CQC We Statement

Theme 4 – Leadership: Learning, improvement and innovation 

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Audit is an essential part of a learning organisation; it supports continuous improvement, responds to user feedback, complaints and quality assurance.

An audit cycle can address service delivery, professional roles and responsibilities or new ways of working, for example: performance management, supervision, outcomes for adults with care and support needs and their carers, case recording and integrated working.

Audits may be conducted on a short or long term basis, and measure simple or complex issues.

Essentially, an audit involves reviewing the way care is provided against agreed and quality standards.

The audit framework has four stages:

  1. Preparing and planning
    • Identify and agree an area of care which requires audit: this may be an issue highlighted by adults or carers, or is one that has emerged as a high risk for example a new area of service / practice or an area for improvement.
    • Agree the aim, objectives and standards: useful guidance includes SCIE or NICE (see Organisations) or local/ best practice standards;
  2. Reviewing quality
    • Develop audit criteria that measure performance against agreed standards: these are the specific elements that describe the quality measurements;
    • Collate and analyse data, report results: as part of this stage, the process for providing feedback to those who took part should be agreed and planned. This includes adults and carers, staff and relevant others;
  3. Improving practice
    • Consider results and formulate improvement plan: the results from the report should be discussed by the quality assurance group, senior management team as appropriate, and other relevant meetings. Discussions may include the potential causes of the problems (for example lack of resources, inadequate knowledge / skills, lack of awareness of procedures), which should be improved and how. Discussions may also include adults, carers and staff;
    • Implement the improvement plan: it may be that amendments to practice may have already occurred as a result of doing the audit;
  4. Sustaining improvement
    • Repeat the data collection to measure improvement: it is important to re-do the audit cycle for a second time in order to discover whether the agreed actions have taken place.
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