continuous quality compliance's podcast: Recent Episodes
Taruna Chauhan
The Show talks about the different areas a Regulated business needs to think about these are businesses that undertake a regulated activity as defined by the Care Quality Commission. the show takes the listener through the different aspects which the regulator looks at and how the business can put these in place.
Welcome to episode 37 of Continuous Quality Compliance this is the last episode as I have recorded all the topics I think are relevant if you would like another topic covered which I have not then please email me taruna@tchauhanconsultancy.co.uk Today I am talking about the different online platforms which can make your life easier. For meetings there is zoom. Add Otter.AI https://otter.ai/ (https://otter.ai/) to that you can then download the audio and get the transcript all you need to do is tidy it up it is great for meetings obviously get permission of the people before you record. If you record video for your business Subly is good for adding captions https://www.getsubly.com/ (https://www.getsubly.com/)
I also like Viddyoze for adding some brilliant graphics and having awesome animated videos . https://app.viddyoze.com/ (https://app.viddyoze.com)
I bought this when it was on offer on Appsumo https://appsumo.com/ (https://appsumo.com/)
I added these to the introduction of my CQC online application course. It is fun too.
For planning there are many platforms such as Trello, I use my Outlook Calendar for all meetings whether personal or business so I know when I am free. I use Office 365 which enable me to use their booking app to make bookings. For social media there are many ways to schedule you need to find the one that works for you. You do a good CRM I use HubSpot https://www.hubspot.com/ (https://www.hubspot.com/)
and Mailer lite https://www.mailerlite.com/ (https://www.mailerlite.com/) now so I can do campaigns and send bulk email to members of the Association of Business mentors rather then typing each address every time also meets GDPR as no one can see other emails. My other favourite platform is Canva I now have the Pro it is so good for creating documents cards , flyers etc. The free is great any I used it for may years free. The pro version allows you to store your brand colours and fonts and save them up and you can resize documents easily .
http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)
Welcome to episode 36 of Continuous Quality Compliance Today I am talking about… planning your year so you are on track to comply with the standards. Planning is key to meet compliance otherwise you will do activities and not evidence or you will not do the right type of activity to meet compliance. I plan in December for the year ahead. It is strategy then I break it down into 90-day cycles. I look at what can be delegated . What you should be looking at is what audits need adding or even taking away look at the frequency of audits sometimes you have to do them more often if you find issues and noncompliance every time or if you consistently are complaint you could reduce the frequency. If you have changed process you would want to audit that. You will also want to audit tasks which are not part of compliance. For instance, look at your Sales and marketing how is you lead generation? Repeat clients, what is the best seller what add on can you have to stand out from others in the same marketplace. Look at the Assessment framework what do you need to achieve for Good once you are working closely to that look at how you can Outstanding . For Outstanding you need to think outside the box be innovative use technology be engaged with your clients and staff. You also need to think about how you will sustain being outstanding. So Good may be more achievable. I believe in being realistic and reduce stress then try to go for Outstanding if it is realistically not going to happen.
Empowering your staff and training them is an important aspect of compliance getting feedback is important. If you have 10 or more employees, then it is good to look at a platform like Engagement Multiplier there is a link in the notes. https://www.engagementmultiplier.com/partner/tarunachauhan/ (https://www.engagementmultiplier.com/partner/tarunachauhan/) You can do a free trial and still get a report which is useful. I have a client who loves using Engagement Multiplier it has helped them to meet so many criteria both for local authority and the CQC and it has given them an idea of what their employees think and they can address challenges and issues as they arise not when its escalated. I am a partner with them I only partner with organisations I trust. By planning how you will meet compliance you will get more accomplished and have a clear idea of where you are headed. I see to many businesses trying to meet the standards without a clear plan. That does not work! I have been accredited for standards other than the CQC I was always working towards being inspection ready with evidence gathering being routine. Not something you rush around trying to gather because you have date for inspection. I made it easy to gather the evidence ensure it is part of business as usual and forms are not cumbersome. When planning for the year talk to staff get ideas from them they will be engaged and help you because they will know what the plan is. I work with business on my 12-month programme to support them to be inspection ready I look wider than just CC because your business is wider than CQC. There are different levels of service depending on how many audits I do. Planning the year ahead is important otherwise it is kike starting a care journey and not knowing the destination. Make sure all staff know your values and what you need to focus on. The registered manager role is complex, and you cannot do it alone if you do because you are small you have to have a clear plan in...
Welcome to episode 35 of Continuous Quality Compliance Today I am talking about Selfcare I bet your thinking what has Selfcare got to do with Continuous Quality Compliance. Selfcare is important because you will be less productive and effective if you are not feeling good. If you are tired because you never stop. Are you the person who does not take a lunch break then reach for the nearest sugary treat?
Did you know that sugar is addictive. It provides Dopamine and when we get the hit we want more. I know when I had a lot of high sugar treat during Diwali I wanted more. I weaned myself off it again. I don’t take sugar in my tea or coffee. I am also wheat intolerant so not eating biscuits is easier.
Selfcare is about giving your brain a rest it is like any other organ it needs a rest. Think of it like your smart phone and you have all the apps open. The battery drains quickly and things slow down. This is what happens to you if you do not take breaks. Research has shown that taking regular breaks makes you more productive. It helps you to come up with solutions to problems you have because your giving your subconscious the time to look at the problem and think of a solution.
Gut health is so closely related to brain and heart health. I was on a workshop the other week and a nutritionist did a session. What you eat impacts the whole body. Movement for your body makes a big difference. I myself have added daily walking to my morning t routine. At first I thought I would hate it I need a purpose to walk so I used my mindset to say I was walking to work which is in fact my home office. That change means every morning after breakfast I go for a walk. I have noticed it has helped my digestion. It has helped with my Mental health and it helps me with topping up my vitamin D which is important for everyone. I also get to meet dog walkers and it lovely to exchange a smile or a hello.
My clients who I coach and mentor tell me the selfcare side of it really helps them The fact hat I asked them to ensure they had a lunch breaks has had an impact on their mental wellbeing and increased their productivity. We are not machines we need time out at regular intervals. We are not designed to be sedentary for long periods. Even stopping and doing breathing exercise or dancing to a favourite tune for 10 minutes will help. We cannot give from an empty vessel leaders have to be effective if you are not looking after yourself what kind of lesson are you giving your employees? If the leadership do not take breaks the staff will feel obliged to carry on.
Give your brain a rest, be hydrated eat well and see your productivity increase. I do all these. I plan my meals and lunches I have greatly reduced my sugar. I exercise and have time for myself. I do have a hectic work as I run my own business I am regional head of the ABM I love cooking and use that to relax. Making sourdough is a mindful activity which I enjoy. Find what you love in downtime and plan in lunch breaks and have a short break after each task.
http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)
Welcome to episode 34 of Continuous Quality Compliance Today I am talking about Report Writing Before you start writing consider.... WHO are you writing the careplan, treatment record for? WHY are you writing it? HOW do you record it? What is written needs to be factual and correct. It also needs to meet the needs of different stakeholders. Steer away from a tick box culture as this will not provide enough information .
What you record can be broken into 4 areas; Times, places, people involved, events happenings /consultation
Good reports should be legible, in simple language jargon free as possible. Clear factual, accurate. /in chronological order, enough information A good way to train staff on good report writing is to have a sample of a good report and one of a badly written one. If you’re a medical professional registered with the GMC, NMC , HCPC they have standards for record keeping which should also be looked at and be part of the organisations policy o record keeping.
If it is not documented it has not been done. Common problems are: An absence of clarity Inaccuracies Spelling mistakes Missing information Failure to record action taken when a problem has been identified.
Good Record Keeping Record keeping makes the continuity of care easier; Record keeping promotes better communication and dissemination of information between members of the multi-professional team; Helps to address complaints or legal processes; Supports clinical audit, research, allocation of resources and performance planning; Helps to identify risks and enables the early detection of complications; Supports client care and communication; Supports effective clinical judgement; Supports delivery of services; Helps improve accountability; Shows how decisions were made relating to the patient’s care.
What I ask is when your are writing would you be happy for what you have written to be read in a court of law? Also read it out a loud you will see if what you have written does not sound right.
Good record keeping is also important as part of being a member of a professional body.
