The Quality Assurance Framework For Adult Health And .
The Quality Assurance Framework for AdultHealth and Wellbeing Directorate services 2012SectionPageExecutive summary2Introduction5Scope and definitions6Existing quality assurance structures8Quality standards11Monitoring quality16Improving quality22Communication24Roles and responsibilities25Governance and accountability28Review29Appendix I: Current quality assurance mechanisms adult socialcare30 Quality assurance in England30 Quality assurance in Tower Hamlets Local Authority38 Quality assurance in the Directorate39 Quality assurance in “in-house” service provision45 Quality assurance in commissioned providers46 Quality assurance in non-commissioned providers47 Summary of monitoring mechanisms48Appendix II: Priorities for 2012-14501
1. Executive Summary1.1 This Quality Assurance Framework lays out the structure through which thequality of Directorate services will be defined, measured and improved. TheFramework marks an increased focus on consumer and self-regulation, andseeks to maximise resources to ensure they are used in a streamlined andeffective way.1.2 The core quality standards for Directorate services are based on the adultsocial care service values1. These, in turn, are consistent with qualitystandards communicated at a service level, Council-wide level and nationallevel. The core quality standards are: We will treat everyone with respect We will provide information that is clear, useful and easy to understand We provide and commission support that helps people to beindependent We will listen to people’s views and act on them where possibleTeams and services within the Directorate may have additional standards thatare specifically relevant to that service or team. These will complement ratherthan replace the core quality standards.1.3 The quality of Directorate services is monitored through: Audits Hearing the views and experiences of people who use services. Reporting Visits and meetings1Accountable; collaborative; empowering; ambitious for customers; respect customers; skilled, knowledgeable and continueto learn; make every pound count.2
1.3.1The diagram below provides an overview of how the quality Directorateservices are monitored in Tower Hamlets. The diagram shows thatmonitoring functions are spread across national, Council, Directorate andcustomer forums.Health &WellbeingBoardreportingLBTHCabinet &ScrutinyPanelsDMT &Quality &Performance BoardreportingMonitoringFramework for TCLGGpeerreviewsSupporting PeoplemonitoringprocessesDirectfeedbackon searchSafeguarding auditsand BoardprogrammeCaseRecordAuditAuditprogrammeCQC andnational/regulatoryinspectionTHINk &Rate kmechanism3
1.3.2 The below table lays out how monitoring activity applies at a team level:All teams Monthly complaints, concerns and incident reporting “Compliments” and good practice reporting Yearly programme of audits and research (led on by Quality and Involvement teamor peer researchers) Acting on feedback gained from the annual User Experience Survey and THINkPSMT /operationalteamsPSMT / inhouse serviceprovisionFSMT /finance teamsCSSMT /commissioningteams- Monthly- Paper- Case Record- Case RecordCSSMT /strategy andperformanceteams- Survey toCase Recordsurveys orAuditsAudits (ART)staff to getAuditsmeetings to get- Paper- Monitoringfeedback- Paper orfeedbacksurveys toFramework- Informationphone surveys- Visits fromusers to get(ART)collectedto users to getindependentfeedback- Monitoringthrough PSMT,feedbackexperts(I&A)FrameworkFSMT and- Adopting- Survey to(SupportingCSSMT teamrelevantstaff to getPeople)activity.sections offeedback- Survey tocommissioningstaff to getMonitoringfeedbackFrameworks1.4 Services provided and commissioned by the Directorate work towards thehighest possible quality adult social care by utilising monitoring mechanismsoutlined. Acting on monitoring information takes place at an individual, teamand Directorate level. Planning functions (e.g. team planning) and thegovernance and accountability structure in the Directorate provideopportunities for this information to be utilised.4
2. Introduction2.1 The “Excellence by Experience” Adults Health and Wellbeing QualityAssurance Framework was first produced in 2009, setting out a systemthrough which the quality of Adults Health and Wellbeing directorate servicesin Tower Hamlets would continually improve. The basis of this Frameworkwas for quality to be assured through a three-stage cycle (Fig. 1 below).StandardMonitorImproveFig. 1 – Quality assurance cycle2.2 In 2012, quality remains high on the national agenda. “Assessing andmonitoring the quality of service provision” is one of the Care QualityCommission’s sixteen essential standards for quality and safety. The 2011Department of Health “Caring for our future” engagement exercise identifiedsix areas that “have the biggest potential to make improvements to the careand support system2”. The first of the six areas is “improving quality andsupporting the workforce”. The importance of quality is also reflected inhealth services: it is explicit throughout the 2012-13 NHS OperatingFramework, and one of the four themes in the Framework directly relates toquality.2.3 Whilst quality remains high on the agenda and central to the experience ofpeople coming into contact with services, since 2009 the system and contextthat adult social care and support operates in has changed significantly. Thisrevised Quality Framework has been developed to address these challenges2www.caringforourfuture.dh.gov.uk5
