Purpose

• To provide staff and managers with a framework for quality and monitoring
• To ensure that the organisation attends to the issue of performance monitoring at the appropriate committees and structures.
• To ensure that BS Care remains accountable to all its

Scope

• This document mainly covers aspects relating to the monitoring of operational performance and methods of reporting on such matters.

Policy

BS Care defines quality service as:

• The provision of Care and support to Service Users and their families which is in accordance with the clearly identified individual wishes of the Service User (or their appointed advocate where it is clearly identified that the Service User is unable or unwilling to express their wishes), fully supporting their human rights, within the confines of legal and fiscal constraints.
• BS Care believes that the management style, policies and day-to-day practices within our organisation should support the human rights of our Service Users by promoting open communications, a culture of problem resolution rather than blame, and the involvement of all participants in the services provided.
• BS Care believes in a culture that is supportive of continuous improvement and maintains a regular auditing and reviewing of the standards of performance in all aspects of the organisation and its personnel, followed by open discussion of strengths and weaknesses and action planning to resolve weaknesses.
• BS Care recognises the importance of quality assurance systems. The term is used to describe the processes and systems that ensure the transparency, replicability, efficiency and fairness of management within an Quality assurance also implies a dedication within the organisation to continually improving the quality of processes and outcomes within the organisation.

Procedure

Mechanisms for monitoring

• BS Care operates monitoring processes that measure the activity and performance of the The primary division of monitoring is between mechanisms operating at an organisational level and those operating at an individual service level.

Admission

• Processes to identify the physical, psychological and social needs of the Service User prior to service commencement.
• Processes to match the Service User to BS Care, which ensure that the stated needs of the Service User are within the services that BS Care is able and willing to offer, and provide a negotiation path to an agreed compromise in situations where BS Care is unable to provide the requested service but the Service User is willing to modify their
• Processes on service commencement to ensure that previously identified requirements of the Service User are made known to all Care staff who will be concerned with the Care of the Service User; ensure that the reception of the Service User is personalised and welcoming; encourage and support further information gathering and recording in order to guide the actions of staff.

Care Planning

• BS Care put in place processes to ensure that Care and support for each Service User is informed by a Care Plan which records sufficient static and dynamic information to provide an individualized and planned service to each Service User.
• Processes to ensure that the Care Plan supports and accommodates the regular reviewing of Service Users’ needs and services, revision of the plan of care, communication of those changes to all persons concerned with the Care of the individual, review of the effect of the changes, followed by further review.
• Individually named members of staff are identified as primarily responsible for the organisation’s interaction with each respective Service User.
• Processes on discharge to other Care facilities/agencies which ensure that Service Users who are transferring are accompanied by sufficient information in order to minimise the disruption caused by the move and to help the receiving organisation to begin providing quality Care services as soon as possible.
• Processes for discharge on death are to ensure that the family and friends of the Service User, and the employees who knew the Service User, are sensitively supported through their grieving process.

Human Resources

• Processes which identify the number and skill-level of employees that is required to deliver quality services to the specified number of Service Users.
• Processes which recruit employees according to the identified skill specification and whose values match those identified as important by the organisation, particularly with respect to the preservation of the human rights of Service Users.
• Processes which inform the employee about the management framework within which they work, the standards of performance required of them, and the opportunities for development which are open to them.
• Processes to support the personal development of the employee through induction and throughout their employment with BS Care, ensuring that the needs of the organisation and the skills of the employees are regularly reviewed and matched via the development programme.
• Processes which ensure that employees are managed in accordance with best practice and statutes, signifying the value of the employee to the organisation.

Administration

• Processes to ensure the financial stability of the
• Processes which identify and accurately record all value transactions between the organisation, the Service User, and the Service User’s representatives, including any sponsoring organisations.
• To ensure the organisation’s compliance with its statutory
• Communication processes to ensure that all employees are fully and accountably informed of information required to carry out their duties.
• A complaints receipt and recording process which promotes the ability of the Service User to control their living environment.
• Processes to control the quality of goods and services brought into the
• Processes which inform the organisation, its employees and customers of the legal, financial and administrative framework within which they interact.
• Processes which check that all audit and review processes are carried out as specified, action planning takes place, planned actions are carried though, and the effects of planned action are fed back into the management process.

Ancillary services

• BS Care has processes to ensure that Service Users’ individual and collective requirements for food are delivered.
• processes to ensure that Service Users’ clothing is adequately cared
• Processes to enable the Service User to maintain their normal life patterns, and their normal connections with their communities.