Reference: NMc, GMc Ausmed , HCPC http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)
Welcome to episode 33 of Continuous Quality Compliance Today I am talking about… Data Protection What do we mean by Data Protection? The ICO The Information Commissioners Office describes it as; Data protection is about ensuring people can trust you to use their data fairly and responsibly. If you collect information about individuals for any reason other than your own personal, family or household purposes, you need to comply. The UK data protection regime is set out in the DPA 2018, along with the GDPR (which also forms part of UK law). It takes a flexible, risk-based approach which puts the onus on you to think about and justify how and why you use data. The ICO regulates data protection in the UK. We offer advice and guidance, promote good practice, carry out audits, consider complaints, monitor compliance, and take enforcement action where appropriate. Data protection is the fair and proper use of information about people. It’s part of the fundamental right to privacy
Does it apply to me? Yes, if you have information about people for any business or other non-household purpose. The law applies to any ‘processing of personal data’, and will catch most businesses and organisations, whatever their size. The ICO expect is not prescriptive in its approach because that would not be tenable. Every organisation is different and there is no one-size fits-all answer. Data protection law doesn’t set many absolute rules. Instead it takes a risk-based approach, based on some key principles. This means it’s flexible and can be applied to a huge range of organisations and situations, and it doesn’t act as a barrier to doing new things in new ways. However, this flexibility does mean that you need to think about - and take responsibility for - the specific ways you use personal data. Whether and how you comply depends on exactly why and how you use the data - and there is often more than one way to comply.
There are some terms used which it is useful to understand in this context. What is ‘personal data’? In short, personal data means information about a particular living individual. This might be anyone, including a customer, client, employee, partner, member, supporter, business contact, public official or member of the public. It doesn’t need to be ‘private’ information – even information which is public knowledge or is about someone’s professional life can be personal data. It doesn’t cover truly anonymous information – but if you could still identify someone from the details, or by combining it with other information, it will still count as personal data. What is ‘processing’? Almost anything you do with data counts as processing; including collecting, recording, storing, using, analysing, combining, disclosing or deleting it. What is a ‘controller’? A controller is the person that decides how and why to collect and use the data. This will usually be an organisation, but can be an individual (eg a sole trader). If you are an employee acting on behalf of your employer, the employer would be the controller. The controller must make sure that the processing of that data complies with data protection law. In this guide, we generally use the term ‘organisation’ or ‘you’ to mean the controller. What is a ‘processor’? A processor is a separate person or organisation (not an employee) who processes data on behalf of the controller and in accordance with their instructions. Processors have some direct legal obligations, but these are more limited than the controller’s obligations. What is a ‘data subject’? This is the technical term for the individual whom particular personal data is about. In this guide we generally use the term ‘individuals’ instead. the DPA 2018? The DPA 2018 sets out the framework for data protection law in the UK. It updates and replaces the Data Protection Act 1998, and came into effect on 25 May 2018. It sits...
Cybersecurity is important for every organisation. Staff need to be communicated on what cybersecurity is and the importance of it. Most cyber security is preventable as they are due to human error. Here is a stat for you Every 40 seconds a business falls victim to a ransomware attack, and rose to every 14 seconds by 2019.
Cyber security is about assessing and resolving issues in your organisation that could compromise your ability to keep information, intellectual property and sensitive data safe. A Cyber security breach can also risk your reputation so its best to have measures in place which reduces the likelihood of a breach. National Cyber Security Centre NCSC . http://www.ncsc.gov.uk/ (http://www.ncsc.gov.uk/)
The NCSC website includes a wealth of information that’s easy to understand. It has many tools for organisations to use too. Your staff are the weak point in your organisation’s defences. I recommend asking all employees to complete the free cyber security training on their website , regardless of their level or experience. We are all vulnerable especially when we are busy. Exercise in a Box is an online tool to help find out how resilient your organisation is to attack. It also lets you practice your response in a safe environment. Action Fraud is the National Fraud & Cyber Crime Reporting Centre. If you become aware of a successful cyber attack on your organisation, make Action Fraud your first point of contact. Action Fraud also offer free services that stop you from visiting malicious websites and protect you from email fraud whether at home or at work. I have used Action Fraud when I have had phishing attacks the more people report there more the attackers can be stopped.
It does not take long at all
To find out if your security details need changing visit the Have I Been Pwned website. This will tell you if one of your online accounts has been compromised in a breach, such as those which affected Canva and Adobe users. If your email is on the list, but your password hasn’t been changed in a long time, now’s a good time to change it. http://www.haveibeenpwned.com/ (http://www.haveibeenpwned.com/) Disposing of old equipment The NCSC has guidance on this on their website. It is important to dispose of old equipment safely but also by ensuring all data on the hard drive has been erased. There are companies to do this. Make sure you go to a company which provides a certificate. ask for a CESG certificate for your records and confirmation of the assets destroyed. These should be kept on file for several years.
Did you know the Air Ambulance provides this service? Here is the link https://theairambulanceservice.org.uk/ways-to-give/reuse-recycle/asset-recovery/ (https://theairambulanceservice.org.uk/ways-to-give/reuse-recycle/asset-recovery/) You can download an audiobook and PDFs from the Met Police site to help you prevent fraud and cybercrime. The Secure Book PDF features step-by-step guides to securing smart phones, zoom meetings and social media accounts (including LinkedIn).
You should have a password policy so staff don’t create easy to hack passwords. A good way is to use 3 random words which mean something to you and also symbols and numbers. Use password managers. It means staff only need to remember one very strong password and others are behind the password manager for different things they need passwords for For example I have LastPass Free.
Infection control is important in all types of premises. In a clinical setting even more so. I work with home care agencies. They should also look at infection control in their clients home for the benefit of the client but also for the safety of carers. They may not be responsible for cleaning but they should still have a say if it affects the client. Especially if you are looking after someone with low immunity. There are many resources for clinicians to follow. For those who are nurse led. The guidance from the RCN is very good especially . The ebook is called. Essential Practice for Infection Prevention and Control, Guidance for nursing staff CLINICAL PROFESSIONAL RESOURCE Practice guidance are evidence-based consensus documents, used to guide decisions about appropriate care of an individual, family or population in a specific context. With Covid it is even more important that good hand hygiene is followed. Hand sanitisers are available.
Safe handling of sharps and safe disposal of clinical waste is also looked at by inspectors. Decontamination of equipment , having that in an appropriate area is also important. I undertook a Quality assurance audit. The Salon/Clinic owner has the autoclave in the staff room right near the microwave. There was risk of cross commination. The staff room is also not the place for equipment of this kind. They also had cleaning fluid in an office on the floor. There are many things to think of like spillage management Managing accidental exposure to blood borne viruses. If this is something that can happen in the clinic then its really important to have a process for when the situation arises. A sharps injury protocol is important. Risk management also places a part look at riskes and themn put in ocntrols that are approprute for your setting ine size does not fit all. At tiems I see small bsuisses copying what corporates do that is too big a jumpo. Different size companies need different levels of measaure that is right for their envirnoemt to keep infecton control at optimum.
Every practice should be following standard infection control precautions as a minimum
You need to also meet COSHH regulations in your premises. Staff need to trained in COSHH.
have a look here for Health Safety Training which includes COSHH and infection control basic awareness I also recommend looking on the HSE website it is a really good resource. https://www.hse.gov.uk/ (https://www.hse.gov.uk/) There are consequences for organisations not adhering to infection control. https://www.tchauhanconsultancy.co.uk/online-training-health-safety/ (https://www.tchauhanconsultancy.co.uk/online-training-health-safety/)
Many organisations have not heard of infection prevention control which is another good resource. https://www.infectionpreventioncontrol.co.uk/ (https://www.infectionpreventioncontrol.co.uk/)
The resources should be used to aid you to write a infection control policy and processes that help you to look reduce infection control reduction.
Welcome to episode 30 of Continuous Quality Compliance Today I am talking about… Recruitment for Directors CQC are getting robust with their initial interviews and want to ensue that the Directors you have in place are fit for purpose. They have also asked for a Fir Director policy. What I have done for clients is to take what Regulation 7 tells us plus what Companies House recommend. I work with a lot of New business owners so todays episode is for going to be talking about what the responsibility of a Director is ;
Directors' responsibilities As a director of a limited company, you must: · follow the company’s rules, shown in its articles of association · keep company records and report changes · file your accounts and your Company Tax Return · tell other shareholders if you might personally benefit from a transaction the company makes · pay Corporation Tax · You can hire other people to manage some of these things day-to-day (for example, an accountant) but you’re still legally responsible for your company’s records, accounts and performance.
Unfit conduct’ includes: · allowing a company to continue trading when it can’t pay its debts · not keeping proper company accounting records · not sending accounts and returns to Companies House · not paying tax owed by the company · using company money or assets for personal benefit
How disqualification works The Insolvency Service may investigate your company (or you personally as a director of your company) if it’s involved in insolvency proceedings or if there’s been a complaint. If they think you haven’t followed your legal responsibilities as a director, they’ll tell you in writing: what they think you’ve done that makes you unfit to be a director they intend to start the disqualification process
how you can respond You can either: wait for The Insolvency Service to take you to court to disqualify you - you can defend the case in court if you disagree with The Insolvency Service give The Insolvency Service a ‘disqualification undertaking’ - this means you voluntarily disqualify yourself and ends court action against you You may want to get legal advice if you get a letter about disqualification from The Insolvency Service. Apart from The Insolvency Service, other bodies can apply to have you disqualified under certain circumstances, eg:
Companies House the Competition and Markets Authority (CMA) the courts a company insolvency practitioner If you’re disqualified You’ll be disqualified for up to 15 years. You can’t: be a director of any company registered in the UK or an overseas company that has connections with the UK be involved in forming, marketing or running a company
other restrictions There are other restrictions if you’re disqualified. For example, you might not be able to:
sit on the board of a charity, school or police authority be a pension trustee be a registered social landlord sit on a health board or social care body be a solicitor, barrister or accountant
If you look at all this you will see why it is important to have a robust process for incoming directors. You need to check them thoroughly and have a consistent process. When you are CQC regulated you also need to bring in the criteria of Regulation 5 . So, ensure that you are meeting both Companies house and CQC criteria. It is something that benefits...
