CQC compliance is typically described as adhering to obligations derived from applicable laws, regulations, values, sanctions, ethics, and the services policies and procedures.
Managers and staff of care homes, domiciliary care and supported living services are required by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 to have effective governance, including assurance and auditing systems or processes. “To meet this regulation, providers must have effective governance, including assurance and auditing systems or processes. Providers must continually evaluate and seek to improve their governance and auditing practice.”
Why perform Internal Audits?
Internal auditing gives insight into a services culture, policies, and processes while assisting management supervision by checking internal controls such as operational effectiveness, risk mitigation mechanisms, and compliance with relevant laws or regulations.
In addition to the regulations managers of social care services are likely to conduct internal audits for one or more of the following reasons:
1. Ensuring compliance to the requirements of CQC Quality Statements, health and safety and where applicable local authority contract standards. 2. To ensure the services quality management system policies and procedures are operating as intended. 3. To explore opportunities for improvement 4. To provide feedback to the management team.
Principles of Auditing
Auditing relies on a number of principles whose intent is to make the audit become an effective and reliable tool that supports management policies and procedures whilst providing objective information that can be acted upon to continually improve the performance of the service.
The following principles relate to auditors.
1. Ethical conduct: 2. Trust, 3. Integrity, 4. Confidentiality 5. Discretion.
Basic steps of auditing
The basic steps to conduct an internal audit are as follows:
1. Identify areas that need auditing In care homes, domiciliary care and supported living services that includes staff who use the policies and procedures being audited. 2. Determine how often auditing needs to be done. Some areas may only require auditing annually to assure compliance. But if a CQC inspection reveals a non-compliance or there is a safeguarding issue, or care incident these may become priority audits. 3. Create an audit calendar. Scheduling audits on a services calendar will assure that they are done consistently. 4. Make staff aware of scheduled audits. Give staff notice of an audit so they can prepare the necessary documents and materials for the auditor. A surprise audit should only be conducted if there is suspected unethical activity. 5. Be prepared. An auditor should come prepared with an understanding of policies and procedures and a list of items for review. 6. Interview staff. The auditor should interview staff and ask them to explain their work process compared to what’s written in a policy or procedure. 7. Document results. The auditor should record the results and any differences in practice to what is contained in the policy or procedure. 8. Report findings. The auditor should create an easy-to-understand audit report to be reviewed with senior management that should lead to the development of an improvement to address any gaps found in compliance during the audit.
After the Audit: Improving Your Compliance
Following the implementation of the improvement plan the manager should arrange a follow-up audit to ensure that the improvements that have been put in place are working as intended, and the service is now compliant with CQC requirements.
Identifying risks to the service There are several risks that your organisation may identify during an internal audit, including:
• Reputation risk • Operational risk • Compliance risk • Strategic risk • Legal risk • IT/Cybersecurity risk
Summary
Internal audits are necessary to care homes, domiciliary care and supported living services because they identify problems before those issues are discovered.
Regular internal audits help to evaluate and improve the effectiveness of risk management, control, and governance processes. By establishing a disciplined, integrated internal audit approach to regulations, and policies and procedures, the manager will be able to demonstrate to CQC Inspectors that the service has a firm grasp on its regulatory and standards compliance, and be able to show transparency into how the service is operating.
While the purpose of compliance is to ensure that a social care service meets the regulatory and standards requirements of the Care Quality Commission, the internal audit function is meant to be more than that. It is essentially a means of monitoring and evaluating a services internal control of the quality of services that are provided for its adequacy, efficiency, and effectiveness.
Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy
Should you be interested in the Bettal Quality Management System that includes internal audit tools and CQC compliant policies and procedures please get in touch.
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