Managing Audits

What is an audit and why do I need to do it?

Audit introduction

An audit in any social care provision is the process used to compare the care you provide now, today, against an agreed view of what good quality care looks like.

Audits however are not an end in themselves. Just doing an audit is not enough, audits are only one part of a whole process to learn and improve quality.

You must be able to evidence that you use the information from audits to improve the quality and safety of your service. You must use the information from audits to plan what you need to do to get from where you are now in terms of quality and to where you need or want to be. You must also be able to track and evidence the progress of those improvements. through further audits.

If you don’t know where you are, and you don’t know where you are going, you’re lost.

This whole process audit, planning and monitoring, forms an improvement and quality cycle which is what CQC is looking for especially in well led. CQC are looking for evidence that you are monitoring, through audits and other processes such as surveys, complaints, falls logs safeguarding etc what is happening in your service and then using that information to improve quality and prevent similar things such as falls or safeguarding’s happening to others in the future wherever possible.

Audit overview

Any audit is simply a series of questions based on an agreed view of what good quality care looks like.

For example, if one of the audits you want to carry out is around dignity one of the questions you may choose to ask is "Do staff treat residents with dignity?"

To robustly answer that question, you need to know what good quality dignified care looks like. You also need to ensure that everyone in your organisation is aware of and agrees on that view of dignity in care.

In this case rather than just make up your own list of things you may choose to use the
SCIE dignity in care standards. This is nationally agreed best practice, not something that’s just made up but is clearly based on evidence and is something other people including contracts and CQC will recognise as best practice.

There are a range of information sources that provide clear standards for what quality care looks like and links to some of these have been included at the bottom of this page.

Once you are clear about these standards across the audit process, you can then assess if staff behaviours, the environment that care is being provided in and the care being provided meets those defined standards.

The most important model of quality care is obviously the CQC framework, they are the regulator, and you MUST meet their stated standards of quality, their model of quality. the Key Lines of Enquiry, the Safe, Well led, Caring, Effective and Responsive.

Information from Government or Government sponsored bodies and professional organisations such as NHS, SCIE, NICE, Royal College of Pharmacy etc all fit into the KLOES and provide further explanation and clarification of the KLOES so it’s not one or the other. They fit together to form a robust picture of quality. Often the additional information is around exceeding or going beyond the CQC standards

Audits should not only identify where there are gaps and where care is below standard but also identify where you are providing good quality care, celebrate the good and provide positive feedback and accolades to staff for good practice as well as dealing with the issues.

After the Audit

Once you have completed your audit you must address those issues, addressing poor practice but also building on what is good to make it even better.

From a regulatory viewpoint knowing about something, having it written down in an audit, you must be able to evidence that you have done something about it. Not being able to evidence that you have addressed that issue is a quick way to Requires Improvement or worse in Well Led.

You must be able to evidence that you have used the information from audits to improve the service.

One way to address the issues is by using a PLAN-DO-REVIEW model (part of the KOLB learning cycle).

You have identified the issues during your audit:

You then PLAN what you are going to do about it.

You then DO the PLAN - you tell people what is required of them and get them doing it.

You then REVIEW the progress of your plan. -if the plan is achieving these desired aims great - if not sit down and review the plan, what is working what is not working and why and then update the plan to address this.

Then go round again with the new plan implement (do) and review

Repeat this cycle until you can sign off the item as having been addressed to your satisfaction as the registered manager and it has resulted in a permanent change.

What questions should I be asking in an audit?

As stated above the key guidance as to what good care looks like are the CQC Key Lines of Enquiry (KLOE's)

This is always your first point of call. The CQC publish a lot of information on what good quality care looks like and how they will form a judgment on the care you provide on the link above.

In addition to the KLOE's a range of specialist organisations provide information on good quality care these are what CQC use to inform a their KLOE. For example, in the case of dignity, the Social Care Institute for Excellence dignity page would be a very good starting point for anyone looking to undertake a dignity audit.