Welcome to episode 29 of Continuous Quality Compliance Today I am talking about… Training and personal development CQC ask for a training matrix. They wan to see that you are covering mandatory training. However it is important o note that as part of Regulation 18 Staffing. Staff skills and knowledge and development of staff appropriately. To me training should be looked at outside the box. Don’t assume that all training has to be either class room based or e learning. It should be a mix but also your staff will have different learning styles so the number one thing is to find out the learning style of staff. Why because they will learn better . Also look at staff development broader then just today. What do I mean. Well for instance in one organisation I am working with we have been discussing succession planning. The senior staff have been with the company for over 20 years so there will come a time when they are ready to retire. If they want staff from within the organisation to apply for their roles they need to be thinking about succession planning so that other senior staff are taught relevant tasks. This needs to be done over a at least 18 months to 2 years’ time frame. I despair because in the NHS I have seen succession planning being none existent. When you are promoting staff especially into management roles please ensure you give them the tools to do their job. I have had personal experience of being thrown into a management role with no experience and it was difficult. I ended up being bullied. I learnt the hard way how to manage I would not wish that on anyone. I blame my managers it was not even in the job advert. There was no training provided I had to ask for relevant training. I learnt a lot but at the expensive of my mental health. My husband found it hard seeing me crying night after night when I was being bullied. The next time I knew what to do. No, I did not leave the organisation because I had not done anything wrong. I actually was being supportive, but the team had been so used to managing themselves in a bad way they didn’t like having a manager. So training is not just about mandatory training it is about give the staff the right tools to do their job and develop them so they wan to stay. If you can have a career path that is even better. Staff who feel valued will usually stay. Training can be learning from journals, personal development books ,going to forums in the local area and imparting the knowledge. It can even be learning from films. So think outside the box when you consider training. If you want some ideas get in touch with me through the contact form on my website For instance Home Instead Care collaborated with the local hospital to reduce hospitalisation after falls and also to reduce unnecessary calls. By working as a team both parties were able to help each other and more importantly their clients. It meant the trust training the Home Instead Staff on a traffic light falls assessment system which they used in hospital . This is what I mean about outside the box thinking. You don’t need to find the answers only within your organisation collaborate with other that you refer to and see how you can help each other. Case Studies can be found on the CQC website http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)
Welcome to episode 28 of Continuous Quality Compliance Today I am talking about Audit. Audits is something the CQC look for in your organisation. Audits are important for any organisation to audit hat their processes are working. Audit is a quality improvement process. The definition of Audit is measures current practice against a defined (desired) standard. It forms part of clinical governance, which aims to safeguard a high quality of clinical care for patients. For Social care take out the word clinical To check that staff are doing what they should be for instance when you audit good record keeping. The areas you need to audit will be dictated by what the organisation does but also bear in mind what he CQC are looking for in terms of the KLOE. Audits need to be reviewed as well so ensure that the person doing the audit is not the one who should be checking it . Also ensure staff have training in how to do an audit. I have found audits not always developed well. They should not be just tick box exercise that is not the reason for audit. Audit should show if something is working if it’s not then it should be analysed and there should be a way to look at how to improve things. Audits can look at: Structure of care Process of Care The Outcome of Care The aim is to find out how the present provision compares with the desired standard. This information can then be used to plan improvements in the service.
The standards are the CQC Standards here . Audit is cyclical but please schedule it so you don’t do all audits in one go. Have then schedules over a period of 12 months. Look at frequency some you will only need to do annually. Some every 6 months, some quarterly, and weekly. These should be appropriate to your organisation and the audit requirements of the topic. NICE has some audit tools especially for Clinical audit use those if appropriate I am a great advocate of not re-inventing the wheel. If you are not sure of what audit need to take place then have a look at the patient/client pathway look at the patient journey and documents journey then look at which areas would be good to review. Remember you know that he areas that CQC ask about need audits but you also need to think of audits appropriate to your organisation. Audits are about improvement and when you need to make changes you need to account for time who needs to be communicated etc, do staff require further training or refresher etc. Audits are not about blame they are about understanding that processes are working effectively. http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)
Today I am talking about Evidence In order for the CQC to ascertain that you are following your Statement of Purpose and that you are meeting the standards you need to provide evidence. Many providers get confused about he level of evidence or how much is required. Evidence should be provided during the carrying out of the services so the forms you use should be created in a way that it provides the relevant information. What you want to do is be effective in gathering evidence. For instance, for Social Care providers they usually have to provide information the local authority. Well make sure the forms cover the local authority criteria and that CQC standards that way you do not need to double up. If you’re a nurse ensure that the NMC requirements are covered.
When you do audits check that the forms are indeed providing you with the evidence you need. Have a look at staff files do they show a robust recruitment process? One organisation I went to there was no notes for interviews their was no consistency in the way recruitment was undertaken. It was so haphazard that if they were taken to tribunal, they would have no evidence to provide.
Evidence should not be burdensome. When I worked in a acute hospital I design ed the evidence to provide me the information required by different regulatory bodies. The consultant solved this approach as it made their life easier. Remember in providing evidence you need to show good record keeping is followed. I say if you are not happy for it to be read in a court of law then do not write it. Think about language and clarity of meaning. Do not make evidence gathering complex that way staff will not comply. Also explain the reason for the forms because staff are more likely to support if they know why they are being asked to do something. If you do not write something that you have undertaken in clients notes it has not happened. SO, ensure staff know that all information pertinent to the client needs to be recorded.
The Key Lines of Enquiry are the 5 areas which a provider gets inspected on. These come out of the regulations. Being the KLOE they can be added to taken always moved around unlike the regulations. But it sis important to look at how your processes align with he Key Lines of Enquiry. There are 2 frameworks one for healthcare and one for social care.
Develop you processes and see how they align with the regulations and Key Lines of Enquiry. The five areas which are looked at are Safe, Caring, Effective, Responsive and Well Led. The way I remember them is using the pneumonic SCREW
SAFE Here you need to show you have robust systems in place. These should include for safeguarding and recruitment. Safe a key are looked at here is Safeguarding. Safeguarding is seen as everyone’s responsibility. The Registered manager should be trained to level 3 other staff dependent on their roles can be at level 1 or 2 most staff should be level 2. Recruitment and induction is key to have safe staff who are fit persons. Values based recruitment is important and a robust Induction as well as a robust training regimen. I always say asking staff to read key policies is not enough you have to check competency too, ask at 3 key questions on the policy to ascertain understanding.
You need to show that you have good risk management processes in place which are appropriate for the activity being undertaken. If you are responsible for medicines management you need to show how that is being done, and that staff are trained adequately and their competency checked.
CQC know that even with the best processes in place things can go they want to know how you deal with the situation. Are lessons learnt and how do you prevent the issue arising again. Do you talk about lessons learnt at meetings?
How do you manage Infection control this needs to be appropriate to the service you provide. For instance infection control in a care home is different to a person home. Clinics will need different levels of infection control protocols dependent on the level of treatments provided
EFFECTIVE CQC want to know if you are an effective organisation . Do you have a good induction process in place. They want to know how you assess care and treatment. Is it evidence based following current practice and legislation. How will you monitor outcomes of your clients, have you discussed their outcomes with them?
ARE you checking that your staff have the right level f knowledge and skills to undertake the treatment procedure or activity. They also want to know that your staff work well in teams whether that is internal or external. To me external is those other health professionals you work with like GP, OT to deliver effective care Where the service is responsible howe will you help people to lead healthier lives? Is consent taken consistently inline with legislation and guidance If staff handover is required for your activity how is this managed. I have seen some very poor practice in this area. Is supervision undertaken? How often is it in an effective way? If you are responsible for peoples Nutrition and Hydration is this done well is it in a person centred way.
CARING How will the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed? I always say how would you like your loved ones to be treated. Do you support clients to express their views? And actively encourage them in the decision making process Is people's privacy and dignity be respected and promoted?
RESPONSIVE How will people receive personalised care that is responsive to their needs? Do you take account of the...
