work well in keeping a record of carers concerns of service users welfare and carers have access to the outcome form so that they know their concern has been addressed and action is being taken.


Recommendations for improvement:


During March 2014 I carried out an inspection on every service user file and found that firstly several care plans appeared out of date, further investigation found that the reviews had been carried out and where there was no change the care plan remained the same. I have made the administration staff aware that where there is no change to the care plans then this needs to be recorded along with the date on the office copy of the care plan, to include the date of the review and outcome on staff plan and archive all old information prior to 2014.






Care plans:


From April 2013- February 2014 the care plans were detailed since February I have started to introduce new care plans with even more detail, I have also redeveloped the risk management so that risks are identified and the control measure ensures the correct information is recorded in to care plans. The new care plans are also reflected in the new days books. We produce two copies of care plans one that we keep with the service user and one that we keep in the office these care plans are kept in arch leaver files and include a full care info pack. The copy at the service users home contains one care plan and this is always the most recent. The copy at the office has two care plans and includes the current care plan and the previous one this file is used only for office staff or inspectorates of CSSIW (we maybe removing this due to the confusion this has caused with CSSIW).


The instructions part is very detailed and allows the reader to understand exactly what is required how to achieve the outcome and where everything required is kept. The care plan also identifies the key workers and this can be checked via the EMS. The care plans are split up in to individual care plans, such as morning, tea, social support ETC so this makes easy reference to the person reading, each call has its own care plan. All care plans are signed and dated by the care manager and service user.



What works well:

The individual care plans make easy reading and save time looking for instructions. The details are of a high standard and are easy to follow. The care plans are outcome focused and person centred. Over the past few months the care plan details have incorporated the risks associated with the service and instructed to refer to the risk assessment, this is starting to filter through all the care plans.

Where service users needs have changed and we have needed to update care plans we have linked with social workers in the local authority to arrange reviews and have their service delivery plan updated so that ours mirrors theirs and we are all working with the same information.  We feel that the joint working with the brokerage team, social services, district nurses and Occupational therapists works well and helps us to improve our service delivery.





During the 2014 Inspection there was only one recommendation made with regards to care plans in the office and that was these are audited more thoroughly as one of the office administrators had placed the new 2014 care plan in the same section as the previous 2013 care plan the inspectorate stated this was a risk as it may cause confusion to carers if they managed to illegally take a client file from the office. All files are audited on a regular basis and the inspectorate was informed that the careplan was placed in to the file as it was being carried to her as it had just been updated.

We are considering removing the previous care plan as it is only there for inspectors to see the changes in service.

Through my inspection I have recommended that the Key workers section of the care plan be kept updated, this is to be done in pencil to allow for changes.

I Also made recommendations with regards to care plans in the previous section that stated " I have made the administration staff aware that where there is no change to the care plans then this needs to be recorded along with the date on the office copy of the care plan, to include the date of the review and outcome on staff plan and archive all old information prior to 2014"


Day record books:


Prior to February 2014  we used person centred day books they were of a good standard and required carers to answer pre set questions based on the service users care plan and identified needs and risks. As of 2014 I have taken over in more of a management position, I have now rolled out the new 2014 day books that are much more care plan management structured Since Taking over as the Manager in March I have rolled out these new day books to approximately one third of our service users and aim to have these with every service user by the end of July 2014 These books tie in with recommendations and instructions from other stake holders in the service users provision of care. The day books include information for District nurses in the format of output charts for catheter management, body charts for monitoring areas of concern,  diet record charts for diabetics and so on.



These give good risk management ensuring that service user’s needs are met.

The new format 2014 is much better, not as detailed as a care plan but does ensure all the needs are met, that risks are managed and good clear recording to ensure service users are getting the required service.






What works well:

The risk management factor.

Recording of meals and drinks.

Monitoring of personal hygiene.

Monitoring that needs are met and independence levels are monitored.








All service users to go on to the 2014 format.

Extra Administration staff employed to meet the requirements of our needs.

Updating the printer to have a finisher will increase the productivity.