Similarly if you are undertaking a medication audit the National institute for Clinical Excellence publish guidance, which is followed by CQC.

Private and voluntary organisations, for example the Alzheimer's Society, provide some good guides on providing high quality dementia care.

These and other links can be found at the ned of this document.

Practical audits and action plans

The audit tools

Once you are clear on what good quality care looks like and the questions you need to ask then you can begin your audits.

You can answer your audit questions in a couple of ways.

By what you or someone you delegate observes (they must record their observations though)

By what has been recorded by staff, including what has been seen by others.

As a registered manager you are legally accountable so assume nothing and don't believe anything until you have seen it yourself or you have it written in a signed and dated document.

These are the only forms of evidence admissible in court, coroners or otherwise. Hopefully you will never have to test this but it is better to be prepared.

For an audit to be useful it must contain clear open questions that are answered by objective statements.

The more information you can gather the better

If it’s just a tick yes or no, then yes you can count up the yes’s, and the no’s, and record 85% of audit questions answered yes Yippee. But it’s difficult to check.

This model can work if everyone is very clear about what standards they are auditing against and everyone’s standards are the same and the audit is diligently carried out,

But if you are having issues for example items not being picked up in audits then the more information you can gather from your audit the better, so it may be a yes/no tick but with an additional requirement that whoever is doing the audit provides a written overview of what they have based that yes/no judgement on, then you can check and hold people to account. This is also a useful route if you are trying to evidence how you are meeting the action plan and the progress being made, CQC or others can see what has been checked and assure themselves of the quality of the audit

So tick yes, the bathroom met the agreed standards.

The evidence that this was the case is

Auditor checked under toilet seats, and under bath lift seats as well as under bath and behind pedestals all clean, bins emptied staff observed cleaning to required standard.

The registered manager or any external auditor then knows clearly what was done and what the judgment was based on, and you or anyone else such as CQC can then check this, to verify the audit.

It also allows you as a registered manager to assure yourself that the people you have delegated this audit to are carrying it out to your satisfaction and against the chosen standards.

The action plan

Sample action
plan
External link

What draws all of this together the plan, do, review and the audit is the action plan a document that provides evidence that you are doing something about it and the progress over time towards completion

You must always be able to evidence that issues were followed through

For example, a water temperature valve needs replacing; the part is ordered, and a delivery date given you will also need to show you have followed the issue up if it is delivered when promised great, if not you will need to be able to demonstrate that you have followed up on the issue for example with emails to the supplier until the valve has been delivered and fitted and shown to be working correctly.

CQC will accept that some things that you need to do will take time, but if you have identified the issue and it is in an action plan that provides evidence that the issue is progressing, and you regularly check and log progress then you are Well Led.

NEVER EVER use ‘on-going’ or ‘as soon as possible’ for dates in an action plan - always provide clear realistic dates by when issues will be dealt with. If you meet them great, if you aren’t meeting them provide a clear explanation of why and what you are doing to progress the issue.

You do not need to include everything on the action plan. If the toilet roll or soap is missing in one bathroom just get someone to deal with it there and then. If they are missing from all bathrooms and this happens recurrently then that should probably go onto the action plan.

Try to chunk things up to reduce the number of lines on the action plan.

For example, if there is an issue with decorating don't list all the areas that need decorating. The action plan should include creating a decorating plan and timetable for the whole building and not list each door that needs painting, if an inspector wants to know where you’re up to he can look at timetable and see where you’re up to and then could the inspector check and see that the plan matches the reality.

When putting actions onto the action plan they need to be clear, unambiguous and owned by an accountable person with a completion date. For example a clear action would be;

"Head of maintenance team to produce a decorating schedule for the senior management meeting on 5th November to address all identified issues within 6 months (6th May), to be monitored monthly by the manager in supervision and walk round".

When the Care Quality Commission question the issues around decoration you can produce the plan, with completed areas signed off and as back up evidence from your walk rounds. This provides evidence that you are assuring yourself of the progress and maintaining your attention to ensure it gets done.

References for best practice