It is important to have a business continuity plan because you do not want to think about the steps when you are in the middle of a major incident you want to have steps already set out. Overall episode topic or theme CIRCUMSTANCES A Business Continuity Plan will be activated in response to an incident causing significant disruption to normal service delivery/business, particularly the delivery of key/critical activities. Examples of circumstances triggering activation of a Plan include: • Loss of key staff or skills e.g. above normal levels of absenteeism due to illness • Loss of critical systems e.g. ICT failure • Denial of access, or damage to, facilities e.g. loss of a building through fire • Loss of a key resource e.g. a major supplier vital to the delivery of a key service The ‘Incident Management’ phase of your response to a business disruption is often the most crucial; actions taken during this phase of your response can impact on your ability to recover efficiently and with minimum disruption. procedures need to be accurate and fit-for-purpose PURPOSE OF THE INCIDENT MANAGEMENT PHASE • Protect the safety of staff, visitors and the wider community • Protect vital assets e.g. equipment, data, reputation etc • Ensure necessary communication takes place • Support the Business Continuity phase • Support the Recovery and Resumption phase the plan should cover who will need to communicate and to whom who will have overall responsibility for the plan when it is instigated. There should be phone numbers for instance for major utilities suppliers in an emergency. Insurance companies The ‘Business Continuity phase of your response is concerned with maintaining a level of continuity with your most critical activities. It is not necessarily about getting all activities back up and running, only those activities that have been identified as a priority. Implementing contingency arrangements such as moving to a relocation site or identifying alternative working practises i.e. suspending non critical activities is a key feature of this phase of the response. It is important that this is aligned to your business needs. The ‘Recovery and Resumption’ Stage This stage is concerned with recovering ‘business as usual’. During the previous business continuity phase, only critical activities are maintained, therefore it is likely you will experience a ‘back log’ of work to catch up with. Now it is about a phased approach building gradually to all activities being recovered with the resumption of ‘normal’ working practises i.e. reoccupation of the usual building, all staff returning to work, or going back to their ‘normal’ roles.
Testing of plans All plans should be tested or exercised to ensure they are valid and that incident responses are rehearsed in a ‘safe’ environment, without the pressure of a ‘real life’ incident. This ensures that plans will actually work in an incident, but staff will also feel more prepared and comfortable in their business continuity roles. Following an exercise it is useful to write a report: contents may include- information about the test i.e. the scenario used, participant information i.e. who was in attendance, general...
Welcome to episode 24 of Continuous Quality Compliance Today I am talking about you Business Plan. For a New registration you require a business plan with a 3 year cashflow forecast. It is required for all Providers now before it was just in the Social care sector . Now a business plan is asked for in both Healthcare and Social care. Why because CQC wan t to know you are serious about your business that you have thought it through. Personally I do prefer using Strategy on a Page approach but the CQC are still old fashioned and require a classic business plan. With a cash flow forecast over 3 years. It does not need to be a thick document. A business plan should be your guiding tool to help you make decision about the business. It should also be done in advance, so you know if the business you wan to do is feasible. Nothing worse then starting a business on a hope and a whim. A business plan gets you to look at different aspects to check feasibility and financial viability. Financial viability is actually checked by the CQC they have a form you need to ask your accountant to complete to show that you are financially viable. Now some of my clients are already running a business and still need to provide a business plan. For these clients I recommend that they look at the past 3 years or 2 years depending on how long they have been going and use that information for the Business plan. You of course need to account for the regulated activity you will be adding and how that affects the other areas. Do you need more staff or do the current staff need further training. They would of course require training in the CQC standards and how that aligns with your business goals.
The purpose of a business plan is to help articulate a strategy for starting your business. It also provides insight on steps to be taken, resources required for achieving your business goals and a timeline of anticipated results. a business plan can be important in providing structure and management objectives to a small business. For existing small businesses, a business plan should be updated annually as a way to guide growth and navigate the expansion into new markets. For that I like to use Strategy on a Page as everything is on one page and you can clearly see what you need to do. The cashflow forecast is a forecast so they do not expect you to know all the numbers, but they do expect you to have an idea of expenses and income. Keep the forecast simple you do not need anything too complicated. You do need it for 3 years showing growth of some sort.
Welcome to episode 23 of Continuous Quality Compliance Today I am talking about Notifications There are certain events for which you have to notify CQC. If you do not notify CQC than it can be classed as breach. The Portal can be used for notifications. I recommend you have a deputy who also knows how to do notifications when the Registered Manager is away. You must notify CQC if the registered manager is going be away more than 28 days. Equally when they return you have to notify CQC too. So put it in a calendar/diary so you don’t forget. Safeguarding allegations needs to be notified to CQC . You should have forms internally to gather the information . Incident reporting forms can be used. AS long as all the relevant information is gathered. Changes to registered details there are different forms for different kinds of changes so ensure you use the right one. Death of a person using the service is notifiable. Serious injury is also notifiable.
The regulations say that the ‘registered person’ must submit notifications. This will often be the registered manager, but you can delegate this task to appropriate members of staff. You need to ensure that your delegation arrangements clearly show which members of staff are responsible for submitting notifications. These, together with your policies and procedures and staff training arrangements, must ensure that CQC is told about notifiable events properly and within the required timescales. In all cases, we need to know the name of the person who submits a notification and who we should contact for more information. There is space in the forms for this. It is the registered person’s responsibility to ensure that notifications are made, and they will be committing an offence if they fail to do so. Any arrangements for delegation of this task must therefore be very clear. For Social care CQC have to be notified of DOLS. It is important to know what is a notifiable incident so you do not inadvertently have a breach if in doubt ring them up.
Welcome to episode 22 of Continuous Quality Compliance Today I am talking about The Statement of Purpose. Every provider has to complete a Statement of Purpose as part of their CQC application . Care Quality Commission (Registration) Regulations 2009 CQC can prosecute for a breach of this regulation or a breach of part of the regulation. This means that CQC can move directly to prosecution without first serving a warning notice. Additionally, CQC may also take any other https://www.cqc.org.uk/guidance-providers/regulations-enforcement/glossary-terms-used-guidance-providers-managers#regulatory-action (regulatory action). The CQC provide a template but I do not like it so I have created my own which covers all part of schedule 3 and its nicer so you can print or email to your new staff during induction. 1. The registered person must give the Commission a statement of purpose containing the information listed in Schedule 3. 2. The registered person must keep under review and, where appropriate, revise the statement of purpose. 3. The registered person must provide written details of any revision to the statement of purpose to the Commission within 28 days of any such revision.
Schedule 3 says: 1 The aims and objectives of the service provider in carrying on the regulated activity. 2. The kinds of services provided for the purposes of the carrying on of the regulated activity and the range of service users’ needs which those services are intended to meet. 3. The full name of the service provider and of any registered manager, together with their business address, telephone number and, where available, electronic mail addresses. 4. The legal status of the service provider. 5. Details of the locations at which the services provided for the purposes of the regulated activity are carried on. Point 3 · If a provider changes their statement of purpose, it must tell CQC what these changes are within 28 days of making the changes. · If a provider is applying to vary a condition of its registration, it should send CQC a copy of its proposed statement of purpose with its application.
Welcome to episode 21 of Continuous Quality Compliance Today I am talking about… Regulation 20 Duty of Candour The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. The regulation applies to registered persons when they are carrying on a regulated activity. CQC can prosecute for a breach of parts 20(2)(a) and 20(3) of this regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, CQC may also take other https://www.cqc.org.uk/guidance-providers/regulations-enforcement/glossary-terms-used-guidance-providers-managers#regulatory-action (regulatory action). Which you can find in the offences section. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology. Providers must promote a culture that encourages candour, openness and honesty at all levels. CQC This should be an integral part of a culture of safety that supports organisational and personal learning. There should also be a commitment to being open and transparent at board level. Definitions : Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered. • Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators. • Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it. To meet the requirements of Regulation 20, a registered provider has to: Make sure it acts in an open and transparent way with relevant persons in relation to care and treatment provided to people who use services in carrying on a regulated activity. Tell the relevant person, in person, as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, and provide support to them in relation to the incident, including when giving the notification. • Provide an account of the incident which, to the best of the provider’s knowledge, is true of all the facts the body knows about the incident as at the date of the notification. • Advise the relevant person what further enquiries the provider believes are appropriate. • Offer an apology. • Follow up the apology by giving the same information in writing, and providing an update on the enquiries. • Keep a written record of all communication with the relevant person. We will consider the size and type of services and the relevance of the regulation to the provided regulated activity.
The registration inspector will check that the provider has robust systems in place to meet the duty of candour regulation. This would include, but is not limited to, training for all staff on communicating with people who use services about notifiable safety incidents; incident reporting forms which support the recording of a duty of candour notification; support for staff when they notify people who use services when something has gone wrong; oversight and assurance.
When they are inspecting the following KLOE’s will be looked at for compliance with Duty of Candour.