Provision of care:


To assess the provision of care I have gone through service user day books, team leader spot check books, quality assurance sampling questionnaires to service users, time monitoring on the EMS, manager monthly check reports and quarterly audits. I have checked the complaints and compliments register and the concerns and outcomes register and my finding are as follows:

The service user day books indicate carers are carrying out the care as required and documenting this, the day books and care plans are detailed enough for the carers to follow. The team leader spot check books indicate there is a good level of care being provided with good guidance. The record book evidenced that carers presentation was clean and tidy and those whose uniforms needed replacing were addressed. There is solid evidence that company supplied gloves and aprons are worn when required. Also that service users are communicated with clearly and professionally, Manual handling equipment is used competently and confidently, service users are given choice and that their dignity is being protected. There is evidence that extra duties have been taken on when required and information passed on to family to ensure problems are rectified this shows carers are using their initiative and sharing information. There is clear evidence that carers are promoting independence. Spot check forms also show carers are polite and show patients not rushing service users. Where care is refused this is recorded and passed on to the relevant persons. Spot check books also show poor points and address these with the carer there and then preventing the issue from arising in the future and sharing experience with the carer. Overall the spot check books evidence that there is a high standard of care being provided and where there are issues they are dealt with there and then by the team leader ensuring the standard does not slip.


Through the quality assurance sampling questionnaires:


Of the 30 questionnaires returned throughout the year there is clear evidence that overall the service is providing a high standard of care throughout the whole range. There is room for improvement is several areas.


Service users explained there were issues with some communication with regards to changes of carers and that their schedules only ran from Monday to Friday and rarely cover the weekend.


It is also evidenced that the majority of the service users are more than happy with the service with feedback including:


"They always let me know who is calling"

"All carers are very good and friendly, they look after me well".

"People vary, some are excellent, and some are improving".

"Very polite, very good, carers are very helpful and were good to my husband before he died".

"They are sensitive to me when I have a bath"

"The care package was not very good, but now I receive excellent care with all the girls being very helpful indeed".


One service users that has been with us for more than three years did rate the service as below average stating that they only want one older carer, they don't know who is going to be calling, young carers ruin the carpets with their shoes and their call time was 15 minutes earlier than what they want.




Provision of care: (cont)


When checking the EMS records it is clear carers spend the correct allocated time, where they have run over the allocated time a Change of circumstances has been recorded and sent to social services, if this has been regular then reviews with social services have been requested so changing needs of service users are identified.


I am introducing Manager monthly check reports to be are carried out on a monthly basis and require the branch manager to check that our in house care plan is relevant to social services care plan, that the day book is relevant, monthly records are relevant to the care plan, to identify if any outcomes have not been achieved, to assess the continuity of care being provided if this can be improved, any concerns reported, assessing the risk assessments. To check for nok details, missing entries into day books, checks on allocated time via teleconfirmation, feedback from main carer, feedback from the service user and an action plan for any indifferences found.


There was an issue with recording of medication records, carers had been writing "A" for administered and "R" for refused. however there was no key for this and only the employees of Pride in care knew what this meant which caused confusion with outside agencies checking the record. Further information can be found within this report with regard to improvements made in this area.


What we do well: (care provision)


Communication with service users and family is a strong point and has received a lot of praise and continues to be a key point in the provision of the service. We also carryout duties in a professional manner, protecting dignity and offering choice, the service is flexible and meets the needs of service users. Service users are not rushed and feel that carers are carrying out their duties to a high standard.  Our spot checks monitor the level of care being provided and team leaders give supervision, advice and support during checks to ensure our carers provide a high standard of care during the last 12 months we spent in excess of £2500.00 on these checks to ensure that we provide a high standard of care. Our rates of pay and travel expenses are very competitive. We have kept our over heads as low as possible so that we are able to achieve high rates of pay and travel expenses along with well structured teams and team leaders.






Communication with regards to change of service, late calls and schedules has much room for improvement and has shown to be a weaker area of the service.

Schedules must include the weekend carers allocated and if there are changes then these need to communicate with the service user.


it is recommended that pay scales be reviewed to try and increase recruitment and retention and this is to be reviewed on a 200 hour increase i.e. wages to carers increase to be implemented when we provide 600 hours of care, 800 hours of care, 1000 hours of care and so on.


We do intend on moving office locations once our budget allows for this we expect this to be once we provide in excess of 1000 hours.