Health & Safety Monitoring

 BS Care conducts regular internal reporting on the Health & Safety status of This reporting consists of an annual Health and Safety Risk Assessments for our clients and local authorities monitoring returns. Managers are required to complete quarterly Health and Safety Monitoring forms.

• BS Care will comply with, and reports on, relevant Fire and Environmental Health visits by appropriate local authority The Health and Safety procedure sets out how such issues are managed and monitored.

• Where protective clothing or equipment is issued to Staff, this is done for their Our staff are regularly reminded that they have a personal responsibility for their own health and safety and that of others and should ensure that they exercise this responsibility carefully, both through their actions and in the maintenance and care of such clothing or equipment.

Assessing Risk

• Workers should at all times safeguard the wellbeing of the Service User, themselves and their colleagues. When visiting new places or premises other than BS Care, carrying out new procedures, or using new materials or equipment, a risk assessment must be carried If in doubt as to whether a risk assessment has been carried out,

the worker must discuss the matter with the Registered Manager. The Manager will, where an assessment has already been carried out, inform the worker of the identified risks and the methods of controlling those risks. Where a risk assessment has not been carried out, the Manager will either prohibit the un-assessed activity or carry out a risk assessment and inform the worker of the identified risks and the methods of controlling those risks.

Training

• The Training and Development Policy, Appraisal Procedure, Induction Policy and Staff Supervision Agreement set out the detail and activities related to monitoring staff performance. All the above and other related Human Resources policies and procedures can be accessed in the BS Care handbook.

Procedure

Quality will be assured by the existence and adherence to the relevant policies and procedures.

See following Policies and Procedures Table 1.

 

Quality Criteria	Process
Processes to identify the physical, psychological and social needs of the Service User prior to service commencement.	Enquiry Record Sheet Support Planning Pack A-Service Commencement Or Service Start Pack B-Support Plan
Processes to match the Service User to BS Care to ensure that the stated needs of the Service User are within the services. BS Care is able and willing to offer, and provide a negotiation path for an agreed compromise in situations whereby BS Care is unable to provide the requested service but the Service	Support Planning Pack A-Service Commencement Or Service Start Pack B-Support Plan
Processes on services at which ensure that the previously identified requirements of the Service User are made known to all Care staff who will be concerned with the Care of the Service User; that the reception of the Service User is personalized and welcoming; that encourage and support further information gathering and recording in order to guide the actions of staff.	Support Planning Pack A-Service Commencement Or Service Start Pack B-Support Plan
Processes to ensure that Care and support reach Service User are informed by a Care Plan which records sufficient static and dynamic information to provide an individualized and planned service to each Service User.	Service Start Pack B- Support Plan Service User Care Planning Notes Service User Care Planning Policy and Procedure Support Planning Pack A-Service

 

Processes to ensure that the Care Plan supports and accommodates the processes of regular review of Service User needs and services, revision of the plan of care, communication of those changes to all persons concerned with the Care of the individual, review of the effect of the changes followed by further review.	Care and Daily Living Policy and Procedure Care Communication and Information Policy and Procedure Changes in Health State Policy and Procedure Promoting Independence wit Continence Policy
An individual member of staff is identified as primarily responsible for the organisation’s interaction with the Service User.	Choice of Carer Gender Policy and Procedure Key Worker Policy and Procedure
Processes and discharge to other Care facilities/agencies which ensure thatServiceUserstransferringareaccompaniedbysufficientinform ation to minimize the disruption caused by the move and help the receiving organization to begin providing quality service as soon as possible.	Hospital     Discharge     Policy     and Procedure
Processes for discharge on death to ensure that the family and friends of the Service User, and the employees who knew the Service User, are sensitively supported through their grieving process.	End of Life Care Planning Policy an Procedure Hospital     Discharge     Policy     and Procedure
Processes which identify the number and skill level of employees required to deliver a quality service to the specified number of Service Users.	Business Plan Training Policy and Procedure

 

Policies and Procedures Table 2

 

Quality	Process
Processes which recruit employees according to the identified skill specification and whose values match those identified as important by the organisation, particularly with respect to the preservation of the human rights of Service Users.	Principles of customer care I philosophy of care Recruitment Policy and Procedure

 