S2: Are lessons learned and improvements made when things go wrong? Prompt...
Welcome to episode 20 of Continuous Quality Compliance Today I am talking about… Regulation 19 Fit and proper Person Employed. The intention of this regulation is to make sure that providers only employ 'fit and proper' staff who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity. To meet this regulation, providers must operate robust recruitment procedures, including undertaking any relevant checks. They must have a procedure for ongoing monitoring of staff to make sure they remain able to meet the requirements, and they must have appropriate arrangements in place to deal with staff who are no longer fit to carry out the duties required of them. Employing unfit people, or continuing to allow unfit people to stay in a role, may lead CQC to question the fitness of a provider. “Person employed” will include any member of staff who currently works in the service including agency, bank staff and volunteers (based on the broad meaning of “employment” set out in Regulation 2, which extends the scope to those engaged otherwise than under a contract).
Point 1 Schedule 3 sets out eight categories of information required to be kept by providers about all persons employed in the provision of services. They wont want to see all but some of them to be utilised as part of checking that’s staff remain suitable. 1 Proof of identity including a recent photograph. 2CQC expects each provider to undertake the level of DBS check for which a particular staff member is eligible 3 Closely looked at when exemptions apply related to the DBS 4 Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to— (a) health or social care, or (b) children or vulnerable adults. Obviously it does not apply if they have not previously worked in the sector.
- Where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why the person’s employment in that position ended. 6 Far as is it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform. 7 A “full employment history” means a career history from the age of first employment. This information may be in the form of a Curriculum Vitae but need not be. 8 Satisfactory information about any physical or mental health conditions which are relevant to the person's capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity. CQC expects providers to be aware of a range of guidelines relevant to their business sector, and to be able to demonstrate that the recruitment and selection procedures are consistent with responsible employment practice. Point 2 The provider is required to undertake sufficient checks so they can evidence the applicant: · Is of good character · Has the necessary qualifications, competence, skills and experience necessary for the work to be performed · Is able to properly perform the tasks (after any reasonable adjustment) Point 3 However, most companies/organisations will only provide a statement confirming dates of employment. When this occurs, providers should assess any potential risk and make sure the person has appropriate supervision until they can demonstrate competence.
Point 4 If providers have any current concerns about the performance, abilities, physical or mental health of any of their staff, the Inspector will want to see what steps they have taken to...
Welcome to episode 19 of Continuous Quality Compliance Today I am talking about Regulation 18: Staffing CQC cannot prosecute for this but they can take regulatory ac tion. To meet the regulation, providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times . .Staff must receive the support, training, professional development, supervision and appraisals that are necessary for them to carry out their role and responsibilities. They should be supported to obtain further qualifications and provide evidence, where required, to the appropriate regulator to show that they meet the professional standards needed to continue to practise. The regulators can be the GMC, NMC, GDC , they can be associations like the HCPC, BABICOM whose standards you should be meeting if you are a member.
Point 1 Providers must have sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people's care and treatment needs.
Point 2 CQC are looking for a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service and keep them safe at all times.
The approach they use must reflect current legislation and guidance where it is available. In determining the number of staff and range of skills required to meet people's needs, they should consider the different levels of skills and competence required to meet those needs, the registered professional and support workers needed, supervision needs and leadership requirements.
Point 3 Staffing levels and skill mix must be reviewed regularly and adapted to respond to the changing needs and circumstances of people using the service. Or in terms of providers undertaking diagnostics and screening they type of reporting you are doing.
Point 4 A robust induction is really important it should prepare the person for their role. You should also ask for feedback on the induction so you can make improvements on it. I have never had a great induction. The worst was turning up and being told the person who was assigned to me was on holiday for the rest of the week. I was just left to fend for myself. It was awful and it was a corporate which made the experience worse. In my other roles I turned up and there was no-one there even to greet me. How do you thing that made me feel. I understand that they were on the wards but a little thought on their part . It could have been a little welcome box or even a simple note would have been better. Luckily It was a new speciality in a hospital I worked so I knew my way around the IT system. But it made me feel unwanted and unwelcome.
Point 5 Staff should be supported to have training. CQC will look for how you are monitoring training and will ask for a training matrix at the least. You should be looking at any additional training which may be required. A good example is when a client of mine was bring in tablets to be sued by staff for their IT platform they were using. A Good move to go paperless. But they had not done pre-requisite work on the competency of their staff and ability of them to use tablets. Some staff did but others were floundering and instead of saying I don’t know how to use this technology they blamed the platform. I wrote an IT competency checklist for my client and is was told to staff that by completing the form it would help the company to know the level
Welcome to episode 18 of Continuous Quality Compliance. Today I am talking about Regulation 17 Governance CQC’s intention of this regulation is to make sure that providers have systems and processes that ensure that they are able to meet other requirements in this part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice. They are also looking for providers to securely maintain accurate, complete and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity. Governance is your overall strategy for the business which encompasses the Quality Assurance element. Your Quality Assurance system will be part of this , the audits you do to look at the evidence you gather and ensure that they are meeting your standards and CQC standards. Remember the CQC standards are the minimum you have to meet. Providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. If you don’t see patients if you are a provider that only does diagnostics reporting, you must still ask for feedback from those that you are providing your service to and those who you employ or those who you contract to do the work for you. CQC are looking for providers should actively seek the views of a wide range of stakeholders, including people who use the service, staff, visiting professionals, professional bodies, commissioners, local groups, members of the public and other bodies, about their experience of, and the quality of care and treatment delivered by the service. Providers must be able to show how they have: · analysed and responded to the information gathered, including taking action to address issues where they are raised, and · used the information to make improvements and demonstrate that they have been made CQC can prosecute for a breach of part of this regulation (17(3)) if a provider fails to submit such a report when requested. CQC may consider that this failure could prevent the provider from taking appropriate, timely action. CQC could therefore move directly to prosecution for a breach of this part of the regulation without first serving a Warning Notice. Continuous improvement is important, learning form audits and the analysis lessons learnt are important. Looking at how you can disseminate the findings to others within the organisation. CQC are also looking for how you are going to improve processes for your clients, they want to know what plans you have in place. Providers must monitor progress against plans to improve the quality and safety of services, and take appropriate action without delay where progress is not achieved as expected. Where providers have to meet relevant nationally recognised guidance these should be looked at on a regular basis for updates. Providers should be aware that quality and safety...
The CQC look at this as part of the Responsive KLOE. The intention of this regulation is to make sure that people can make a complaint about their care and treatment. To meet this regulation providers must have an effective and accessible system for identifying, receiving, handling, and responding to complaints from people using the service, people acting on their behalf or other stakeholders. All complaints must be investigated thoroughly and any necessary action taken where failures have been identified. When requested to do so, providers must provide CQC with a summary of complaints, responses and other related correspondence or information. CQC can prosecute providers for a breach of the part of this regulation (16(3)) that relates to the provision of information to CQC about a complaint within 28 days when requested to do so. CQC can move directly to prosecution without first serving a Warning Notice.
16.—(1) Any complaint received must be investigated and necessary and proportionate action must be taken in response to any failure identified by the complaint or investigation. (2) The registered person must establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons in relation to the carrying on of the regulated activity. (3) The registered person must provide to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request, a summary of— (a) complaints made under such complaints system, (b) responses made by the registered person to such complaints and any further correspondence with the complainants in relation to such complaints, and (c) any other relevant information in relation to such complaints as the Commission may request.
Point 1 People must be able to make a complaint to any member of staff, either verbally or in writing. • All staff must know how to respond when they receive a complaint. • Unless they are anonymous, all complaints should be acknowledged whether they are written or verbal. • Complainants must not be discriminated against or victimised. In particular, people’s care and treatment must not be affected if they make a complaint, or if somebody complains on their behalf. • Appropriate action must be taken without delay to respond to any failures identified by a complaint or the investigation of a complaint. • Information must be available to a complainant about how to take action if they are not satisfied with how the provider manages and/or responds to their complaint. Information should include the internal procedures that the provider must follow and should explain when complaints should/will be escalated to other appropriate bodies. • Where complainants escalate their complaint externally because they are dissatisfied with the local outcome, the provider should cooperate with any independent review or process.
Point 2 Information and guidance about how to complain must be available and accessible to everyone who uses the service. It should be available in appropriate languages and formats to meet the needs of the people using the service. • Providers must tell people how to complain, offer support and provide the level of support needed to help them make a complaint. This may be through advocates, interpreter services and any other support identified or requested. • When complainants do not wish to identify themselves, the provider must still follow its complaints process as far as possible. • Providers must have effective systems to make sure that all complaints are investigated without delay. This includes: Undertaking a review to establish the level of investigation and immediate action required, including referral to appropriate authorities for investigation. This may include professional regulators or local authority safeguarding teams. o...
