Annual Quality


 Assurance report





























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 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.

Evidence how many complaints have been received and how these were dealt with and in what timescale.


Quality assurance report January 2011 -January 2012


Information gathered with regards to acceptance of a service user:


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.







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.



Recommendations for improvement:


The form would benefit from a section to allow the identification of the main carers and a section to sign to state whether the main carers were introduced prior to the care commencing and should be carried out when the care plan is returned to the service user for approval and signing.



Some packages of care start with less than 48 hours notice and makes it difficult to get the initial review in place prior to care commencing.  Therefore this should be taken into consideration prior to giving a start date to the brokerage team as a careplan must be in place before the care begins.




Reasons they cannot be implemented:


This is to be implemented as soon as possible.




Service user file:


The quality of service users 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 ISC'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, a new format of risk assessment is being used which is a lot more personalised and easier to follow than the previous risk format. The files also benefit from a record of concerns made by the carers and outcomes to these concerns. Recently a new form has been added which require the team leader to go through the complaints process and details of the file kept within the service users home and how they can request to see files held on them. This is signed by the service user so that it is evidenced this has been carried out.


Overall the service user files are clean and tidy and well presented with lots of details. they are stored securely within the office.




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.





Recommendations for improvement:

Not all files have a signature to state they have been checked. a separation page stating previous care plans/reviews etc would be of benefit this is in some files but not all.














care plans:


To assess the care plans I have checked a cross section of care plans from throughout the year, I have reviewed the current care plan and the previous ones and have found:  The care plans have not been changed since the updated format in late 2010 they are well detailed but would benefit from being a little more detailed. They state how the service user would like to be addressed and emergency contact details. There is also a section for background information and the morning routine to be followed by the carer. These would benefit from being more current. This also states the time of the call. The outcome for the service user to achieve is generic and not detailing much on the service users ability. 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 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 detail is of a high standard and is easy to follow, it indicates the outcome to be achieved. 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.






Care plans from now on are required to give more detail on the outcome to be achieved under the heading of carer to achieve. Under the heading for the service user to achieve there is to be more detail on what it is the service user should be doing to achieve their outcome. The background information should read less formal and be continually updated recording any increases in care or decreases due to improved independence. It should include whether there have been any improvements or deterioration during the term of care provided by pride in care and whether we have carried out any joint working. The routine section should outline what it is that is required and in which order the service user would like this to run. Care plans are now required to address an outcome of maintained/improved independence.



Risk assessment control measures should state that the care plan is a control measure as is the daybook and reflect how this reduces the risk.













Day record books:


In assessing the day record books I have read through several different service users day record books from random service users at random times through the year, these have recently been updated although the new format was written at the beginning of the year it is only now being introduced to every service user.

Day record books vary from book to book, there are 2 formats of daybooks being used. The books are based over a month and are returned to the office for auditing and achieving. The first format is usually used for the first 4 weeks of a care package starting however it is clear that these are used when time is short and the books need to be produced urgently. The basic format simply requires the carer to state whether or not the outcome was achieved and to give a short comment on the outcome. There has been an improvement to these since around October 2011 this is the second format. These run in line with risk assessments and are also used as a control measure. They ask the carer if the outcome was achieved but rather than giving the heading it asks specific questions with regards to the care enabling clear monitoring of the outcomes and changes to the service users needs. the day book also requires the carer to record the time in and out and also to sign the daybook. The recorded time can be checked against the EMS on carrying out several checks this was evidenced.



What works well:

The day book is in a clear format and easy to monitor, it works well as a control measure in risk reduction and reflects the care plans identified outcomes. Since the introduction of these day books we have eliminated the lack of information being recorded and the ability of carers to state "all care given" both protecting the carer and service user.




To include outcomes such as choice, dignity, independence within the day books.

Room to comment on how the person was feeling and how they were in themselves. The day books to be more thorough with regards to outcomes and who is to achieve them.





















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 50 questionnaires returned 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 that they found on several occasions other carers who were not their regular seemed to be rushed and not sure of what they were doing and some of the younger carers need more life experience. There was also a lot of issues with regards to communication of changes of carers the feedback with regards to this was very mixed some service users getting schedules and being informed of changes and others have no communication of schedules or changes to carers. There is evidence that this has improved but there is still room for improvement on this.


It is also evidenced that the majority of the service users are more than happy with the service stating that the if regular carers are excellent, stating they do not feel rushed and carers make extra effort when required, they stay longer than allocated where there are unforeseen circumstances and are understanding and patient. There are several comments from family members praising the level of communication with regards to concerns and issues and they feel they are involved with the care being provided.









Provision of care: (cont)


When checking the EMS records it is evident that some calls are regularly late and by the same time each call indicating that there is a need to adjust the roster to ensure the times are correct, it has been noted that some carers carry out the call slightly different to the way they are on their roster and this has been agreed with the service user however this information has not been updated on the roster system showing that records are incorrect. This does show that carers have adopted changes to suit service users but also identifies the information is not passed to office staff to implement on the system.


