Quality Assurance Policy

1. Purpose

Quality assurance is how we know — not assume — that care is safe, effective and kind. This policy sets out the systems we use to monitor our own performance, act on what we find, and evidence it to the Care Quality Commission, commissioners and the people we support.

It applies to every part of the service and is owned by the Registered Manager.

2. The governance framework

• Daily — visit completion checks, missed visit escalation, and review of incident reports submitted in the previous 24 hours.
• Weekly — management huddle: staffing, safeguarding, complaints, incidents and any open actions.
• Monthly — management meeting: audit results, key performance indicators, complaints and compliments, training compliance, and progress on the improvement plan.
• Quarterly — Board meeting: quality report, risk register, safeguarding data, workforce data and financial performance.
• Annually — self-assessment against the Single Assessment Framework, mock inspection, review of all policies, and the annual statement published on our website.

3. Audit calendar

4. Key performance indicators

We monitor and set targets for:

• percentage of visits delivered as planned (target 97% or above)
• percentage of calls starting within the agreed window (target 95% or above)
• care plans reviewed within the last 12 months (target 100%)
• medicines errors per 1,000 visits, and the proportion with actions closed
• safeguarding referrals made within 24 hours (target 100%)
• complaints answered within 28 days (target 100%)
• mandatory training compliance (target 95% or above)
• supervision completed every three months (target 100%)
• staff turnover, and vacancy rate
• number of compliments received, and themes

Any indicator outside its target for two consecutive months triggers a written improvement action with an owner and a date.

5. Listening to people

• An annual survey sent to every person we support and, with consent, their family.
• A quarterly telephone check-in with a sample of people and families.
• Comments captured at every review.
• Complaints and compliments analysed for themes, and reported in the quality report.
• A "you said, we did" summary published and shared with staff.

6. Care record and practice assurance

Senior carers complete a minimum of one unannounced spot check per worker per year, observing dignity, respect, communication, infection control, medicines practice and record quality. Findings are discussed in supervision and recorded. Where practice falls short, we act immediately and consider whether the concern meets the safeguarding threshold.

7. Learning from incidents and safeguarding

Every incident, complaint and safeguarding concern is reviewed to identify root cause. Learning is captured on a single action log with owner and due date, and shared with the whole team. We check that actions have actually changed practice at the next audit cycle — completing a form is not the same as fixing a problem.

8. Inspection readiness

We maintain an evidence file mapped to the CQC Single Assessment Framework, containing for each quality statement:

• the policy and procedure relied on
• the records that demonstrate it in practice
• the audit results and actions taken
• feedback from the people we support and staff

An annual mock inspection is carried out using the CQC assessment framework, and the resulting action plan is approved by the Board. We also notify CQC of all events required under Regulation 18 without delay.

9. Roles

• Registered Manager — accountable for quality and for this policy; reports to the Board.
• Quality Lead — coordinates the audit calendar, collates indicators and maintains the improvement plan.
• Senior carers — carry out audits, observations and spot checks.
• All staff — report incidents, contribute to reviews and take part in improvement.

10. Review

This policy, the audit calendar and the indicator set are reviewed annually, and whenever regulation, guidance or the needs of the service change.