Today I am talking about… Premises and Equipment I do realise that the Regulations are not the most exciting However they are important and if you get this right it helps to have a great inspection. CQC are not prescriptive. They love innovation and out of the box thinking although you would think otherwise when you try and navigate their website.
Main part of episode CQC write in the regulation that ; The intention of this regulation is to make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located, and that the equipment that is used to deliver care and treatment is clean, suitable for the intended purpose, maintained, stored securely and used properly.
Providers retain legal responsibility under these regulations when they delegate responsibility through contracts or legal agreements to a third party, independent suppliers, professionals, supply chains or contractors. They must therefore make sure that they meet the regulation, as responsibility for any shortfall rests with the provider. This means that if you have cleaners coming to your premises you can’t assume they know what they are doing. You are responsible for making sure what the expectations are. Where the person using the service owns the equipment needed to deliver their care and treatment, or the provider does not provide it, the provider should make every effort to make sure that it is clean, safe and suitable for use. A few years ago I went to support an aesthetics clinic and this was around preparing the clinic owner who was also a doctor to meet the requirements of his appraisal but they also wanted help with the operations side of the business. I picked up on poor stock keeping but also not a robust enough cleaning regimen for the equipment. One piece of equipment was full of gunge. I insisted that the pieced of equipment was de- commissioned until it was cleaned and then it must have a cleaning regimen to stop this happening again. In respect to stock keeping I saved him hundreds of pounds . He was not moving stock around so ended up with medical times expired which then could not be sued. These were not cheap items. He had no process for ordering and checking what items needed to be replenished a simple excel sheet for them to use. Point 1 The CQC outline that —(1) All premises and equipment used by the service provider must be— (a) clean, (b) secure, (c) suitable for the purpose for which they are being used, (d) properly used (e) properly maintained, and (f) appropriately located for the purpose for which they are being used. (2) The registered person must, in relation to such premises and equipment, maintain standards of hygiene appropriate for the purposes for which they are being used.
Point 2 If you are in a rented space and it’s the landlords cleaners you must ascertain he cleaning regimen. The CQC says Providers retain legal responsibility under these regulations when they delegate responsibility through contracts or legal agreements to a third party, independent suppliers, professionals, supply chains or contractors. They must therefore make sure that they meet the regulation, as responsibility for any shortfall rests with the provider. Providers should: o Use appropriate cleaning methods and agents. o Operate a cleaning schedule appropriate to the care and treatment being delivered from the premises or by the equipment. o Monitor the level of cleanliness. o Take action without delay when any shortfalls are identified. o Make sure that staff with responsibility for cleaning have appropriate training.
Using the appropriate level of security needed in relation to the services being delivered. Health and Social Care Act...
Safeguarding is relevant to every business whether your in health or social care The term safeguarding is used to define actions taken to protect vulnerable groups from harm. This harm might come from adults or other children and, as someone working closely with vulnerable groups, it’s important you understand what safeguarding is and why it’s important. Part of the safeguarding process is identifying and protecting children suffering from, or likely to suffer from, significant harm. All children are covered by child protection and safeguarding guidance and legislation. A vulnerable adult is defined as a person who, for any reason, may be unable to take care of themselves or protect themselves against significant harm or exploitation. Safeguarding vulnerable adults involves reducing or preventing the risk of significant harm from neglect or abuse, while also supporting people to maintain control of their own lives. This does not only refer to adults who lack capacity. Adults with full capacity can still be considered vulnerable if they are unable to take care of themselves or protect themselves from significant harm. Safeguarding training is vital when working with vulnerable groups, as it helps to ensure that your employees can carry out their duties knowledgeably and safely. Point 1 CQC want to see that you have processes in place to ensure that if safeguarding come sup all your staff know what to do. Point 2 What CQC say is that systems and processes must be established and operated effectively to prevent abuse of service users. (3) Systems and processes must be established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of such abuse. (4) Care or treatment for service users must not be provided in a way that— means that you are discriminating against them in reference to the Equality act 2010 It should not be degrading for the service user nor should it significantly disregard the needs of the service user for care or treatment.
For the purposes of this regulation— “abuse” means— (a) any behaviour towards a service user that is an offence under the Sexual Offences Act 2003(a), (b) ill-treatment (whether of a physical or psychological nature) of a service user, (c) theft, misuse or misappropriation of money or property belonging to a service user, or (d) neglect of a service user. (7) For the purposes of this regulation, a person controls or restrains a service user if that person— (a) uses, or threatens to use, force to secure the doing of an act which the service user resists, or (b) restricts the service user’s liberty of movement, whether or not the service user resists, including by use of physical, mechanical or chemical means.
To meet the requirements of this regulation, providers must have a zero tolerance approach to abuse, unlawful discrimination and restraint. This includes: • Neglect. • Subjecting people to degrading treatment. • Unnecessary or disproportionate restraint. • Deprivation of liberty. Providers must have robust procedures and processes to prevent people using the service from being abused by staff or other people they may have contact with when using the service, including visitors. Abuse and improper treatment includes care or treatment that is degrading for people and care or treatment that significantly disregards their needs or that involves inappropriate recourse to restraint. For these purposes, ‘restraint’ includes the use or threat of force, and physical, chemical or mechanical methods of restricting liberty to overcome a person’s resistance to the treatment in question. Where any form of abuse is suspected, occurs, is discovered, or reported by a third party, the provider must take appropriate action without delay. The action they must take includes investigation and/or referral to the appropriate...
The intention of this regulation is to make sure that people using the service are treated with respect and dignity at all times while they are receiving care and treatment. To meet this regulation, providers must make sure that they provide care and treatment in a way that ensures people’s dignity and treats them with respect at all times. This includes making sure that people have privacy when they need and want it, treating them as equals and providing any support they might need to be autonomous, independent and involved in their local community. Providers must have due regard to the protected characteristics as defined in the Equality Act 2010.
Today I am talking about… person-centered Care which is Regulation 9 of the Health and Social Care Act The intention of this regulation is to make sure that people using a service have care or treatment that is personalised specifically for them. This regulation describes the action that providers must take to make sure that each person receives appropriate person-centered care and treatment that is based on an assessment of their needs and preferences. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves. Providers must make sure that they take into account people’s capacity and ability to consent, and that either they or a person lawfully acting on their behalf, must be involved in the planning, management, and review of their care and treatment. Providers must make sure that decisions are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families, and/or advocates where appropriate. The regulation is looking for collaboration with the person your providing treatment for designing care or treatment with a view to achieving service users’ preferences and ensuring their needs are met; enabling and supporting relevant persons to understand the care or treatment choices available to the service user and to discuss, with a competent health care professional or other competent people, the balance of risks and benefits involved in any particular course of treatment; enabling and supporting relevant persons to make, or participate in making, decisions relating to the service user’s care or treatment to this means your speaking with their advocate whether they are a relative or a professional. it means giving the advocate as much information as is appropriate and relevant to help them to make a decision. Where a person lacks the mental capacity to make specific decisions about their care and treatment, and no lawful representative has been appointed, their best interests must be established and acted on in accordance with the Mental Capacity Act 2005. Other forms of authority such as advance decisions must also be taken into account. This means you have to provide enough information they need to help them to make a decision for the purpose of treatment. Making reasonable adjustments to enable the service user to receive their care or treatment; Assessments must take into account current legislation and consider relevant nationally recognised evidence-based guidance. Assessments of people’s care and treatment needs should include all their needs, including health, personal care, emotional, social, cultural, religious, and spiritual needs. Assessments should take into account specific issues that are common in certain groups of people and can result in poor outcomes for them if not addressed. These include diseases or conditions such as continence support needs and dementia in older people and diabetes in certain ethnic groups. Assessments should be reviewed regularly and whenever needed throughout the person’s care and treatment. This includes when they transfer between services, use respite care, or are re-admitted or discharged. Reviews should make sure that people’s goals or plans are being met and are still relevant. Where providers share responsibility for providing care and treatment with other services through partnership working, integrated care, and multidisciplinary assessments, they should also take into account information from all relevant teams, staff and services. A person’s care and treatment must be designed to make sure it meets all their needs. There may be times when a person’s needs and preferences...
CQC writes; The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staff has the qualifications, competence, skills, and experience to keep people safe. Providers must make sure that the premises and any equipment used are safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely, and administered appropriately to make sure people are safe. Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety, and welfare. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people using their services and to manage risks that may arise during care and treatment. CQC must refuse registration if providers cannot satisfy us that they can and will continue to comply with this regulation. CQC can prosecute for a breach of this regulation or a breach of part of the regulation if a failure to meet the regulation results in avoidable harm to a person using the service or if a person using the service is exposed to a significant risk of harm. CQC do not have to serve a Warning Notice before prosecution. Additionally, CQC may also take other regulatory action.