Time monitoring:

With regards to time monitoring this is mainly carried out by the team leaders, they receive an email from the EMS  where a carer is more than 15 minutes late, they then find out the reason why. Where this is a regular occurrence the team leaders tend not to chase this up. The percentage of confirmed calls is of an acceptable level however there is room for some administration on the EMS. Deviations reasons should be input to evidence calls have been checked and to state why the call time is wrong or the carer is late.  Where carers are carrying out call time changes to suit themselves then disciplinary action should be taken. It was evident that some call times were as early 40 minutes and as late as 30 minutes prior/after the original call time and there is no reason stated for this. This is a rare occurrence and would therefore be easy to record the reason why in the deviation tab on the database.





Managers to be made aware of regular late calls and changes made on the system to amend the time (tbc with service users) Deviation reasons to be recorded where calls are more than 15 minutes past the start or finish time.




Joint working:


There is clear evidence of joint working and this has been a strong point, good working relations have been build with all stakeholders and there is clear evidence of reviews being called prior to the 12 monthly reviews due to service user’s change in circumstances and changes to social services care plans. As a result of joint working, recording and reporting we have assisted service users to have the introduction of manual handling equipment, adaption's to service users homes and clear records of communication with district nurses, family members and NOK's. It is evident that pride in care continues to build relationships with outside stakeholders in the best interest of the service user ensuring an ongoing support network for service users.





It would be of a slight benefit to see outcomes from joint working recorded in care plans under the background in general, this would help in noticing changes in the service whether this be independence or dependence.





Staff files:

6 staff files were checked in the process of this QA monitoring and overall the information in them is detailed and kept in good order, there is a clear index that lists what information is kept in the file and what page this info is kept on There are 15 sections which go above of that required in the National minimum standards. In each file there is a information on references these were cross referenced with the job application form and the people listed to obtain a reference from in all 6 these were accurate. Where the applicant had worked in care previous to this was documented and a reference was in place from all previous care sector positions. Where they had not this was recorded clearly. The newer Job application forms had been reviewed and updated to include a section to identify and record any gaps in employment.

There was a concerning point identified, staff supervisions were not being kept up to date. several carers had not their supervision meetings, they had been spot checked and there were no issues with the service they provided but they had not been brought in to the office for a one to one supervision meeting, this is in breach of the regulations and action must be taken to rectify this.

There is also a list of the spot checks and details of what took place during the check that had taken place. Each file has a signed contract and within the contract is a job description and some points from key policies. There is also a list of courses completed and planned in the carer file, a list when they are booked and when they expire. Completed courses are evidenced by a section for course certificates.

For 2014 I have introduced a two weekly supervision book for new starters this book will be used for support and guidance throughout the probation period and used up until the annual appraisal.








That supervision meeting formats need to change and include much more evidence and planned support and guidance of areas of concern.

Records of staff files are updated on staff plan so that the electronic database is accurate for the purpose of monitoring and auditing at the head office.

A recent inspection in 2014 identified that 2 files checked had the gaps in employment checked and investigated but the manager at the time only recorded that the gap was investigated and not the reason, this is a breach of the regulations and a noncompliance was issued. The 2 files were amended the same day and a 100% check was carried out on all the staff files.




Feedback from staff:


We recently attempted to gain feedback from 10 staff members but only managed to receive feedback from 4 members of staff, this was done over the phone by the manager of the south Wales branch to ensure that there was no pressure or biased choosing of staff. On average staff stated they felt they were treated with respect  both on the phone and face to face the average vote was "very good"


With regards to support, which included training, spot checks, and helpfulness of senior staff the average was between good and very good. one member of staff stated she felt this was average down to not being spot checked enough recently.

Staff felt that the recruitment and selection was between good and very good and felt new carers do have enough shadowing.  All 4 staff stated that their morale was either good or very good with regards to their role. All staff stated that they rated the care they provide as either very good or excellent. One member did stated she would like more supervision. The staff stated they felt all the team leaders were very good with one member saying they were good, there was no negative feedback. The staff were asked how did they feel the office staff represented the agency all staff stated either very good or good, one member stated she didn't want to answer.       When asked how did they rate their record keeping staff stated excellent, very good, good and average.