Processes to inform the employee about the management frame work within which they work, the standards of performance required of them, and the opportunities for development which are open to them.	Absenteeism Policy and Procedure Alcohol and Drugs Policy and Procedure Annual Holiday Policy and Procedure Casual(“Bank”) Workers Policy and Procedure Development Appraisal Policy and Procedure Discipline Policy and Procedure Employee Handbook Family Leave Policy and Procedure General Management Protocol Policy and Procedure Grievances Policy and Procedure Harassment Policy and Procedure Moon lighting Policy and Procedure Notice Periods Policy and Procedure Part-Time Employees Policy and Procedure Poor Performance Policy and Procedure Principles of customer care I philosophy of care Public Holidays Policy and Procedure Sickness Absence Policy and Procedure Staff Rota Policy and Procedure Statement of Main Terms and Conditions of Employment-Variation  Statutory Time Off Policy and Procedure Supervision Policy and Procedure Temporary Workers Policy and Procedure
Processes which support the personal development of the employee through induction and throughout their employment with us, ensuring that the needs of the organisation and the skills of the employees are regularly reviewed and matched via the development
	Induction Policy and Procedure
programme.                                                                         Recruitment Pack-Induction and Job Start Training Policy and Procedure
Processes which ensure that employees are managed in accordance with best practices and statutes, signifying the value of the employee to the organisation.	Employee’s Appearance Policy and Procedure Employee Termination Record Keeping Policy and Procedure Equality and Diversity Policy and Procedure Maternity Leave Policy and Procedure Monitoring of Business Communications Policy and Procedure Working Time Regulations Policy and Procedure

 

 Policies and Procedures Table 3

 

Quality	Process
Processes to ensure the financial stability of the organisation.	Business Plan Financial Administration Policy and Procedure
Processes” which identify and accurately record all value transactions between the organisation, the Service User, and the Service User’s representatives. Including any sponsoring organisations.	Financial Administration Policy and Procedure Service User’s Finances Policy and Procedure
Processes which ensure the organisation’s compliance with its statutory responsibilities.	Access to Information Policy and Procedure Accident and Incident Reporting Policy and Procedure Archiving, Disposal and Storing of Records Policy and Procedure Disabled Workers Policy and Procedure First Aid Policy and Procedure Health & Safety Policy and Procedure Moving and Handling Policy and Procedure Tender Information Policy and Procedure
Communication processes which ensure that all employees are fully and accountably informed of information required in order to carry out their duties.	Action Planning Policy and Procedure Administration Communication and Action Communication Policy and Procedure Document Publication Policy and Procedure Management Meetings Policy and Procedure Personnel Communication and Action Quality Meetings Policy and Procedure

 

A complaints receipt and recording process which promotes the ability of the Service User to control their living environment.	Advocacy Policy and Procedure Complaints, Suggestions and Compliments Policy and Procedure Service User Communication with Organisation Policy and Procedure Service User Satisfaction Survey- Domiciliary Care
Processes to control the quality of goods and services brought into the organisation.	Purchasing Policy and Procedure Receipt of Delivered Goods Policy and Procedure
Processes which inform the organisation, its employees and customers of the legal, financial and administrative framework within which they interact.	Service User’s Finances Policy and Procedure Service Users’ Handbook Statement of Account Policy and Procedure
Processes which check that all audit and review processes are carried	Administration Audit and Action Plan Care Audit and Action Plan
	Personnel Audita nd Action Plan Management Meetings Policy and Procedure
though, and the effects of planned action feedback into the management process.

 

 Policies and Procedures Table 4

Quality Criteria	Process
Processes to enable the Service User to maintain their normal life patterns, and their normal connections with their communities.	Promotion    of    Recreational      Activities Policy and Procedure Service Start Pack B-Support Plan Support Planning Pack A- Service Commencement

 

 Auditing 

• Each area      to      audit      is      supported      by      a      full      policy      statement (purpose/scope/policy/procedure).
• The purpose of audit is to verify the implementation of stated and documented policy, procedure and standards.
• Audit reports will identify action required to achieve
• Employees will be involved in the audit process, and results will be reported to
• Specific communication strategies will be implemented to support audit and the carrying out of remedial action and improvements, such as Quality Meetings, Team Meetings, Staff meetings and Management Meetings

Confidentiality Policy and Procedure

 Purpose

• To ensure that sensitive information is only shared for the purpose of a Service User’s wellbeing such as ensuring the smooth running of a medical procedure or protecting the person from abuse.

• To ensure that all information is collected, recorded, stored, shared and disposed of in the best interests of the Service User and staff with regard for their human rights and in line with legislation.

• To ensure the Service User and staff are aware of the organisation’s confidentiality policy and procedure.

Scope

 All staff and everyone involved in the care or support of Service

Policy

The Service User’s rights to confidentiality must be safeguarded in accordance with the common law duty of confidentiality and Article 8 of the Human Rights Act 1998. The Care service employee will use information only in the best interests of the Service User and where possible with their express consent.