and opportunities for us to improve what we do. It maintains the same threestage cycle of “standards”, “monitoring” and “improvement” used as thefoundation of the 2009 Quality Assurance Framework; but the Framework hasan increased focus on consumer and self regulation, and it seeks to maximiseresources to ensure they are used in a streamlined and effective way.Overall, this revised Quality Assurance Framework lays out the structurethrough which the quality of Directorate services will be defined, measuredand improved.3. Scope and definitions3.1 Scope3.1.1 The main focus of this Framework is the services provided by Adults Healthand Wellbeing directorate in Tower Hamlets Local Authority3. This thereforeincludes services provided directly by the Directorate, and services for whichthe Directorate acts as lead commissioner. The Framework describes howthe quality of Directorate services is assured (including, for example, socialwork practice, in-house day care service provision, commissioning activity and“back office” functions). The Framework also describes how the quality ofservices commissioned by the Directorate is assured.3.1.2 This Framework does not apply to services where we are not the leadcommissioner (i.e. mental health services) as these services fall under QualityAssurance Frameworks held by other bodies, such as the NHS. However, theFramework has been developed with an awareness of alternative QualityAssurance Frameworks to ensure consistency where possible.3In 2012, the Adults Health and Wellbeing directorate will integrate with the Children’s, Schools and Families directorate toform the Education, Social Care and Wellbeing Directorate. This Framework will apply to adult social care services in the newintegrated Directorate.6
3.2 Definitions3.2.1 Quality: The term “quality” is defined as a degree, standard or grade ofexcellence. It therefore acts as a measure, whereby the quality of somethingcan denote how excellent or poor it is. This Framework seeks to identify whatthis excellence looks like in practice.3.2.2 Framework: A framework is defined as “a skeleton or structure for a way ofdoing something. This could be a set of principles for example that should beused when making decisions and can form the basis of an agreement on howpeople will work4”. In the context of a Quality Assurance Framework, this canbe viewed as a structure that defines what quality is, how it will be measuredand how it will be improved.3.2.3 Service user, carer, resident and customer: a “service user” is defined asan individual who currently uses or has used services provided orcommissioned by the Directorate. A “carer” is defined as an individual whospends a significant amount of their time giving unpaid support to a familymember, partner, or friend who is ill, frail, disabled or has mental health orsubstance misuse problems. The definition of a carer is therefore wider, andincludes those who do not receive carer services, and those who provide carefor non-service users. A “resident” is anyone who resides in Tower Hamlets.As all these groups can come into contact with social care and be affected bythe quality of support, the terms “customer” will be used as a general term forease of use.3.2.4 Operational staff: Refers to staff in First Response, Reablement, LongerTerm Support, Occupational Therapy, Community Learning Disability Serviceand in-house home care and day care teams.3.2.5 Commissioning staff: Refers to staff in brokerage, TransactionalCommissioning, Strategic Commissioning and Supporting People teams.42011 Adults Health and Wellbeing directorate Strategy and Policy Toolkit7
3.2.6 Strategic and support staff: Refers to staff in Strategy and Performance,Finance and Business Support teams.3.2.7 Adult social care: Is used as a general term to describe all the supportservices provided or commissioned by the Directorate.4.Existing quality assurance structures4.1 Quality assurance in England4.1.1 There is already a wide range of quality assurance structures applicable toadult social care services in Tower Hamlets. The current and plannedstructures through which quality is assured in England are summarised in thetable on the next page (please see Appendix I for full details). Differentservices and teams in the Directorate are often “covered” by differencestructures.Department of Health –Social CareDepartment ofHealth - HealthDepartment ofCommunities andLocal Government– Social careRegulationCare QualityCommission (CQC) &HealthWatch England& Monitor*CQC & CQUIN &Monitor* &HealthWatchEngland*Supporting PeopleQualityAssessmentFramework (QAF)Commissioningand providermonitoring andbest practicesupportSocial Care Institute forExcellence & ThinkLocal, Act Personal &National Institute forClinical Excellence(NICE)*AuditCommission** &Sitra & SupportingPeople QAFKeyframeworksAdult Social CareOutcomes FrameworkNICE* &Healthcare QualityImprovementPartnership(HQUIP)* & NHSInstitute forInnovationNHS OperatingFramework &Quality InnovationProductivity,Prevention (QIPP)Quality AccountSupporting PeopleQAFKeyLocal Accountn/apublications* To be developed as part of the 2010-12 Health and Social Care Act** Due to be abolished8
