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Total quality management: a way of managing people and business processes to ensure complete customer satisfaction at every stage internally and externally (Department of Trade and Industry, DTI 2010). Although different quality experts emphasize different experts of this methodology, its major components can be summarised as follows: processes, people, management systems and performance measurement. According to Ross and Perry (1999), in addition to creating delighted customers through empowered employees, total quality management processes also lead to higher revenue and lower cost. In our Nursing home, every department is involved in implementing quality management to offer the best quality of service; we always work as a team and ensure we have offered the best quality of care that our residents need.
Continuous quality improvement: is a system that seeks to improve the provision of services with an emphasis on future results (Marshall, 2003). In our nursing home, the manager ensures that every service provider receives training, implements what they have learnt and they are supervised if there is need for retraining again we are retrained this ensures that we receive updated information to offer the best quality of service.
Quality standards: The Care Quality Commission for England has produced a guidance to help providers of health and adult social care to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009 (CQC, 2010b). This guide contains the regulations and the outcomes that the CQC expects people using a service will experience if the provider complies. This forms the basis for the quality standards in care homes. There are 16 core ones range from respecting people receiving the services to safety and suitability of premises and staffing levels just to mention a few. In my care setting, we get an annual inspection from UKAF over and above inspections from CQC and have been given a star rating of three. All activities this year are geared towards a rating of four.
Quality cycles: According to QCC (2010b) quality cycles represent periods within which care homes should be reviewed to determine compliance in its service provision. This may be annually. However private organisations like the United Kingdom Accreditation service also offers a quality cycle inspection called the Residential and Domiciliary care Benchmarking (RDB). The RDB annual ‘quality cycle’ supports strategic planning by providing comparative feedback on a home’s care provision and enables the identification of performance gaps and cost/benefit assessments to be made (UKAF, 2010). In this model we have four major aspects to be looked into namely: planning, doing, checking and acting.
Quality and principles of care
Legislation -these are laws and rules set by the government on how the provision of care should be for example protection of vulnerable adults. In our nursing home, every service provider should be ready to protect all residents from any form of abuse we attend mandatory trainings such as safeguarding vulnerable adults according to regulations by the CQC (2010b).
Safety- in our nursing home we always do risk assessment on every service user and put measures in place like using bed rails to prevent falls by doing this we have protected residents from accidents and this ensures quality service to our residents.
Independence-service users should be made in control of their lives by allowing them to do some of the things like arranging their wardrobes, making and tidying their rooms by themselves because some of the residents are very active and would like to do what they used to do before and we always encourage them to do while we supervise them and this makes them happy hence promoting the quality of service as they are satisfied.
Rights- service users should continue to enjoy the same rights when in nursing homes like they used to when they were living independently. Every service user supported in nursing homes has the right to say “NO”, right to have a relationship and the right to have a say in their care plan. Service providers always tend to balance service users rights against their responsibilities whether both are at risk or not.
1.4) External agencies: These are bodies that regulate quality of care including:
The Care Quality Commission – an independent regulator for health and social care in England (CQC 2010a; 2010b). They regulate care provided by NHS, local authority, private company and voluntary organisations. Their aim is to make sure better care is provided for everyone. In our nursing home Care Quality Commission makes a minimum of three inspections annually (two announced and one unannounced) on such things as how we provide care in terms of cleanliness of the home and to service users.. It has a wide range of enforcement powers to take action on behalf of service users if services are unacceptably low.
The CQC makes sure that the voices of service users are heard by asking people to share their experiences of care services. It makes sure that users’ views are at the heart of its reports and reviews. The CQC takes action if providers do not meet essential quality standards, or if there is reason to think that people’s basic rights or safety are at risk (CQC, 2010) through a wide range of enforcement powers, such as fines and public warnings, and can be flexible about how and when to use them. It can apply specific conditions in response to serious risks. For example, it can demand that a hospital ward or service is closed until the provider meets safety requirements or is suspended.
The National Institute for Health and Clinical Excellence (NICE)- this is an independent organisation responsible for providing national guidance on promoting good health preventing and treating ill health (NICE, 2010). In our Nursing home, residents who have anxiety, panic attacks request for sedatives in order for them to sleep they are usually reassured and instead a government practitioner is consulted to review and advice them accordingly. Service providers take NICE guidelines trainings on different medical conditions for example diabetic foot (identification and care of the foot).
