Social care quality improvement

September 2015: Please note that HQIP is currently reviewing its social care guidance and resources. The text below remains current, but is archived content. Please see our News section for for further updates or subscribe to our eBulletin.

Contents:

  • Background to quality improvement in social care
  • Dementia care audit: pilot in care homes
  • Social care guidance and resources
  • Social care quality improvement FAQs

Background to quality improvement in social care

Introduction

All social care practitioners, teams and provider organisations want to ensure that they deliver the best possible care they can, and that the services they offer meet best practice standards. Excellent practice already exists in many care settings, confirming the sectors' on-going commitment to quality. There is a long tradition of quality improvement in the sector and there are many examples of inspiring and imaginative practice, within individual organisations and at the sector level.

However, as the process of continuous quality improvement is still a developing field in social care, although there is a well-developed tradition of QI, as yet there is no systematic and sector-wide approach to quality improvement. Quality Cycles, used in comparable settings such as healthcare, where they are known as clinical audit, offer the potential to provide such a sector wide approach.

In the coming months we will look to promote the agreed approaches - changing the language and process as needed- through consultation, to pilot these in suitable settings, and to find early adopters to trial, test and refine the methods. Over time we will develop an education and training programme, and possibly national review projects that mirror those in healthcare. We will work with key organisations to develop sector specific ‘audit' tools for specific care environments.

We are pleased to be working in partnership with the Social Care Institute of Excellence (SCIE) as we take this work forward.

Background and rationale

Quality matters in care services.

In healthcare, clinical audit is well established and is a fundamental building block of clinical governance, assuring the quality of services and driving continuous improvement. In contrast, the social care sector, despite serving a large and often vulnerable client group, has no nationally agreed framework and wider system of quality assurance and improvement to mirror that in health.

Whilst there is a genuine commitment to assuring and improving the quality of services, in the absence of a central approach, local providers often develop ad hoc systems responding to local needs and commissioning requirements. Not only does this create challenges for providers and their commissioners, but it limits comparability and usability from the perspective of someone using services.

Care audit is a means to showcase excellence across the sector, to identify unmet need or unacceptable variation in care, and to drive improvement where necessary.

We have to prove the quality of the care that we deliver and account for the resources that are allocated, to verify that people who use our services are receiving the best possible care in relation to these resources. We also need to be prepared to compare them to other models of care.

People who use services, family members, carers and advocates all want care to be of the highest quality and to be able to make meaningful choices based on clear, transparent and comparable information.

Increasingly providers want and need to understand how they can improve care, and demonstrate the quality of their services in a competitive marketplace.

In turn, commissioners need robust evidence of the quality of a provider's practice and the ability to compare services across the sector.

With a shift towards achieving high quality outcomes for people who use services and an increasing focus on value for money, there is urgent need for these goals to be supported by high quality intelligence and information systems.

Care audit is aligned with the expectations and requirements of government policy including departmental aims around personalisation, dignity, integration of health and social care, end of life care and dementia strategies as well as the requirements of statutory regulation.

The benefits of care audit - care audit can help to:

  • Work in partnership with people who use services to prioritise local concerns
  • Provide a check for care providers i.e. "are we actually doing what we think we are doing?"
  • Implement and sustain improvements in services
  • Provide evidence of current practice against national guidelines
  • Provide evidence about the quality of care in a service to establish confidence among stakeholders
  • Deliver a return on investment.

A person-led approach

High quality care services equal a high quality experience for the person using the service, carers, advocates and family members. Good care services put the people who use them at the heart of improvement work, and measure the things that are meaningful and important to the person in receipt of care.

Ultimately, a good outcome in social care will be determined by the person in receipt of that care, and delivered in partnership with the responsible professional organisation, team or individual. Much time has been given to thinking about how the essential process of care audit can best be utilised to make sure that the care people receive is not only competent in technical delivery but also that it meets the subjective needs of each individual.