4.1.2Economic pressures and the coalition government aim of reducing regulatoryburdens are influencing the structure and function of quality assurance in allpublic services. The focus is around localism and promoting individualresponsibility. The theory is that cutting away bureaucracy and ensuringtransparency will enable public scrutiny to drive up the quality of serviceswhilst money is saved. Consumer power and self-regulation are thereforeincreasingly being looked to as the answer. This can be seen in the LocalGovernment Group “self regulation” proposals, in the Department of HealthAdult Social Care Framework and in the creation of HealthWatch England.That being said, the 2010-12 Health and Social Care Act may add more“layers” to the existing quality assurance structures by extending the role ofthe National Institute for Clinical Excellence (NICE) and Monitor into socialcare. This Quality Assurance Framework seeks to bring these structurestogether so that the overall picture is clear.4.1.3The quality assurance mechanisms in health services – whilst not directlyapplicable to adult social care – are still relevant to social care, particularlywith regard to integrated working and joint commissioning arrangements.Some of the main quality assurance mechanisms in health services include:The Care Quality Commission The National Institute for ClinicalExcellence (NICE)MonitorThe Commissioning for Quality andInnovation (CQUIN) payment frameworkThe annual NHS Operating FrameworkThe NHS Quality, Improvement,Productivity and Prevention (QIPP)agendaThe Healthcare Quality ImprovementPartnership (HQIP)The NHS Institute for Innovation andImprovement9
4.2 Quality assurance in Tower Hamlets4.2.1 The quality assurance mechanisms in Tower Hamlets function at a borough,Directorate, service and customer level, and are summarised in the tablebelow (please see Appendix I for full details). Again, these structures oftenapply to different services within the Directorate.CouncilAWHBCommissioningand providersPublicForums,groups andmeetings- Cabinet- Overviewand Scrutiny- HealthScrutiny- Health andWellbeingBoard- Monitoringmeetings- Providerforums- THINk5- Customerforums- PeerResearchersTools to setstandards- Policies &procedures- Core Values- DMT- Quality andPerformanceBoard- Partnership &SafeguardingBoards- Staffmanagement- Policies &procedures- Service Values- Servicespecifications- Servicespecifications- Contracts- Generalfeedback- LocalAccountfeedback- MonitoringFramework fortransactionalcommisisoning- SupportingPeopleMonitoringFramework- Enter-andView- Rate OurService- Peerresearch- AnnualSurvey- OngoingfeedbackFrameworks - Internal audit - Qualityto monitor- ManagementAssuranceandFrameworkLeadership- PerformanceFrameworkManagementFramework- Case RecordAudits4.2.2 The focus of quality assurance locally reflects the national direction of travel:consumer and self regulation can be seen in the development of mechanismssuch as peer research6 and in new monitoring systems for commissionedservices that aim to give providers more responsibility to conduct their ownassessments. One of the key challenges for the Directorate going forward isto ensure that affordability is not prioritised above quality, given theunprecedented financial challenges we currently face7. Other emerging5The Tower Hamlets Local Involvement Network (THINk) will transition into HealthWatch by 2013In 2011, the Adults Health and Wellbeing Directorate commissioned PPRE to develop a group ofapproximately twenty “peer researchers”, who have experience of adult social care services andare able to carry out research with other adult social care users.7The intention is to reduce central funding to all local authorities by 27 per cent our four years.610