2.1) Quality Standards
Benchmarks: According to Philip B. Crosby (1999) benchmarks are indicators of best practice including access to care environment and the culture of a home. The Benchmarks is one of the most comprehensive sets of social and environmental criteria and business performance indicators available (Daniels et al 2000). Our nursing home is accessible publically, to wheel chairs, a spacious car park and a section for activities for residents and relatives. We also have a signing in visitors’ book stating whom they are visiting.
Code of practice for social care workers and employers for social care workers
This document is developed by General Social Council and it contains agreed codes of practice for social care workers and employers of social care workers describing the standards of conduct and practice within which they should work ( GSCC, 2002). Employers use this set of code of practice to make decisions about the conduct of staff and support social care workers to meet their code of practice. Service users and members of the public use the codes to help them understand the behaviour of social workers (how they should behave towards them) and also how employers should support social care workers to do their job well. It is the responsibility of social care workers to make sure that their conduct does not fall below the standards set in the code of practice and no action or omission harms service users (NCSC, 2010). Social care workers must protect the interests of service users, maintain confidence, respect rights, promote independence, be accountable for the quality of their work and take responsibility for maintaining and improving their knowledge and skills. The general social council expect social care workers to meet the codes and may take actions (deregistering) if registered workers fail.
2.2) Different approaches to implementing quality
Communication is a means of passing information from one person to another. In our nursing home we have different ways of communication like when doing care plans we always document what we have done for a resident so that whoever takes over knows what to do next to ensure continuity of care. Also when handing over is done during change of shifts information about residents is shared and everyone is aware of any changes in care plans in accordance to CQC guidelines (CQC, 2010). We also have staff meetings where certain information is passed on and in cases where staffs have a problem it is addressed and solutions are given out. For effective communication systems there should be a language that everyone understands.
Policies and procedures
These are guidelines set on how to do things often informed through regulations as outlined in various government documents (GSCC, 2002; NICE, 2010; CQC, 2010a. 2010b). In our Nursing home we have different policies and procedures for example in cases of accidents to residents we are required to fill a resident incident report and pass it on to the supervisor families, friends and relatives are informed about the accident then precautions are put into place walking frames, to avoid future occurrences of similar accidents.
Infection control policy helps to prevent spread of infections within our nursing home. We always use personal protective equipment when offering personal care to residents, handling of any infectious wastes. We also use the proper technique for hand washing. There are also hand gels in each resident’s room, in public toilets and at the entrance of the building for sanitation purposes and all wastes like clinical and kitchen wastes are usually put in the bins ready for collection. In cases of disease outbreaks like diarrhoea and vomiting residents are isolated and managed separately and proper hand washing techniques are used to prevent further spread of the infection.
Whistle blowing policy is designed to deal with issues that do not directly affect the employee and their employment but are a cause for concern in relation to the harm that may be done to other employees, residents or the wider community. Any employee who is concerned about their personal situation should raise their concern with their line supervisor or manager. This policy is for reporting issues like elderly abuse, misuse of drugs, faulty machinery that may cause accidents, illegal dumping of waste. The policy protects not only employees but the wide community.
Confidentiality- all residents or service users’ information is private and confidential. It is not a proper practice to discuss residents’ information in public like their conditions and behaviours by doing that is breaching the policy and legal action should be taken. In nursing homes all information is kept safely and only accessible to relevant persons. This promotes quality of service
2.3) Quality systems
ISO 9001 involves a set of procedures that cover all key processes in the business, monitoring processes to ensure they are effective, keeping adequate records and facilitating continual improvement. They have certain requirements like internal regulations, claims and procedures for residents, suggestion box and contract with uses. It also covers the importance of understanding and meeting customer requirements, communication, resource requirements, training and products, Leadership, Involvement of people, Process approach, and System approach to management and Continual improvement (Tricker and Sherring- Lucas, 2001).