Drivers and enablers

The social care sector is currently experiencing a convergence of drivers and enablers to establishing a shared approach to quality improvement. These provide additional impetus to the genuine desire within the sector to improve quality and professionalism:

  • Organisational commitment to quality: Our work with leaders in the social care sector has underlined how practitioners, teams and services want to ensure that they provide the best possible care, and that the service they offer is in line with best practice standards. This helps to ensure better use of resources by improving the effectiveness and efficiency of care, potentially saving money.
  • Satisfying service users and commissioners: In an increasingly diversified and competitive environment of care delivery and personal budgets, providers need to be able to demonstrate that their services are high quality, meet the expectations of the people who use services, and demonstrate commercial edge.
  • Meeting the requirements of regulation, inspection, registration and accreditation: Service providers at every level, from individual practitioner through to whole organisations, are increasingly required to provide evidence of the quality of what they do and that they have processes in place to ensure the quality of care they provide.
  • Focus from central government: Social care is high on the Government's agenda, with a focus on the integration of health, social care and education to reflect the overlap between these areas of life.
  • Development of national standards: Evidence-based quality improvement requires quality standards and guidelines against which practice can be measured and the findings used to develop and improve practice. As NICE starts to fulfil its extended remit in developing quality standards for social care, these will provide a building block to support the social care sector to review and benchmark performance.
  • Professional development and regulation: Professionals in social care want to be able to show that their work is effective and leads to real changes for service users and society. This desire to assure the quality of their work is now being incorporated into professional regulation. For example, the Health Professions Council (the UK-wide regulatory body responsible for setting and maintaining standards of professional training and skills and health) has adopted the key messages around clinical audit near wholesale from healthcare guidance into its regulatory framework for social care.

Dementia care audit: pilot in care homes

Background

In 2013 the government described its plan to change the care and support system in its White Paper ‘Caring for our future: reforming care and support’. As part of quality-related plans for care and support, it stated the government’s intention to ‘pilot a new care audit in 2013 to highlight how well residential care providers are delivering dementia care, encouraging them all to improve their care’.

The Department of Health commissioned the Healthcare Quality Improvement Partnership (HQIP) – which runs the national and local clinical audit programmes – to lead on the development of an online care audit tool to be used to improve the care of people with dementia in care home settings. The aim is to test whether the benefits of a national audit approach, as used successfully in the NHS through clinical audit, can be realised in social care, if suitably adapted for the sector.

The Care Audit Advisory Group and Project Delivery Team

The Care Audit Advisory Group was set up in 2013 and met quarterly to inform and guide the delivery of the pilot. It was chaired by Pat Jones-Greenhalgh, national dementia lead for the Association of Directors Adult Social Services (ADASS), to represent people who use care services, carers, care providers, commissioners, regulators and standard-setters and includes representatives from organisations such as the Registered Nursing Home Association, National Care Forum and Skills for Care.

To deliver the work, an expert project team was put in place, whose members were:

  • The Department of Health which has commissioned the pilot.
  • HQIP, responsible for the overall project management and development of audits within social care
  • The Royal College of Psychiatrists, developed content and questions for the audit
  • The Social Care Institute for Excellence, recruited care home sites, developing benchmarking software and providing training and support for the pilot
  • Clinical Audit Support Centre partnering with Healthcare Quality Quest, evaluated pilots

Results of the Dementia Care Audit Pilot 2013/14

The Dementia Care Audit Pilot took place between February and March 2014, testing the concept of a national care audit in the social care sector (focused on dementia care).

The evidence and results from the Impact Evaluation Report, was presented on the 29 April 2014, to the Care Audit Advisory Group. The group produced further recommendations for the Department of Health to consider and a final response was provided by the Department, summarized below:

  • The original terms of reference for the pilot project were as a first step in testing proof of concept for a nationally supported audit approach in social care; and whilst the evaluation suggested there was some desire, it did fall short of the original stated aims.
  • In order to fully meet the objectives further significant investment would be required and the Department of Health would be unable to provide this at present.
  • To ensure important contributions and the learning from this project are not lost the Department of Health is therefore working with the National Institute for Health and Care Excellence, the Social Care Institute for Excellence and the Think Local Act Personal quality forum to develop a stronger evidence base for improving quality in the sector.
  • If we can secure a stronger evidence base for what works then further roll out of a care audit approach may be possible subject to funds being available in a future year.
  • In light of this, DH thought it prudent to disband the Care Advisory Group; however, should this work be picked up again we could reconvene if it is felt beneficial.