• All information about Service Users and staff, verbal, written, electronic or photographic I video I audio recording is managed in line with the Data Protection Act

• Confidential Information should be shared in line with the Caldicott Principles 1998. Information about Service Users may also be covered by the Access to Health Records Act 1990. Procedure

Vernal Exchange of Information

 In order for staff teams to work consistently with the people they support, it is necessary for verbal information to be exchanged.

• This may take the form of “team meetings”, or “handovers11 The service must provide areas where these activities can take place without being overheard.

• Staff will be trained and advised to only conduct discussions in private areas with people who “Need to Know” the information in connection with their work with the Service User.

• Verbal breaches of Confidentiality will be treated with the same seriousness as a written breach.

Data Collection and Storage

• Staff must ensure that any information collected and stored is limited to that which is essential for the care and safeguarding of the Service User. This relates to personal data and health information essential to establish individual needs and provide staff with the means to plan care and support.

• Any information collected and stored about staff is limited to the essential information needed for their employment with the organisation.

• Staff must retain information and data securely in locked storage when not in use. Electronic data should be password protected and access limited to essential users only. Computer screens should be located so that personal data is hidden from general view. Photographs and video or sound recordings should not be shared without the express consent of Service Users, staff members or their legal advocates.

Disclosure

 Confidentiality Policy and Procedure

 

• Data and information should only be shared with those identified as eligible to access it. Service User data must only be shared for the purposes of ensuring individual needs are met and for the safe delivery of care. Information passed to a care worker may therefore be shared with members of the care team where they are concerned with the care and treatment of the Service User. Staff must be advised of the requirement to confirm the identity and right of access of any third party seeking information about a Service User or BS Care in writing, by telephone or in person before any disclosure is
• Consent to disclose Service User information with family members should be obtained from the Service User. There are many good reasons why informal carers should be informed and involved with the professional care of their loved one. Care should be taken, however, if a family member shows an unusual interest in their loved one’s financial If family members wish to pass on their concerns or views to a member of care staff this does not constitute a breach of confidentiality by the care staff.

Consent

• As far as reasonably practicable, written consent to the use of personal information should be gained from each Service User or their advocate. Staff should inform the Service User when gaining consent of the specific details of the information/action to be shared and with whom. This should form part of the information provided at the outset of service provision.
  1. If the Service User lacks the mental capacity to consent to information being shared, staff may share information if it is in the Service User’s best interests (in accordance with the principles of the Mental Capacity Act 2005). Staff should still clearly explain to the Service User the reasons for the decision to share information and accurately record

1. Where a Service User has appointed a Lasting Power of Attorney under the Mental Capacity Act 2005 that person should be consulted where information is to be shared in someone’s best interests.

• If there are any concerns in these areas you should seek advice from your supervisor.

• Access to data and records must be managed in line with legislation. Permission to access information may be sought by Service Users or their advocates in writing and access must be managed appropriately. It is good practice to involve Service Users with the collection and recording of personal data as this ensures focus on the needs and rights of each individual. This paragraph should be read in conjunction with the Access to Information Policy and Procedure.

• The use of social media should be avoided unless strict management of information is assured to protect the
• rights of all Service Users and staff members. Staff must not discuss confidential information about Service Users or staff in any place where third parties might access it, such as on an outing.

• Staff must ensure that all data and information held pertains only to that individual. Care must be taken to limit recording to identify only the Service User or staff member whose record it is, and not to include sensitive identifiable data about others’ Care Planning files and record entries.
• Confidentiality with respect to a Service User may only be breached if:
  1. Where information is required by statute or court

1. Information suggests the Service User is at risk of harm to themselves or from others, or others may be at risk of harm from the Service User, and where the passing on of information would be in the person’s interest, or the wider public interest.

• Information, if withheld, could put others at risk; and where the passing on of information would be in the public interest.

1. Where the Service User may have broken the criminal law and where there is justification in the public interest to breach confidentiality, Section 115 of the Crime and Disorder Act 1998 gives a power (but not an automatic duty) to organisations disclose information to the police ‘for the prevention, detection and reduction of crime’. This applies in England and Wales and in Scotland (where the Crime and Disorder Act is amended by the Criminal Justice (Scotland) Act 2003).

• Inappropriate breaches of confidentiality by staff members will be treated as a disciplinary matter.

Disposal of Confidential Information

In the event of a Service Uses death or leaving the service, records should be removed from circulation and retained in secure archive storage. Care records should be kept for not less than 3 years, but it is good practice to retain records for up to 20 years to meet insurance requirements.

