Effective Auditing in Care Services
A guide to auditing for managers.
Managers and staff often consider internal auditing to be a daunting task. This is hardly surprising given the many other tasks expected of them and the time involved.
It may however have something to do with their understanding of what auditing is, or their experience of carrying out an audit programme, and the methods used to identify and record evidence of the audit.
It is my aim in these guidance notes to improve managers understanding of the audit process and provide best practice guidance that will and enable managers to feel more confident about auditing.
The guidance on auditing will be produced in non-technical language and appropriate to care settings.
It draws on the British Standards Institute approach to internal auditing.
2.0 DEFINING AN AUDIT
A good place to start in our understanding of auditing is to define what an auditing is trying to achieve. Putting it simply the purpose of auditing is:
To obtain evidence of what you are doing in your practice to ensue it is in line with what you say you are going to do in your policies and procedures, care plans and other relevant documentation.
Managers should note that CQC inspectors are using this approach as part of their audit trail by checking with service users and staff that the service is providing what they say will do in care plans and policies and procedures.
The Healthcare Quality Improvement Partnership (HQIP) are to pilot the use of care audits in social care. They define a care audit as:
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.
3.0 WHY AUDITING IS IMPORTANT
Managers need to know that the service is operating as intended. Auditing provides written evidence that users of the service, carers and staff are involved in measuring the effectiveness of the service. CQC for example, focus their attention among other things on Care Plan Auditing.
Auditing demonstrates and provides evidence to CQC and Local Authority Commissioners that the service is able to respond to the Key Lines of Enquiry and meet the Fundamental Standards.
Corrective actions to address any shortfall demonstrate a willingness to put things right and a commitment to improvement.
Auditing is an essential ongoing tool that should become an integral part of the service. In doing so it ensures that standards and service user requirements continue to be met. If managers are assured that their service is operating as intended they will have confidence in meeting enforcing officer’s inspections.
4.0 TYPES OF AUDITS
There are a number of different types of auditing processes, but for the purpose of this guidance I will focus on internal auditing.
5.0 WHAT AREAS SHOULD BE AUDITED IN YOUR SERVICE
Audits may focus upon a number of different areas, namely:
- Auditing of your Quality Management Systems of Policies and Procedures.
- Care plan auditing.
- Health and safety auditing.
- Auditing of infection control practices.
- Environmental audit.
- Fire safety audit.
- Kitchen hygiene and practices audit.
- Staff Training Audit.
- Staff Personnel file audit.
6.0 PRINCIPLES OF AUDITING
There are five key principles that I believe should underpin auditing in the care sector auditing:
- Focus on the Service user.
- Clear measurable statements of service user requirements and preferences.
- Clear policies and procedures that refer to National Standards and best practice.
- Evidence of meeting service user requirements, preferences and outcomes.
- Continual improvement.
7.0 PLANNING AN AUDIT
Managers should plan internal audits through an audit schedule. The schedule should contain all the policies and procedures within the service quality management system. The schedule will contain the date of the planned audit and when it was carried out.
The date for audits of care plans should be set at the care plan review.
Managers may wish to apply to internal audits the model:
PLAN – DO – CHECK – ACT
PLAN Define the audit programme
DO Implement the audit programme
CHECK Review the audit programme
ACT Improve the audit programme.
8.0 SELECTING AUDITORS
Managers should select staff to be internal auditors who are independent and carry no responsibilities for the area to be audited. Ideally, auditors should be trained to carry out internal audits.
Where resources do not provide for training staff should be selected who possess the following qualities:
- Demonstrated integrity.
- Demonstrated competence and due professional care.
- Is objective and free from undue influence (independent).
- Is committed to the mission and values of the service.
- Demonstrates a commitment to quality and continuous improvement.
- Communicates effectively.
- Is insightful, proactive, and future-focused.
- Promotes service improvement.
9.0 PREPARATION FOR AN INTERNAL AUDIT
Before commencing an audit staff should be allocated time to prepare. This will include time to:
- Thoroughly read policies and procedures relevant to the area to be audited.
- Identify questions to be asked.
- Production of an audit checklist.
10.0 AUDIT CHECKLIST
There are 4 main tools used by an auditor:
- The audit checklist.
- Asking questions.
- Listening carefully to what is said.
- Observing what is being done.
Before an audit takes place the relevant policy and procedure should be read by the auditor to identify the actions required to be carried out as part of a procedure or policy. The role of the auditor is to create a checklist that contains the required identified actions and the questions to be asked to confirm that they are being done as intended.
11.0 AUDITING PERSPECTIVES
The Auditor should ensure that every audit situation is examined from three perspectives:
1.0 Intent - Does the policy or procedure clearly state what the service said it will do?
In other words do the documents adequately express the services intentions?
2.0 Implementation - Has the service done what it said it would do?
In other words do the observed and recorded practices conform to the intent?
3.0 Effectiveness - Has it been done well?
In other words have the outcomes been achieved?
Effectiveness can be defined in terms of: Did staff follow the procedure as required and were outcomes met?
12.0 OBTAINING EVIDENCE
After determining the procedure requirements, the auditor should gather objective evidence using the following methods:
- Interview personnel
Based on your audit planning and checklist questions, ask staff questions relating to their responsibilities within the procedure. Listen to what they tell you and see if their explanations match the process defined in the procedure. Use open-ended questions to elicit more complete responses. Do not be afraid to challenge and probe or follow an audit trail to see where it leads you. Talking to people is the best possible way to test their understanding of the requirements of the procedure.
- Observe operations
Aid your own understanding of the process by watching it being performed. See if the observed practices comply with requirements. You will discover the persons being interviewed are more relaxed when you allow them to demonstrate their jobs. In addition, internal audits will be less disruptive since work is actually being completed.
- Review documents and records
Ask the staff being interviewed what documents and records are used in their work. The auditor may find documents, records and forms beyond those identified in your audit planning.
See if the documents are adequately controlled and available for use. Refer to the documents and records to help you follow the work being shown. Verify the records described in the documents are being properly used.
- Examine records
Auditors cannot interview every person, observe every activity, look at every document, and evaluate every record. The auditor should strive for representative samples that allow for informed judgements.
13.0 AUDIT REPORTING
When writing up their audit report the auditor should:
- Complete – include the specified requirement and objective evidence.
- Correct – take care to accurately and correctly convey the information.
- Concise – express the statement as briefly and succinctly as possible.
- Clear – use easy to understand words and terminology.
- Confirm –The information needed to carry out corrective actions has been stated.
14.0 REVIEWING THE AUDIT PROGRAMME
When reviewing the results of the audit programme the manger should along with the auditor ask the following questions:
- Are the services internal audit plans and schedules being met?
- Do the service audit plans focus on service user satisfaction?
- Is the service meeting service user requirements and the Fundamental Standards?
- Where there are problems are we identifying the root cause?
- Are audit reports of a good standard?
- Are non-conformities written clearly and simply to be easily understood?
- Do we give sufficient compliments for good practices?
- Are we identifying opportunities for improvement?
Bettal Quality Consultancy
Fellow Chartered Quality Institute
The Cared 4 quality management system contains all the tools you require to carry out effective auditing of your quality management system.