“Don’t assume your quality assurance mechanisms are as robust as you think they are” was the clear message from October 2018’s ‘Ask Listen Do’ event, hosted by the VODG in partnership with NHS England.
‘Ask Listen Do’ focuses on people with a learning disability, autism or both, and their families. The aim is to help the care and support providers who work with these people to encourage, learn from and act on feedback.
At October’s event, one organisation gave a heartfelt presentation about abuse that had been uncovered at one of their services. They described the organisational soul-searching that had followed and, most importantly, how they have changed things as a result. Although the service had recorded incidents, a big picture was not drawn, and the culture that had developed at the service was not identified until too late.
As the Head of Service at Hightown Support responsible for quality assurance, I listened attentively to their learning.
I returned to work thinking about the following questions, and determined to make changes that would improve their answers:
- How do we link incidents or non-compliance across multiple recording systems (e.g. our accident and incident log, our employee relations system, training records) to build a big picture?
- What additional measures do we have when there are gaps in operational management or interim management arrangements?
- Are our channels for feedback from people who live in our services and their families really robust enough?
- How well do internal audits capture the ‘feel’ of our services?
My team are performing a pincer movement to make sure that we get the right answers to these questions. We’re driving quality improvement from these two angles:
- Digital transformation
- Having the right systems so that they simplify tasks for staff and help to prevent error.
- Greater digital recording and monitoring allowing us to be more proactive in identifying where standards in our services need to improve.
- Service user involvement and feedback
- A new Complaints Scrutiny Group and Mystery Shoppers
- Review of how feedback is captured and acted on at a service level
The Quality Matters initiative being led by the DHSC and CQC, is also coordinating action across the sector around a shared commitment to quality - “so that care is consistently high-quality even when no one is looking.”
This is a commitment I believe in, but it is a challenge, and it is important that we do not get scared by the scale of the challenge. I am grateful to be part of professional networks where people are brave enough to share their experiences of when it goes wrong.
Quality assurance requires hard work all the time – if our services operate 24/7 then our systems to prevent error and abuse must as well.Isabel Connolly
Summed up as only the Health and Safety Executive know how: “The challenge is to develop error tolerant systems and to prevent errors from initiating; to manage human error proactively.”
‘Ask Listen Do’ is a challenge to the sector, let’s all work to be better.