What next for Social Care Audit?

HQIP believes the accumulation of interest and willingness demonstrated by the sector over the initial phase of the project substantiates a case for further developments in support of Social Care Audit. In light of this, a range of potential activities will be considered by the HQIP Board in December. These proposals will be:

  • Promoting audit practice at a local level by: a) Identifying & promoting good practice; b) Building regional support networks for QI workers in social care; c) Developing resources & learning tools.
  • Working in partnership with our key stakeholders such as NICS and SCIE and engaging with Local Authorities and/or Clinical Commissioning Groups to develop an online Social Care Audit Tool for Care Homes and other sectors.

Further information

Please contact Simon Marrow, HQIP interim senior project manager via simon.marrow@hqip.org.uk

Social care guidance and resources

Care audit resources for social care professionals

HQIP will develop two guidance resources for social care professionals looking to develop care audit within their local care setting.

Both 'Care audit: A guide for leaders' and 'Care audit: A practice manual for frontline leaders and teams' will be produced in consultation with the sector, to give practical advice for enacting care audit within social care settings.
This guidance will show how a simple, proven approach, care audit, is flexible enough to be used in almost any social care environment, from a single team or care home to a large national provider organisation. These resources are due for publication in 2014.

Care audit: A guide for leaders

This guide will describe the benefits of care audit to people using services, organisations, teams and individuals, provides an overview of the process and set out the role of operational and strategic leaders in implementing care audit within their organisation, as part of a whole-systems approach to quality and service improvement.

Care audit: A practice manual for frontline leaders and teams

This manual will set out a step-by-step approach to carrying out care audit using a quality improvement cycle approach.

At its most basic, a care audit involves reviewing the way care is provided against agreed and proven standards for high quality, taking action to improve practice to meet these standards, then re-measuring to identify and make further improvements.

By applying systematic approaches to reviewing the impact of care within the sector, organisations themselves and the people using their services can understand whether all the different elements that contribute to quality as a whole are working.

Further details will be announced in the eBulletin.

Social care audit FAQs

What is HQIP's definition of care audit?

‘Care audit is a quality improvement cycle that involves review of the effectiveness of social care and social work practice against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care, experience and outcomes for people who use services and carers.'

What are the benefits of care audit for people who use services?

Care audit is all about taking a personalised approach to care: how people who use services, their carers and the wider community can work in partnership with care professionals to enhance the quality of services provided.

What is the thinking behind ‘person-led improvement'?

People who use services and their relatives must be at the centre of decisions about care. Their voices and those of their advocates must be heard, and their choices and priorities known and respected.

What is meant by ‘supporting people to make informed choices'?

It is crucial that people who use, or are about to begin using, a care service have access to good information that will help them decide which service to use.

Why is it important to design services in partnership with the people who use them?

The perspective of those who use services is fundamental to understanding how well a service is doing and how it can be improved. Involvement is key throughout the care audit process, from identifying topics, defining standards for high quality and contributing to data collection, to suggesting improvements and agreeing action plans.

How can care audit demonstrate quality?

Even those who are already using a service are often unclear about what they should expect or the quality of the service they are receiving. Care audit means more transparency, which can help to empower people who are already using services.

What are the benefits of care audit for providers?

In a sector where increasingly people are being encouraged to ‘commission' their own care (e.g. through the use of personal budgets) providers need to understand the quality of their services so they can continuously adapt them to reflect the needs and preferences of those people who are in receipt of care.

  • Care audit can help providers to address quality issues systematically and explicitly, providing reliable information to confirm quality and highlight areas for improvement.
  • Care audit can help providers to identify and promote good practice leading to improvements in service delivery and better outcomes for people who use services.
  • Care audit can help providers to ensure better use of resources and provide information to confirm this to others; a key benefit in terms of enhancing organisational reputation.
  • Care audit can provide education and training opportunities through the identification of need and help staff to demonstrate competence in key areas of care.
  • Care audit helps different organisations to match their practice to the standards of the best. Different organisations may see what standards others are working to and adopt them - if organisations publish the findings from their care audits, other providers are encouraged to ‘raise their game' to match or exceed them.