The CQC said the intention of this regulation is to make sure that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided. Providers must make sure that they obtain the consent lawfully and that the person who obtains the consent has the necessary knowledge and understanding of the care and/or treatment that they are asking consent for. Consent is an important aspect of providing care and treatment, but in some cases, acting strictly in accordance with consent will mean that some of the other regulations cannot be met. For example, this might apply with regard to nutrition and person-centered care. However, providers must not provide unsafe or inappropriate care just because someone has consented to care or treatment that would be unsafe. CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, CQC may also take other regulatory actions. CQC must refuse registration if providers cannot satisfy us that they can and will continue to comply with this regulation. The person taking consent must have training in the Mental capacity act because they will need to decide whether the person has the capacity to give consent. When a person is asked for their consent, information about the proposed care and treatment must be provided in a way that they can understand. This should include information about the risks, complications, and any alternatives. A person with the necessary knowledge and understanding of the care and treatment should provide this information so that they can answer any questions about it to help the person consent to it. Discussions about consent must be held in a way that meets people's communication needs. This may include the use of different formats or languages and may involve others such as a speech-language therapist or independent advocate. Consent may be implied and include non-verbal communication such as sign language or by someone rolling up their sleeve to have their blood pressure taken or offering their hand when asked if they would like help to move. Consent must be treated as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and/or withdrawn at any time. When a person using a service or a person acting lawfully on their behalf refuses to give consent or withdraws it, all people providing care and treatment must respect this. Where a person lacks the mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. Consent procedures must make sure that people are not pressured into giving consent and, where possible, plans must be made well in advance to allow time to respond to people's questions and provide adequate information. Policies and procedures for obtaining consent to care and treatment must reflect current legislation and guidance, and staff must follow them at all times. The organisation must audit that consent is taken as per the organisations policies and procedures. That the forms used are completed accurately and record-keeping is excellent. Providers must make sure that staff who obtain the consent of people who use the service are familiar with the principles and codes of conduct associated with the Mental Capacity Act 2005, and are able to apply those when appropriate, for any of the people they are caring for. If you are registered with the GDC General Dental council, BMA, British Medical Association, or the GM General Medical Council there is information on their websites about consent. Always important to know what they require.
This is important because many businesses I work with is a Private ltd company and therefore require to have a Registered Manager in post. If you’re an individual or a partnership the rules are different. This is because providers who comply with the regulations should have a registered manager who: Is of good character. Is able to properly perform tasks that are intrinsic to their role. Has the necessary qualifications, competence, skills and experience to manage the regulated activity. CQC expects providers to have a robust recruitment process which is Values-based to ensure they have a suitable RM who understands the complex role. The registered manager should be appropriately skilled with the qualification(s), knowledge and experience and demonstrate the competency required to manage the regulated activity. The registered manager should demonstrate that they have appropriate knowledge of applicable legislation including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3), relevant best practice and guidance and understand the consequences of failing to take action on set requirements. The provider must have appropriate processes for assessing and checking that the individual holds the required qualifications and has the competence, skills and experience required to undertake the role. These processes must be followed in all cases and relevant records kept. The provider must have processes for considering the person's physical and mental health in line with the requirements of the role. All reasonable steps must be made to make adjustments for registered managers to enable them to carry out their role. These must be in line with requirements to make reasonable adjustments for employees under the Equality Act 2010 In essence, you need to know that the person undertaking the role understands their duties and is competent. I have certainly found in some case managers who had been with a provider for many years before the CQC was created Many find it hard to adjust to the CQC regimen and either leave or are asked to resign because they are not a Fit Person. I have also seen managers step up to the plate and be prepared to learn. The Registered Manager has to ensure that the organisation is CQC compliant, Make sure all Governance and Quality assurance measures are in place. They will need to have a robust recruitment process in place. Must have an audit schedule. Training matrix. Know how to review and analyze incidents. They will need to be aware of infection control at level 3 at a minimum Registered Manager has to have excellent Leadership skills. They need to be a person in authority.
Regulation 5 recognizes that individuals who have authority in organizations that deliver care are responsible for the overall quality and safety of that care. For the purpose of this regulation, these individuals are board directors, board members, and individuals who perform the functions equivalent to the functions of a board director and member. This regulation is about ensuring that registered providers have individuals who are fit and proper to carry out the important role of the director to make sure that providers meet the existing requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The regulation applies to all registered providers, but not if they are an individual would be a Sole Trader or a partnership1 (other than limited liability partnerships). To ensure that providers comply with the regulation, they must not have an unfit director in position. Ultimately, a provider should determine which individuals fall within the scope of the regulation, and CQC will take a view on whether they have done this effectively. Although FPPR does not apply to individual providers or to partners in a partnership, Regulation 4 of the Health and Social Care Act expects that these providers must be of good character, possess the right competencies and skills and be physically and mentally fit to do the job in line with the Equality Act 2010. They must be able to supply CQC with documents that confirm their suitability What constitutes a breach? A director has been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere, which is provided in England, would be a regulated activity. What CQC expects to see when a provider implements the regulation The provider must be able to show evidence that appropriate systems and processes are in place to ensure that all new and existing directors are, and continue to be, fit . The provider should be able to demonstrate that appointments of existing directors (and new directors) have been secured through robust and thorough appointments processes. CQC recognizes that a provider may not have had access to all relevant information about a director, or that a director may supply, or may have supplied false or misleading information. In these situations, CQC will look to see that the provider has since made every reasonable effort to assure itself about an individual by all means available and that it has addressed the issue in the light of new and additional information. Providers need to consider the mismanagement and misconduct behaviors in relation to the services they provide, the role of the employee and the possible adverse impact on the provider Notifying CQC of a change of director You do need to notify CQC of a change of Director. At the point of registration CQC’s registration application form asks for information about directors, where relevant, for all new relevant applicants who are applying to be registered as a service provider. We require the chair of an applicant to declare that appropriate checks have been undertaken in order to reach a judgement that all directors are deemed to be fit and that none meet any of the unfit criteria. This self-declaration forms part of the application form. CQC does not keep a list of individual directors, as this information is kept on the register of Companies House. CQC expect applicants to be able to demonstrate that they have robust recruitment, management appraisal, disciplinary and dismissal processes in place, supported by appropriate policies. When conducting the interview of the nominated individual, CQC’s registration inspector will need to establish the extent to which the applicant understands Regulation 5; what systems and processes are in place to ensure all directors are fit; whether the directors understand
Today I am going to give an overview of the CQC. Before I go into detail in the next podcasts I think it is important to have a view of the requirements of CQC. When looking at the CQC it is important to note that The regulations will be around for a long time because they are part of the Health & Social Care act. The Key Lines of Enquiry is what they use to inspect each regulated provider however these can bee added to or change over time. So whilst it is important to know what they are and what you need to know. However, remember the Regulations is the overarching basis for these. The best way to get to know what the CQC look for is to look at the CQC website; You need to look at guidance for providers. Once in that section look at the guidance appropriate for what your organisation will do. https://www.cqc.org.uk/guidance-providers
Today I am talking about having a profitable business. To have a profitable business you need to know your numbers. Time again research shows those businesses who do not have a handle on their numbers are the ones who get into trouble. I know numbers can be boring but they are important. I look at mine weekly and monthly in my planner I have the target for the month. I reached that by knowing what I want to have at the end of the year. You need to know how many leads you need what they are worth. How well they convert. How do you get repeat clients? You need to think about referrals. What kind of lifestyle do you want? What do you need to live on these are all important considerations? When I started my business, I did work out what I needed to live on but from that point, I was not sure what to do to get leads. I had my website-built thinking that would help. Now I know that just because you build a website does not mean people will come and buy your service. They need to know you exist. Point 1 You need to know where your sales are coming from which are the most profitable and where your expenses are going . For instance, my main sales are from supporting people with their CQC registration. However, I also have a e-learning platform client tend to buy these courses after they have bought my Registration service. I have levels of service so clients can buy the level that suits their budget. I have a name for each of these services and I can check the percentage of sales from each income stream. Point 2 I have a handle on my expenses. I do a lot of personal development, so I have a high spend on training. But I do have a budget which I will not go over for the year. In the beginning, I made mistakes with going for any training without looking at how it fitted into my overall business plan. Now I use tools which help me to decide whether the course will be worth it or not. These could be free or paid for. The same principle applies. The time I give a course or webinar is time not spent in the business. So I need to know what my return on investment is. Point 3 In terms of expenses I know each year I need to account for my accountant, Microsoft for business software, my subscriptions to other platforms. My membership for example of the ABM. I know how much this cost and what sales I need to generate to cover my expenses. Point 4 Forecasts are also vital for your business so you can manage your cash flow and expenditure. If you want to grow your team you need to know how much you need to spend on recruitment Point 5 There are some key indicators you should be looking at. These will be different for different business. However, some of these should at least be a focus; Number of new customers Numbers of retained customers Customer feedback I use Google Reviews as it can be seen by anyone who Googles my business. Conversion rate so how many people who sent an enquiry converted to a sale. What did you do? I also know that those with whom I have a telephone or zoom call convert better than those with whom I just have email correspondence. The zoom calls convert the best this is because they get a chance to meet me even if it is virtually. I also know those who receive my book convert better as they have a chance to get to know me by reading my book. It is key to know where customers come from and the conversion rate. If you have a referral system how does these convert? Do you have a loyalty scheme? For instance, a podiatrist I know gives a discount if you block book treatments. This s good for them because they know how many appointments, they have on their books in advance plus they get paid upfront so that helps with cash flow. To help me keep an eye on my numbers I use electronic accounting platform. I used to have a Simplex D book, then I moved to a spreadsheet, but it was too cumbersome. I was so pleased when I finally moved to an...
