CQC We Statement
Theme 4 – Leadership: Learning, improvement and innovation
We statement
We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.
CENTRAL BEDFORDSHIRE SPECIFIC INFORMATION
Employee information:
Within Central Bedfordshire Council (CBC), a quality and governance framework and case audit procedure is in operation.
Good governance means that an Adult Social Care Service recognises its accountability, acts on lessons learned, and is honest and open in seeking the best possible outcomes and results for the people we serve.
Practice audits are completed regularly and in a variety of ways ranging from quality improvement independent audit, 1-1 manager-practitioner audit, peer audit, group reflective audits and periodically management group audits are held.
Where audit identifies practice or recording below the expected standard open and honest conversations will take place to support practitioner continuous learning and development.
In addition to practice audit, themed audits also take place at regular intervals with the intention of completing an evidence based deep dive to identify current research, best practice and service successes and gaps within a focused area.
Thematic audits are primarily concerned with practice, behaviours and scope of knowledge. Reporting and action planning from themed audit is used to inform procedure and practice change.
All audit activity within CBC is reported to the quality improvement manager who collates and identifies possible trends, gaps, and issues that warrant further analysis and action.
Emerging improvement themes and quantity of audits completed is reported upward to the performance board quarterly. Improvements are tracked against baseline figures and in addition qualitative theme analysis is reported for continuous learning and improvement planning purposes.
Audit is an essential part of a learning organisation; it supports continuous improvement, responds to user feedback, complaints and quality assurance.
An audit cycle can address service delivery, professional roles and responsibilities or new ways of working, for example: performance management, supervision, outcomes for adults with care and support needs and their carers, case recording and integrated working.
Audits may be conducted on a short or long term basis, and measure simple or complex issues.
Essentially, an audit involves reviewing the way care is provided against agreed and quality standards.
The audit framework has four stages:
- Preparing and planning
- Identify and agree an area of care which requires audit: this may be an issue highlighted by adults or carers, or is one that has emerged as a high risk for example a new area of service / practice or an area for improvement.
- Agree the aim, objectives and standards: useful guidance includes SCIE or NICE (see Organisations) or local/ best practice standards;
- Reviewing quality
- Develop audit criteria that measure performance against agreed standards: these are the specific elements that describe the quality measurements;
- Collate and analyse data, report results: as part of this stage, the process for providing feedback to those who took part should be agreed and planned. This includes adults and carers, staff and relevant others;
- Improving practice
- Consider results and formulate improvement plan: the results from the report should be discussed by the quality assurance group, senior management team as appropriate, and other relevant meetings. Discussions may include the potential causes of the problems (for example lack of resources, inadequate knowledge / skills, lack of awareness of procedures), which should be improved and how. Discussions may also include adults, carers and staff;
- Implement the improvement plan: it may be that amendments to practice may have already occurred as a result of doing the audit;
- Sustaining improvement
- Repeat the data collection to measure improvement: it is important to re-do the audit cycle for a second time in order to discover whether the agreed actions have taken place.