issues include the need to agree our future approach to assuring the quality ofnon-commissioned support purchased with a Personal Budget. This QualityAssurance Framework seeks to bring together existing structures and sets outa new way of assuring quality through the development of a core set of qualitystandards for the Directorate.5Quality standards5.1 The diagram below provides an overview of the documents containing qualitystandards applicable to Directorate adult social care and support services.The bottom tier of the pyramid represents the standards communicatedacross England; the middle tier represents the standards communicated inTower Hamlets (please see Appendix I for full details of these); and the toptier represents an overriding core set of quality standards based on the “ACE”service values8.ACE/CoreStandardsCharterPolicy and procedure /Organisational values / Serviceand staff person specifications /Commissioning CQC 2* and SPGrade C servicesStatutory duty of care / Care Quality Commission essentialstandards / Supporting People Quality AssessmentFramework / NICE Quality Standards / ProfessionalStandardsFig. 2 – Quality Standards in Adult Social Care8ACE service values (developed in 2011 for the Adults Health and Wellbeing directorate): I respect our customers; I amaccountable; I am ambitious for our customers; I am collaborative; I am skilled, knowledgeable and continue to learn; I makeevery pound count; I am empowering.11
5.2 Messages arising from quality assurance in England5.2.1 Information on quality standards in England9 make it clear that people whoreceive adult social care can expect to be treated fairly and with respect bystaff who are skilled and trained, to be involved in their support and for thatsupport to be personalised, and for their risk and safety to be managed.5.2.2 Recent publications10 show that the national view of “good” social care hasexpanded to include a bigger focus on prevention. In addition, good qualitysocial care is increasingly viewed as simultaneously being more about theindividual (by being person-centred and promoting choice and responsibility)and the community they are part of (by focusing on partnerships, informationand advice for all and the role of community). Furthermore, the new publicsector equality duty highlights the need to look at the quality of people’sexperience in a range of different ways11.5.2.3 The image below summarises the view of quality adult social care in Englandby highlighting the words most commonly used in quality standard and qualityassurance documentation:9Information drawn from the Care Quality Commission essential standards of quality and safetyand the Supporting People QAF – Grade C.10Information drawn from: A Vision for Adult Social Care: Capable Communities and ActiveCitizens (DoH 2010); The 2010-11 Adult Social Care Outcomes Framework (DoH 2010); ThinkLocal, Act Personal – Making it Happen (2011); Supporting People QAF – Grade A (2009); SCIEand Sitra messages.11The new public sector equality duty came into effect in 2011. This requires services to look atperformance, access, satisfaction and complaints across nine equality strands.12
5.2.4 The 2011 Dilnot and Law Commission reports provide indications as to thefuture direction of travel for quality, as they highlight the experience of carersand the role of information and advice. This Quality Assurance Frameworkreflects these themes in a core set of quality standards for the Directorate thatapply to anyone coming into contact with adult social care. This Frameworkalso lays out how adult social care in Tower Hamlets will be monitored andimproved, so that it increasingly reflects the national view on what goodquality adult social care looks like.5.3 Messages arising from quality assurance in Tower Hamlets5.3.1 Local information12 on what people can expect from Directorate serviceshighlights themes of staff that learn; treat people with respect, and providesupport that empowers, prevents ill-health, promotes independence andbuilds confidence. The importance of customers and staff having a clear levelof individual responsibility is implicit in these, and is linked to things likeensuring value for money, ensuring transparency and working effectively withothers. More “practical” quality standards include things like providing timelysupport.5.3.2 Staff, stakeholder and customer views13 on what good quality Directorateservices look like continue this focus on independence. The importance ofinformation and users and carers “being informed” and involved is highlighted,as is the importance of customers being on an equal footing withprofessionals. Timeliness and the quality of buildings (in buildings-basedsupport services) are highlighted in THINk’s “Rate our Service” system, alongwith the importance of service activities and customer access to thecommunity.12Information drawn from Council Core Values, Adults Health and Wellbeing Directorate servicevalues, the Adult Customer Journey Service Specification and elements “embedded” in AdultCustomer Journey procedures.13Information drawn from the Community Plan, the AHWB Case Record Audit, THINk “Rate OurService”, 2010-11 resident and customer feedback.13