Manager monthly check reports are carried out on a monthly basis and require the 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. By auditing these I have found that the majority of audits indicate care packages are running well and communication between team leaders, carers and the office is working well, these also indicate signs of joint working with  district nurses family members and other stakeholders.  The completion of the forms could be more detailed and this will be addressed with the managers completing the forms. At the time of this report no quarterly audit were available.



Over the last 8 months there have been a total of 10 complaints the common theme being inconsistency of carers or punctuality of carers, of these 10 complaints all where rectified within 7 days of the complaint being received almost all of the complaints were able to be rectified as soon as the complaint was received. There was also 7 concerns made where the service user didn't wish to complain but ask if issues could be resolved, of these 7 all were rectified the same day as the office was made aware, this shows good evidence that service users complaints are listened to and taken seriously, it also shows that the reason behind the complaint is human error and could have been avoided however all complaints were resolved in a timely manner and were monitored to prevent reoccurrence. All complaints have a detailed outcome form attached listing actions taken to resolve the complaint.


Reading through the concerns book I have noticed that there is good evidence of communication of concerns and the correct actions are being taken ensuring the welfare of service users is being considered and the information is passed on to those that need to know. All concerns and incident forms have an outcome form attached and this evidences that information is passed on and actions are taken. There is also evidence of care plan changes and reviews due to concerns and incidents showing reviews take place on a 6 monthly basis and as and when required due to changes in circumstances.



There is an array of compliments recorded in the compliments book as well as the quality assurance questionnaires this indicates that the level of care being provided is of a good level one or two carers name stand out in several compliments recording that they provide an excellent level of service and are outstanding carers. There is sufficient evidence to show the level of care being provided is of a high standard and that there are areas that require some attention to improve the service.


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 a key pint 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.







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, there is mixed feedback but the majority of feedback indicates that less than half the service users where not satisfied with the level of communication with regards to changes.


Rosters need to be managed and times adjusted to ensure the care being provided does suit the service user and is acceptable.







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 6 monthly review due to service users change in circumstances and changes to social services care plans as a result of this, introduction of manual handling equipment, adaption's to service users homes and clear records of communication with POVA coordinators, district nurses, adult placement centres 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 great 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.


 All supervision and appraisals were in place and had been held on a one to one basis in the office. There is also a list of the spot checks and details of what took place during the check that had taken place over the previous 3 months and these were used during the supervision. 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.





The staff files would benefit from a signing sheet stating who completed and who checked the file prior to the staff member "going live" on the roster system.


Job descriptions and person specifications to be included in the staff file and signed by the member of staff, this is to be implemented for all new employees.


Staff training:


The training wing in the head office is well equipped with all the necessary equipment to provide all the training being provided, this includes resuscitation dolls, medication training props, profiling beds, hoists and numerous slings and slide sheets, hand outs and power point and projector and other training aids. The training room is a suitable size to provide training to a medium to large group. Most training is carried out by the full time in-house trainer and training courses take place on a daily basis. All new staff carryout full training prior to their CRB checks being returned.


After each course an evaluation form is handed out to the course participants I reviewed around 6 of the course feedback for each of the following courses delivered; Manual handling (all Wales passport), Induction, Medication, POVA, food hygiene, dementia and first aid. overall the feedback was excellent and training being provided is of a high standard.





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.


The service users files have been improved so that there is a copy of the previous care plans from pride and care and from the local authority allowing easy assessment of changes to the service users needs over the past 6-12 months. There has also been an update in the risk assessments and these are now more personalised and simplified they also link to the risk assessment and vice versa. In the previous CSSIW inspection  it was noted that some entries were not completed in service users day books which could have indicated missed calls. We did implement a control measure for this and asked carers to recorded if a call was cancelled in to the book. This is always recorded on the roster system in the office, after a short time we cancelled this as we found the office copy of cancelled calls was sufficient.  New financial books were also introduced and these are audited by team leaders and the local manager on a regular basis. We have also improved the team leader spot check books allowing for much more monitoring based around carers performance, competency, record keeping and service user feedback. 

Improvements have also been made in the service user day books allowing these to be used as a control measure to minimise risk and asses service users needs and what duties the carers are carrying out.


In the last 12 months we have introduced Manager monthly check records and quarterly reports which assist in the assessment of the quality of care being provided.

In the last 12 months we have also improved training being provided and are starting to provide more training and improve the knowledge of our in house training team.

The quality assurance process has also been greatly improved and includes a much more broadened look in to the service being provided.


The continuity of care has also improved mainly due to staff retention which has also improved over the last 12 months.



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. 


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


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 will also being looking to improve our risk assessments even further.


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.





This report was completed by the registered managing director of pride in care and covers the period of January 2011 through to January 2012 this report is based on the services being provided within the counties of  Caerphilly and Torfaen with 1050 hours being provided in CCBC and 260 Being provided in TCBC.




 The following 12 months monitoring will be completed by Mrs Leanne Phillips and audited by Marcus Hobbs ( Managing Director of Pride in Care).




The next quality assurance quarter is due in March, June, September and December with the final annual report being published in January 2013.


On behalf of myself and the two other area managers (Leanne Phillips and Toni Williams) 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.





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