Today I am talking about working effectively and getting the most out of your day. There used to be a time in the early days of my business where I would walk up to my home office and see what the day had in store for me. I had no tasks list or what I wanted to get out of the day. The day usually just ended up me doing a bit of a task, get interrupted by a phone call and do something else. I didn't finish tasks and wasn’t sure where I should be in terms of projects. I would have a few projects on the go and never finish any, or it took me a while to complete them and I would be drained. https://blog.rescuetime.com/context-switching/ Part of the problem was I was multi-tasking, writing an email whilst answering a phone call thinking that was being effective. I would switch from one project to another. Something had to change as I was not working effectively and it was leaving me tired. When I researched this I found that several really well-conducted studies into human psychology and brain science show that we don’t actually multitask. Not in the sense that we’re doing two activities at the same time with sufficient focus. Instead, what the brain does is called “task switches” constantly between the two different demands vying for its attention. And it doesn’t switch all that well. The reality is no one can multitask. It is not effective and it is actually draining and reduces productivity. I like the analogy of Juggling which was used in an article in Psychology Today. When a person is juggling if the balls are your task or projects, well at some time you're going to drop the ball. The question to ask is can you afford to drop a ball and which one? The result of dropping the ball in an office environment could be having too many typos in an email or sending the email to the wrong person because their names are similar. MIT neuroscientist Earl Miller revealed that our brains are “not wired to multitask well . . . when people think they’re multitasking, they’re actually just switching from one task to another very rapidly. And every time they do, there’s a cognitive cost.” Multitasking has been found to increase the production of the stress hormone cortisol as well as the fight-or-flight hormone adrenaline, which can overstimulate your brain and cause mental fog or scrambled thinking. He says Multitasking creates a dopamine-addiction feedback loop, effectively rewarding the brain for losing focus and for constantly searching for external stimulation. To make matters worse, the prefrontal cortex has a novelty bias, meaning that its attention can be easily hijacked by something new A study at the University of London demonstrated that people who multitask while performing cognitive tasks experience measurable IQ drops. Believe it or not, the IQ drops were akin to what you see in those who skip a night of sleep. In the words of Tim Elmore, It’s a good idea to look at monotasking.
Today I am talking about planning. Planning is so important. In the early day of my business, I did not plan. I was used to structuring given by the workplace. I used to rock up to my desk whenever I felt like it and thought that I would get inspiration by just seeing what he day brings. I can tell you that approach does not work and meant that I was going to fold my company. Planning what you want out of the year is crucial then breaking that down into 6 monthly and quarterly then monthly and finally your weekly goals and micro daily goals. This will get you super focus on the task and will keep you on track. You can adjust easier when an emergency happens because you have planned. I even plan my weekly meals so each day I know exactly what I am cooking or one of the family is cooking. When we run a business it's so easy to work in the business to do all the tasks but you do need to work on your business too. Take time out on, bi-weekly to view your business and how it's going. Of course at the end of the 90 day look at next 90 days. Plan for the next 90 days and so on you will see the progress your making and the adjustments you need to make. Use a wall planner so you can see what hte 90 day plan looks like.
If you have been following the previous episodes you will now have your vision, values, and purpose all written down on your strategy on a page. Today we get into the more strategic territory. I want you to look at what makes you different from your competitors, this is called your unique selling point. For example, mine is that I am flexible so clients can call me later in the day. I am the consultant you always get. I get to know your company and how it works. Not like a corporate where you may be assigned different people because it’s about numbers rather than client. Look at your market place who are the players what approach do they take? How much of the market would you like? How do geography and demographics play a part? The marketplace is both the sector and the physical location. If you are not in the right location for your client base then the business will not be as great as you would like. Now is the time to think about what customers will always get from you What do you want clients to say about you? this is about how you want your company to be seen. Clients want consistent results. All clients should be treated equally. Foundations are important. You wouldn’t build a house without a good foundation because you want it to be standing for a long time. Same goes for your business you need to build it on a strong foundation and that is what you are doing. To grow without the building tumbling the foundation needs to be strong. Take time to do these steps because, in the long run, they will pay dividends There are some core pillars that you should be looking at as part of the strategy
Today I am talking about organisational values and why they are important both for you as the owner and for your staff to understand and all of the organisation living them. Organisational values describe the core ethics or principles which the company will abide by, no matter what. They inspire employees' best efforts and constrain their actions. ... Over time, they will improve the organisation's ethical character as expressed in its operations and culture. Our values are important because they help us to grow and develop. They help us to create the future we want to experience. Every individual and every organisation is involved in making hundreds of decisions every day. The decisions we make reflect our values and beliefs, and they are always directed towards a specific purpose. That purpose is the satisfaction of our individual or collective (organisational) needs. There are four types of values that we find in an organisational setting: individual values, relationship values, organisational values, and societal values. INDIVIDUAL VALUES Individual values reflect how you show up in your life and your specific needs-the the principles you live by and what you consider important for your self-interest. Individual values include enthusiasm, creativity, humility, and personal fulfilment. RELATIONSHIP VALUES Relationship values reflect how you relate to other people in your life, be they friends, family, or colleagues in your organisation. Relationship values include openness, trust, generosity and caring. ORGANISATIONAL VALUES Organisational values reflect how your organisation shows up and operates in the world. Organisational values include financial growth, teamwork, productivity and strategic alliances. SOCIETAL VALUES Societal values reflect how you or your organisation relates to society. Societal values include future generations, environmental awareness, ecology and sustainability. Corporate Social Responsibility is important for every business. Mine is that I recycle and buy less plastic and clothes. I purchase refills so I reuse containers. It's both a CSR and personal value. I work from home so all these reflect on my business too. Corporate Social Responsibility is important for all organisations and how you display CSR will depend on your values.
The vision for the company is about what you want to achieve. If you were looking at the company from your chair in 20 years' time, what do you see? Your vision can be as big and bold as you want it to be because later on when you're doing your business strategy, you can pull it back. Vision gives you clarity. It helps give you alignment and harmony with your goals, but also with your employees and with the work that you do. Your vision can also help you to attract amazing staff because if you know what your vision is, you'll then know what your value is and when you're writing your job descriptions, you'll be writing them in a way to attract staff that has similar values, they understand and align with your vision, so your vision can really inspire and motivate people. When you have a clear vision, it's easier to make decisions within your company. Filtering what you do as a business and what you commit to each day becomes easier as you consider your vision in the decision process. If a decision aligns with the purpose of your vision and your business's values and mission than you should invest time, resources, and management attention to it. If not, get rid of it. Simple as that. your vision will help you to look at other areas of the business because you want to check in every six months to make sure you're doing all the things you need to do to help you get closer to your vision. https://bit.ly/2zjZ1pH (https://bit.ly/2zjZ1pH)
Why does your company exist? What outcomes do you provide? What is the reason your company exists? It's important to know this because it will help you to look at the purpose and your vision and values which are all things you need to look at goals and your business strategy. In order to meet the CQC compliance you also need to look at the wider business because part of CQC role is to look at governance. You need to know what your governance framework will be that comes from knowing your purpose and reason for being. Your why what your bold vision is. My Why is because I want to support providers to meet compliance so that they can provide person-centered care to those they look after. You hear about the horror stories of people having horrendous experiences sometimes its to do with the process. Your Why is important To the success of your business because when you have days which don’t go as well as you expected. It will be your Why which will keep you going. You see the issue as a challenge and work out ways to overcome it. Once you have written you're Why you need to let your team know what it is so they can support you with it. To quote Simon Sinek, "People don't buy what you do or how you do it, they buy why you do it." The purpose should permeate everything you do. https://bit.ly/2zjZ1pH (https://bit.ly/2zjZ1pH)
I started this podcast because new providers coming into the sector and undertaking a regulated activity don't always understand the complexity of the CQC regulations and how they can meet compliance. There are five different areas to look at and that can be quite daunting and it can be difficult to see what evidence you should be providing. My reason for being is to support providers to be compliant so they, in turn, can give person-centered care or treatment to those they look after. The podcast takes the listener on a compliance journey but also looks at business strategy because your business isn't just about the Care Quality Commission Standards. It is wider than that.