5.3.3 The image on the next page summarises the view of quality adult social careand support in Tower Hamlets by highlighting the words most commonly usedin quality standard and quality assurance documentation:Fig 4 – Words used in quality assurance documentation in Tower Hamlets.5.3.4 These themes have already been brought together and communicatedthrough the Adults Health and Wellbeing directorate “ACE” service values.This Quality Assurance Framework reflects these themes in an overarchingset of core standards, which in turn are based on the directorate servicevalues. It also lays out how adult social care in Tower Hamlets will bemonitored and improved, so that it increasingly reflects the local view on whatgood quality adult social care looks like.5.4 Core Quality Standards5.4.1 The Directorate core quality standards for adult social care and supportservices are based on Directorate service values. These, in turn, areconsistent with quality standards communicated at a service level, Councilwide level and national level. The standards represent a core and simple setof standards that everyone can expect from directorate services. They reflectthe growing emphasis on the importance of customer perspectives of qualityand ensure that all services within the Directorate have a core set of qualitystandards to work to. The core quality standards for the Directorate are asfollows:14
Core quality standards1. We will treat everyone with respect2. We will provide information that is clear, useful and easy tounderstand3. We provide and commission support that helps people to beindependent4. We will listen to people’s views and act on them where possibleThe table below provides an overview of how the core quality standards link to the5.4.2 “ACE” service values:Core standard1. We will treat everyone withrespectService valueRespect customers2. We will provide informationAccountable; empoweringthat is clear, useful and easy tounderstand3. We provide and commissionsupport that helps people to beindependentEmpowering; ambitious forcustomers;4. We will listen to people’s viewsand act on them wherepossibleCollaborative; skilled, knowledgeableand continue to learn5.4.3 It is important to note that these standards will apply to different teams andservices in different ways. A few examples of this are listed on the next page:15
Core Standard1. We will treat everyonewith respect2. We will provideinformation that isclear, useful and easyto understand3. We provide andcommission supportthat helps people tobe independent4. We will listen topeople’s views andact on them wherepossibleApplication- Operational teams: apply to staff interactionwith service users and carers.- Commissioning teams: apply to staffinteraction with providers and colleagues,and provider interaction with users andcarers.- Income and assessment team: apply towritten information sent to service usersand carers.- Strategy and performance teams: apply tostrategy and policy documents.- Operational teams: apply to information,advice assessments, support planning andreviews.- Commissioning: apply to commissioningstrategies and monitoring frameworks.- Commissioning: ensure user perspectivesare considered in commissioningprocesses.- Strategy and performance: ensure userperspectives are considered in strategyand policy development.5.4.4 Teams and services within the Directorate may have additional standards thatare specifically relevant to that service or team. These complement ratherthan replace the core quality standards.6. Monitoring quality4.1 An overview of how we monitor qualityThe quality of directorate services is monitored through the following keyactivity: Audits. Hearing the views and experiences of people who use services. Reporting. Visits and meetings.16
4.2 Monitoring quality across England and Tower HamletsThe diagram below demonstrates how this activity is carried out at a nationaland borough-wide level. More detail on this is available in Appendix I.LBTH Cabinet& ScrutinyPanelsHealth &WellbeingBoardreportingDMT & Quality &PerformanceBoard reportingLGG peerreviewsSafeguardingaudits andBoardQualityMonitoringIn Englandand LBTHCQC andnational/regulatoryinspectionTHINk & Rateour backmechanismsFig 5 – Key monitoring activity at an England and borough-wide level.4.3 Monitoring the core quality standards4.3.1 Monitoring the core quality standards for the Directorate is carried out throughthe key activity described below. The Quality and Involvement team in theDirectorate act as the central point of contact for this information, and produceregular reports demonstrating the quality of Directorate services based on this(please see section 9 for more details of roles and responsibilities).4.4 Audits4.4.1 Case Record Audits: Each month, managers from relevant teams audit a setof customer case files and records against a set of pre-defined standards(based on the core quality standards) in order to assure the quality of thoserecords.17