In our nursing home for the provision of all these elements and reporting them on day to day basis for example there is a clear procedure for residents’ complains. Carers, residents and relatives are informed and logged in a special complaints book and complains are followed up. When all this are put into practice, there is employee and customer satisfaction, resulting from better defined and implemented business processes. As a result of this we have motivated staffs, who understands their roles and how their work affects quality, improved product and service quality, happier customers, and improved management and operational processes, resulting in less waste (both time and materials)
Business excellence is a widely used framework that helps companies to review their performance and practices in a number of areas and identify targets and actions for improvement based on principles of customer service stakeholder value and process management ( British Quality Foundation, BQF 2010). Managers develop the mission, vision and values and are role models of a culture of Excellence. Studies in Taiwan have shown that in care homes where this model is applied, managers are personally involved in ensuring the organisation’s management system is developed, implemented and continuously improved are involved with customers, partners and representatives of society and also motivate, support and recognise the organisation’s people (Cheng B, Chang, C and Sheng L. 2005). In our nursing home we use a balanced score card to keep track of activities by staff and measure consequences arising based on the British Quality Foundation model ( BQF, 2010).Service users families and relatives measure in a scale of 1-5 where one is poor and five is excellent. We work hard in poorly rated areas to improve the quality of service. At the same time managers set a number of targets on key areas of each staff members roles which are then assessed on monthly review and awards are given to the best. This motivates other team members to work hard and best to attain the best and by doing so they provide best quality and we excel.
2.4) Trainings this refers to a learning process that involves the acquisition of knowledge, sharpening of skills and concepts (Stevens, 2004. In our nursing there are mandatory trainings offered to service providers before commencing to work like basic food hygiene, manual handling
Healthy and safety is ensuring that the environment where we are working is safe for service users, other staff and others in general by our actions and omissions. It is a responsibility to all staff to ensure that the environment is safe to work on. For safety purposes in our nursing home we do not use equipment unless it has been checked and serviced. Also default equipments are labelled “DO NOT USE” to prevent and avoid accidents. We also have controlled cupboards where substances that are hazardous to health are stored and locked away. When there is a defect on the environment like chipped floors, loose hanging electricity wires we report to the maintenance coordinator and they are rectified immediately to avoid accidents. Again when housekeeping team are doing cleaning they always display cleaning boards and everybody is aware that cleaning is on progress or the floor is wet and they avoid using it until it is dry by doing this they minimise chances of accidents like falls
2.5) According to Marshall (2003) and Stevens (2004), external and internal barriers to delivering quality are any obstacle which prevents a given policy instrument being implemented or limits the way in which it can be implemented. They include:
Resources: lack of adequate resources hinders quality of service for example inadequate or shortage of staff affects the quality of services offered and this leads to unsatisfaction of service users as they get services that are not adequate and for service providers because they are overworked. In nursing homes when there are staffs shortages they arrange cover shifts earlier by either bank staff or some agencies registered with the home. Financial barriers include budget restrictions like food supplies and other supplies like incontinent products limits the overall expenditure and this leads to inadequate provision of quality services to residents
Personal Appearance: Hygiene and grooming, eating habits and attire can vary from country to country and culture to culture. For example, some people may wear attire such as a headdress as part of their custom and beliefs. To remain true to their beliefs, some workers may want to continue to wear this dress at their workplace. Employers may view this as inappropriate or unsafe. It is particularly problematic in workplaces where workers wear uniforms.
Religion: In many cultures, religion dominates life in a way that is often difficult for employers to understand. For example, workers from some cultures may want to pray while at work times in accordance with their values and beliefs. There may also be religious holidays on which people of certain religions are forbidden to work. These differences need to be respected, where possible, and not ignored and they affect the quality of service.
Language barriers often go hand-in hand with cultural differences, posing additional problems and misunderstandings in the workplace. When people cannot communicate properly they are frustrated when communicating with supervisors, co-workers and residents this can be dangerous because people may end up performing poorly in their work thus affecting quality of service offered.
Legal and institutional barriers -these include lack of legal powers to implement a particular instrument and responsibilities which are split between agencies limiting the ability of an institution. Like the law states that students should work for twenty hours only which creates shortages at work affecting quality of services.
3.1) According to Business Dictionary.com (2010), policies are principles, rules and guidelines formulated or adopted by an organization to reach its long term goals. They are designed to influence and determine all major decisions, actions and activities take place within the boundaries set by them and procedures are specific methods employed to express policies in action in day to day operations of the organization. For example, in nursing homes the National Care Standards Commission for England, NCSC (2010) has outlined requirements that these homes must meet which in effect guide their policies and principles. These policies include, but not limited to: manual handling procedures, Risk assessment and Infection control.
These are techniques used to handle or move service users like hoisting, using belts and sliding sheets to move residents these are safe procedures for both residents and service providers as they minimise accidents to both cases and this promotes quality of service (CQC, 2010). On the other hand, they have disadvantages like time consuming when doing procedures like hoisting which requires two or three persons and also residents may not like the experiences of hoisting and thirdly it needs trainings to be carried out.