It is my recommendation that staff receive more spot checks and these are evened out so that every carer gets checked and support on a regular basis this is to include assistance with record keeping. Over the last 12 months more than 330 spot checks were carried out on staff. Staff questionnaires to be carried out during supervision meetings.



Staff training:

On review of the training matrix it is clear that training is being provided to all the staff at pride in care, the training is provided in a room within the same building as the office is located. The room is fitted with manual handling equipment and can be rearranged to reflect a service user’s bedroom so that trainees receive training in an environment they will be working in using equipment they will be using.


This includes the all Wales passport manual handling.

Emergency first aid & Infection control

POVA & Dementia and mental health.

Health and safety & Safe food handling (not food hygiene as the majority of

The food hygiene course does not apply to the role carers carryout)

Confidentiality & Record keeping and company forms.

Effective communication.

New for 2014 includes:

Pressure ulcer prevention

Mental capacity training & Deprivation of Liberties



What we have improved over the last 12 months:


The initial review forms have been modified and have become more and more person centred and outcome focused, the newest format is now in a book format and requires the team leader to introduce the main carer prior to the service commencing.

We have redeveloped our care plans and daily record books to be more individualised and  person centred. We have redeveloped our risk management to include better recordkeeping and safer service users care management.                         In March 2014 the MAR Charts had been completely redeveloped and distributed to every service user. Training was updated to include dementia training.


A manager was employed in May 2013 and applied to register with CSSIW as the registered manager, she only stayed with the company for 9 months however during the 9 months she was not informed by CSSIW of the process of her registration and as a result of CSSIW not registering the manager we was without a registered manager. The staff files were improved which included new application forms, a new staff member to take the role of ensuring these met the requirements of current legislation. Last year our staff files were missing employment references there were gaps in employment that had not been identified one had no employment history there was no evidence on file of supervision meetings taking place.

This year there was an improvement of the all references were in place, there were no gaps in employment that had not been investigated however the reasons for the gap had not been recorded. Two files did not have the most recent supervision meeting reports in their file however there was evidence that these had taken place on the electronic system we have as a backup.

The training matrix, record keeping with regards to courses and course material has improved. We have also fitted a lockable post box, there was a potential for mail theft and this was identified by CSSIW.                                                                                          




What we need to improve on:


Overall the service being provided is of a high standard however communicating with service users over changes of the service was the most noticeable downfall of the agency.  This can be improved by ensuring service users are informed of any changes and recording this in the service user journal and or via the deviation tab on staff plan roster so that this is able to be audited to see who made the change and why they did not contact the service user.


The local Manager will be required to fulfil the recommendations within this report to ensure the service is improved.


Supervision meetings need to be checked to ensure these are booked on to the roster system so these do not get missed.


Management of the office with regards to reviews of carers and service users to ensure these are carried out and recorded appropriately.





·         Over the next 12 months we will be looking to improve Medication recording ensuring all service users that we administer or prompt medication to have the correct medication recoding sheets in place.


·         We also need to improve on gathering feedback from other stakeholders we work with such as District nurses, OT's, Pova coordinators etc. At present the QA sampling we send out very rarely gets returned so over the next 12 months we hope to change the way in which we gather information from other stakeholders.


·         The training evaluation forms need to be completed on each course delivered ensuring there is a complete auditable feedback trail to be followed.


·         Staff retention is always an area of concern, it has been publically documented that the low funding towards providers is the main reason for low wages. I feel that until this issue of poor funding is addressed there will always be a high turnover of staff.


·         Spot check records need more information and the team leaders need to follow the instructions in the spot check books.


·         The new 2014 MAR Charts need to be monitored and audited to ensure staff are completing them.


·         Staff meetings need to occur more regular with more attendee’s.


·         Supervision meetings need to be more structured and the meetings must be input in to the system to ensure that carers do not go more than 3 months without a supervision meeting.




This report was completed by the registered provider of pride in care and covers the period of April 2013 through to April 2014 this report is based on the services being provided within the county of Wrexham where we provide a service to approximately 40 service users providing 600 hours


On behalf of myself and the Local branch manager (Rebekah Swinnerton) I would like to thank all the carers, team leaders and office staff for the hard work, understanding and professionalism in a very demanding and ever changing role.


Thank you to all our service users for your feedback and honesty it does go a long way to improving the service we provide.

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