4.4.2 Safeguarding Audits: Audits of safeguarding cases occur with the support ofthe Safeguarding Adults team, whereby safeguarding cases are assessedthrough a set of audit questions.4.4.3 Audit programmes: The directorate carries out regular audits on specifictopics (for example, an audit of service users employing family members witha cash personal budget or direct payment). These audits are planned as partof business planning processes, and can be determined by staff or bycustomers.4.5 Hearing the views and experiences of people who use services4.5.1 It is important to note that “people who use services” can include serviceusers, carers, providers and staff. For example, the people who receive “backoffice” services are often other staff. However, feedback from service usersand carers can be considered a reflection on the quality of all services, sincethey are the “end user”.4.5.2 Getting general feedback and using this information to monitor the quality ofservices is done in a variety of ways. This includes feedback andrecommendations from customer forums, mystery shopping, staff andcustomer representation on decision-making forums (for example, theLearning Disability Partnership Board), and by monitoring formal complaints,Member Enquiries and locally resolved concerns. It also includes serviceuser, carer and provider feedback raised in forums (e.g. provider forums) andmonitoring visits in commissioned services.4.5.3 THINk play a key role in enabling the Directorate to hear the views of peoplewho use services. THINk collect “community intelligence” by collectingcomments, feedback and by visiting services. This information is used tomonitor and make recommendations to adult social care. THINk sits outsideDirectorate services and structures14, thus providing a valuable independentmonitoring role.14Tower Hamlets commissions Urban Inclusion Community to host THINk. The contract for Urban Inclusion Community isheld and managed by the Chief Executive Directorate.18
4.5.4 Getting direct feedback on the core quality standards is also done in a varietyof ways, described below:Activity to get feedbackDescriptionWhoResearch programmesResearch carried out tofind out views andexperiences on aspecific issue.Annual survey sent toFACS eligible serviceusers.Annual survey to gainfeedback from recipientsof “back office” functionsPaper or phone surveysgiven to service usersand carers, to getfeedback on eachservice.Includes managersattending meetings orevents, or managersshadowing front-linestaffStaff, THINk or peerresearchersUser Experience SurveyStaff and ProviderSurveyLocal surveysMeetings / mechanismsfor senior managementto have contact withpeople who useservicesQuality and Involvementteam.Quality and Involvementteam.Distributed by teams.Analysed by Quality andInvolvement team.Senior ManagersExample of a local survey:What do you think?We are really interested to hear your views on your experience of reablement. Please fill inthis questionnaire and return it to the Council. Your feedback will be anonymous, and willhelp us to improve adult social care services across Tower Hamlets. Thank you!1. How satisfied are you with the service youreceived?YesA bitNotNoN/Areally2. Did staff treat you with respect?YesA bitNotreallyNoN/AYesA bitNotreallyNoN/AYesA bitNotreallyNoN/AYesA bitNotreallyNoN/A3. Did your support help you to be independent?4. Did staff listen to your views and act on themwhere possible?5. If you have been given information or advicefrom staff, was this useful and easy tounderstand?19
4.6 Reporting4.6.1 The Directorate Performance Management Framework: This Frameworkoutlines the approach to planning, performance management, data qualityand public accountability. The Framework enables the Directorate to keeptrack of progress against key strategic objectives15 and to monitor outcomes.It also includes a number of local priority measures: each team has targetsand a set of key performance indicators, linked to the wider objectives of theservice and Directorate. Local outcome performance measures can includethose related to programme and strategy management, and a range of activityincluding:-The number of clients receiving a review-Equipment and adaptations delivered within 7 working days-The number of people admitted to residential careThe monthly performance “scorecard” compiled by the Strategy andPerformance team and reviewed by the Directorate Management Team bringstogether relevant performance management information into one place.4.6.2 Core reporting activity that relates to the quality of Directorate servicesincludes reporting information on:-Complaints and locally resolved concerns-Member Enquiries-Serious untoward incidents-Legal challengesThis information is reported regularly to the Quality and Performance Boardand to the Directorate Management Team.15The 2011/12 strategic measure set for the Directorate within the Healthy and SupportiveCommunity theme are NI120a, Strategic042a: All age, all cause mortality rate – Male /NI120b: All age, all cause mortality rate – Female / NI127, Strategic045: Self reportedexperience of social care users / NI130, St
Quality assurance in “in-house” service provision . 1.3.1 The diagram below provides an overview of how the quality Directorate services are monitored in Tower Hamlets. The diagram shows that monitoring functions are spread across national, Council, Directorate and
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