According to healthy and safety at work act (1974) the Management of Health and Safety at Work Regulation (1999) states that it is the responsibilities of managers to do risk assessment to employers and employees. to reduce and prevent risks to them in future and they are included in their care plan so that quality of care can be improved for example residents with risks of falling have walking frames, falling mats and bed rails put in place to avoid falls but again things like bed rails have caused accidents in that residents are trapped and some sustain fractures which affect quality of service
3.2) factors that influence the achievement of quality of personal care
‘Quality’ is a difficult concept to capture directly. However, resident or organisational outcomes are often used as a proxy for quality (Marshall, 2003). There is considerable debate about the relationship between quality of care and quality of life as joint, but not necessarily competing, measures of quality. A study for the Joseph Rowntree Foundation indicates that residents’ perceptions of nursing staff are a good indicator of quality of care (JRF, 2008).The importance of measures of social care and of ‘homeliness’ epitomise the divide between health and social care provision in care homes. Factors influencing residents’ satisfaction with care are discussed below:
Heath care workers working in ‘teams’ has been recognised as an improving the quality of care (Stevens, 2004; Borill et al 1999). According to Stevens, the intention is for carers to share tasks and learn from each other and possibly improve based on their experiences. This can be illustrated by the quotation below:
“The best and most cost-effective outcomes for patients and clients are achieved when professionals work together, learn together, engage in clinical audit of outcomes together, and generate innovation to ensure progress in practice and service.” (Borill et al 1999 p.6).
Stevens has for example reported from a number of surveys from UK nursing homes to suggest that there is a reduction in carer burden and significant reduction in stress when staff work in teams resulting in better coping and satisfaction. Both these studies (Stevens, 2004; Borill et al 1999) found that service users surveyed showed more satisfaction when carers and health workers worked in teams
Healthy and safety at work
The responsibilities of care home proprietors are subject to a range of health and safety legislation among them the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 which require employers to assess the risks to employees and other who may be affected by their undertaking, (residents) and the control of Substances Hazardous to Health Regulations ( Care Quality Commission, 2010).
These regulations have led to dramatic improvements in the safety of residents and people working in care homes according to the care quality commission. For instance, guidelines requiring minimalist manual handling has significantly reduced the numbers of health workers staying off work due to illness which has a positive effect on the level of personal care of residents ( CQC, 2010a). However, a report for the Joseph Rawtree Foundation (JRF, 2008) showed that the percentage of medication errors and adverse events in nursing homes
have increased despite regular inspections by the CQC. Stevens (2004) has also reported survey results from 27 residential homes with dementia patients where 19% cases of medication errors were reported.
In my care setting, clear improvements can be seen from less harm to residents when using the hoist but not many service users like to use the hoist. Some risk assessments in care homes have made it very difficult to take residents outdoors or even for activities outside the home for fear of not meeting the Health and safety requirements and this ends up reducing the quality of care.
3.3 The following recommendation can improve the quality of care in Nursing homes
This means acquiring knowledge and skills or new information on how to do things according to the recommended regulations and standards ( Stevens 2004). This is a very important aspect in nursing homes all trainings as it provides ongoing trainings to update service providers and equip them with relevant and current information that enables them to provide the best quality of care that will be satisfactory to service users. In our nursing home trainings are offered and need to be implemented then supervision is done and in cases where need for retraining arises, arrangements are done and they are offered for the benefits of service users, service providers and the community at large as it reduces or minimises preventable accidents and this promotes the quality of service
This means going through the set of targets or planned activities to see the progress whether it is improving or getting worse. This alerts and actions or precautions are put in place to make the situation improve for better quality of service ( Stevens, 2004). For example in our nursing home there are always monthly reviews of care plans of service users this includes individual or family interviews to determine whether residents are improving or need some improved care plans like in moving and handling procedures (use of hoist or belts) and then action is taken accordingly. Also for staff there is quarterly staff meetings or when need arises and previous discussed or current issues are raised and a way forward on how to carry on is agreed. There are always individual supervisions done by allocated persons and each employee identifies areas that need improvement and good performing areas by doing this there is improvement of quality of service
It has been shown that in order to improve services to users in the social care sector, it is important to follow principles, guidelines and procedures set by government, industry bodies or even individual homes. There is also need for planning, doing and checking and then reviewing to assess shortcomings in order to design improvement regimes. Similarly, it has been shown that although there is legislation and care industry standards, it will require long term commitments in developing methods, instruments and communication procedures involving all stakeholders at care or residential home level.
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