What are the benefits of care audit for commissioners?

A huge percentage of social care services, whether directly commissioned by local authorities or through personal budgets, are publicly funded. Both commissioners and providers need to demonstrate that public funding is spent appropriately on good quality services.

Care audit can provide commissioners with better information at provider level, over and above that supplied for compliance with statutory requirements and the CQC's Essential Standards for Quality and Safety.

How does care audit differ from clinical audit?

Clinical audit is an approach that is ‘part of the furniture' in healthcare, used for many years in the NHS as a means to drive up quality. In turn, care audit takes place in social work and social care settings, and as a result, is intended to improve the quality of social care services.

Although the principles of a care audit cycle - review and action - are very similar to a clinical audit cycle, the method has been adapted and enriched in consultation with the sector to ensure it is fit for purpose. Improving outcomes in social care presents a different challenge as this type of review often starts from a different point.

Social care work seeks to start with the person as the determinant of how their needs are assessed, rather than in healthcare where the starting point is the clinical perspective of what their problems might be. Healthcare quality improvement has tended to focus on procedures, interventions and conditions without looking at the whole person. Care audit can place a greater focus on a person's whole journey rather than looking at specific interventions for specific parts of their body!

Healthcare quality improvement can usefully learn to focus on patient experience and the sense of the person as a whole being. In turn, social care could benefit from the tradition of systematic quality improvement, with all the gains it could bring in suitably adapted form, to social care settings.

Can care audit support health and social care integration?

Providing high quality, integrated services is a shared goal across health, community and social care services. Through use of a systematic approach, audit can provide a consistent means for services to work together to provide the highest quality of care for recipients, especially where care services interface and overlap.

Several of the national audits that HQIP supports, including Falls and Bone Health in Older People and Continence Care, collect information from social care settings, and illustrate some of the challenges of supporting people and providing joined up care, across multiple care environments.

However, challenges remain, including whether it is valuable to develop measures that reach across the whole care service journey, and if so how this could be approached.

Is care audit another term for performance management?

Care audit is about improving care, not monitoring performance and most audit has nothing to do with any external review process; it's an internal self-review process.

Care audit differs from performance monitoring or research because it is focused on making improvements to the service. These can be quite small changes to things you do every day that make a difference to the people using the service.

Care audit is not about finding faults or blaming individuals, it is about sharing responsibility for improving the service. Such a discussion preferably requires an atmosphere of trust to encourage an honest, open and constructive dialogue.

Where does care audit fit with statutory regulation and CQC requirements?

Care audit helps to showcase and promote excellent practice where it exists and look at actions for improvement where care can be bettered.

Where practice meets and exceeds compliance with CQC's Essential Standards of Quality and Safety, care audit is a means to demonstrate this.

Does this mean more paperwork?

Care audit is not care audit if it is an exercise in pointless box-ticking.

Data rarely speak for themselves. This is why the next steps in the audit cycle - taking action and making adjustments - are of fundamental value: where audit is properly conducted it is about change. The whole cycle has to happen, not just the review of existing practice, but also the next steps taken by a professional or team to ‘close the loop' and take action to improve things next time around.

Is care audit expensive to carry out?

Care audit can be undertaken by existing staff, so organisations do not need to invest in external consultancy. However, staff time will need to be released to undertake the work, and staff, particularly those leading the work, are likely to need some training and support when they first start undertaking care audits.

Will care audit lead to additional costs to my organisation?

Many changes that improve services can be made at little or no cost. However, the care audit may well identify some training needs or other developments to support the service which have a cost attached. The investment in these is likely to be offset by the improvement in the service leading to better outcomes and potentially leading to cost savings or improved business performance elsewhere.

What is outcome measurement?

Outcome (noun): A final product or end result; consequence; issue

Outcome measurement is a way of measuring the change in a person's current or future status that can be attributed to preceding social care intervention. Outcome measurement can be used for clinical care, social care, audit and research purposes.

Outcomes are at different levels - national, organisational, local community, individual user. Whilst there is a general desire to move away from a narrow focus on the outcomes of specific services and towards user-focus, there are associated challenges. Our forthcoming resources address these challenges in more detail.