When confidential information no longer needs to be stored, destruction of paper records must be by shredding to ensure no risk of third parties accessing sensitive data. Destruction of electronic records by deletion must be undertaken by means that ensure no future retrieval is possible.

Archiving, Disposal and Storing of Records Policy and Procedure Purpose

• To ensure compliance with statutory and insurer’s requirements on information

• To comply with statutory requirements for

Scope 

• All Service Users’, employees’, financial, health and safety and maintenance records of BS Care .

• Note: The timescales for retention in this policy are driven by liability requirements under product and service liability regulations. The source of these timescales, which generally exceed Care Regulator requirements, tend to be Insurers, in whose interest it is for the past or present client to retain records allowing effective investigation and defence of claims, which can occur many years in the future. For example, exposure to asbestos.

Policy 

• Records will be archived and stored in a manner which complies with statutes, regulations and insurance requirements, held in secure and safe storage, and are

• Documents and other media will be disposed of in a manner which protects

Procedure 

• All archived records which contain the name and/or personal details of a Service User or employee will be stored with the same security restrictions as if they were live. Documents which require locked storage and/or restricted access when live must be similarly protected when archived.

 Retention and Storage 

• Staff rota records will be archived in a safe place, with the contents recorded on the outer package, and retained for 20 years.

• Records of agency staff will be archived in a safe place, with the contents recorded on the outer package, and retained for 20 years.

• Records of food provided will be archived in a safe place, with the contents recorded on the outer package, and retained for three years.

• Records of Fire practices, tests of equipment and remedial actions will be archived in a safe place, with the contents recorded on the outer package, and retained for three

• Records of all visitors will be archived in a safe place, with the contents recorded on the outer package, and retained for three years.

• Service User’s records will be archived in a safe place, with the name of the Service User recorded on the outer packaging, for a period of 20 Regulatory authorities require the retention of records of detention, restraint, deprivation of liberty and incidents and occurrences and incidents for a period of three years, but it is recommended that these records are held with other Service User records for the full period of 20 years to meet insurance requirements.

• Employee records will be archived in a safe place, with the name of the employee recorded on the outer packaging, for a period of 20 years.

• Accounting records will be archived in a safe place, with the financial year recorded on the outer packaging, for a period of 7 years.

• Final annual accounts will be archived in a safe place, with the financial year recorded on the outer packaging, for a period of 30 years.

• Company legal records will be archived in a safe place, with the financial year recorded on the outer packaging, for a period of 7 years.

• Health and Safety records, including occurrences and incidents which require notification to regulatory bodies will be archived in a safe place, with the contents recorded on the outer packaging, for a period of 20 years.
• Maintenance records, including electrical testing, fire safety water testing, and medical gas safety storage and transport, will be archived in a safe place, with the contents recorded on the outer packaging, for a period of 20 years.

• Purchasing records, excluding medical devices and medical equipment will be archived in a safe place, with the month and year recorded on the outer packaging, for a period of 18 months.

• Purchasing of medical devices and equipment records will be archived in a safe place, with the year recorded on the outer packaging, for a period of 11 years.

• Money or valuables records will be archived in a safe place, with the year recorded on the outer packaging, for a period of 4 years.

• Policies and procedures will be archived in a safe place, with the year recorded on the outer packaging, for a period of 4 years.

Disposal of Documents

• Any document which may identify or allow the identification of any person and/or contains personal information must be shredded before disposal.
• A cross cut shredder is the preferred method of disposal; failing that, a fine cut single pass shredder must be used
• A shredder must be supplied at all locations within the establishment wherein documentation is separated out for disposal, in order to reduce the risk of whole stored documents being erroneously disposed of whilst in transit.
• For establishments with large volumes of documentation disposal, the preferred method will be disposal through a registered document disposal contractor which shreds the documentation on site where the process can be monitored by the

Disposal of Electronically Stored Data

• Computer hard drives which may contain personal information must be wiped clean before disposal or sale using appropriate “shredding” Deleting files or routine formatting do not provide sufficient safeguard from the retrieval of data.
• Other data storage media which may contain personal information, such as memory sticks, must have the data overwritten in a manner that fills the drive before disposal or sale, preferably using specialist software.
• Optical storage media which may contain personal information, such as COs and DVDs, must be physically destroyed before disposal.

• Magnetic storage media which may contain personal information such as tapes must be physically destroyed before disposal.
• If in doubt, physically destroy the data storage

Signed:	BA
Date:	1st June 2022
Policy review date:	30th Jan 2023