Readers of my recent articles will; be aware that I have covered topics on the understanding internal audits and the carrying out of an internal audit. I thought this week I would continue to build on this theme and demonstrate to providers how the internal audit process can help address a noncompliance issue contained in a CQC Inspection Report.
Checking the accuracy of evidence in the CQC Draft Inspection Report
The first action to be taken by the provider is to check that you agree with the evidence of non-compliance provided in CQC Draft Inspection Report. If the provider does not agree, then they will need to provide evidence to challenge the issue raised.
Steps to be taken to address CQC non-compliance
The following steps should be taken to address a noncompliance issue:
1. Identify the non-compliance. 2. Gain an understanding of the reason for the non-compliance. 3. Notify staff involved. 4. The corrective steps to be taken to avoid non-compliance. 5. CQC Report.
Action to be taken to identify the non-compliance
The provider should arrange for an internal audit to be carried out in the area of the service involved to confirm that evidence provided by the CQC is correct or not correct. The audit will reveal if staff have followed policies and procedures as intended or if they require amendment. Where the non-compliance issue impacts on the care of people who use the service, they should be interviewed by staff.
Where the non-compliance issue involves staff performance this should be covered as part of staff supervision.
Reason for noncompliance
The purpose of the internal audit is to establish the reason for the non-compliance this includes the root cause. And how the issue may impact on other policies and procedures and the running of the service.
Notify staff involved
The manager should call a staff meeting to bring the CQC Inspection Report to the attention of staff, the reasons for the non-compliance and the steps to be taken to address the issue. The corrective steps to be taken to avoid non-compliance.
The manager should decide on the appropriate steps to be taken to avoid future non-compliance. These may involve, changes in policies and procedures, record keeping, health and safety and care of people.
The manager should create a report for the CQC. A record that includes:
1. The outcome of the internal audit. 2. How the non-compliance issue was identified 3. The reason for the non-compliance 4. Date of action taken to resolve the issue. 5. Date of when the corrective actions will be completed.
The manage must ensure that all staff are informed of any changes to policies and procedures that impacts of the running of the service.
Care homes, domiciliary care and supported living services can gain great benefit from having a regular programme of internal audits in place. It is an approach that pre-empts CQC Inspection Reports containing non-compliance. CQC Inspection Reports containing non-compliance issues can be disappointing for the manager and can in many cases be avoided.
If the steps, I have highlighted in this article (which are based on best audit practice) are followed by managers, they will not only satisfy the compliance requirements of CQC but know that their service is operating as intended.
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.
If you wish to discuss, please connect with me on LinkedIn.