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Commitment to Quality

Our commitment to providing a high quality service is reflected in everything we do. We provide a needs led, responsive, high quality of care service, which promotes outcome focused recovery and independence and is targeted to improve the well-being and quality of lives, for those individual’s that we are supporting.  We are always receptive to any feedback and suggestions to improve the quality of the services we provide. 


We recognise the importance of maintaining a quality service and regard it as essential that the quality of the care individuals receive is carefully monitored to maintain, and exceed where we can, the standards of care required for a company such as ours.

Quality assurance systems are central to this process to ensure that our high standard of service delivery is maintained.

We monitor the quality of our service provision by:

·      comprehensive systems monitoring at our weekly operations meeting

·      regular and on-going discussions with individuals in our care including monthly house meetings in the residential care homes

·      carefully selected and trained social care staff

·      comprehensive inductions, mandatory training requirements and specialised training programs and reflective practice sessions, regular staff supervision, probationary periods, appropriate training, annual appraisals

·      regular staff team service meetings

·      gathering feedback from individual’s, relatives, stakeholders, inspectors, other external organisation’s and visitors by feedback questionnaires and monthly newsletters

·      responding to and investigating all complaints received

·      compliments received

·      RI quarterly audits of the services and facilities that we provide

·      additional internal audits as required

·      annual quality assurance reports for each service

·      regular policy review

·      CIW (Care Inspectorate Wales) inspections

·      National Collaborative Framework for Younger Adults commissioning (All Wales Framework) audits

·      External Health and Safety Consultant- Anthony Arcari- AA Consultancy

·      External Fire Risk Assessor- Shaun Doyle- Ivorfire

·      ISO 9001:2008 compliance and QMS International audits (need to decide re this)

Our quality assurance systems ensure that we continually focus on the quality of all aspects of the services that we are providing to:

the individuals in our care the stakeholders that choose to place with us and the staff that we employ.

We ensure that we continue to meet all regulatory and legislative requirements in our residential care homes and the domiciliary care agency support that we provide and we continue to receive excellent CIW (Care Inspectorate Wales) inspection reports on our services.

Here is some feedback from the latest CIW inspections:

Cadoc House- last Care Inspectorate Wales (CIW) inspection Jan 2018

Cadoc House provides a good quality service where people are supported to lead as independently as possible with the help they need, when they need it and in the way they want. The people who live there are able to express their views and opinions and are clearly listened to and their needs are understood by staff. The home is well managed and staff are trained and supported to ensure good outcomes for people.

The service is committed to quality assurance and the views of people who use the service, staff and professionals are taken into account to develop and improve the service. We saw that the manager and provider assessed the quality of the service in a variety of ways. For example, monitoring staff performance and paperwork; feedback from people during reviews, monthly meetings and through questionnaires; feedback from staff during team meetings; letters and cards of thanks from relatives; questionnaires completed by social workers and health professionals; monthly visits by the responsible person and maintenance manager and comments and complaints logs. The quality of care report was available at the time of inspection. The report was very comprehensive and referenced comments and feedback from people living in the service, their relatives, staff and visiting professionals. The achievements over the past year were listed along with improvement plans. People receive good quality care and support from a service which sets high standards and is committed to constant improvement.

Gordon Rd- last (CIW) inspection Oct 2017

There are robust systems in place to measure the quality of the service. Both staff and residents told us that their views were sought and acknowledged by the manager and the wider organisation. The quality monitoring report was comprehensive, detailed and evidenced considerable contact with staff and residents, whose views were sought and recorded. An action plan was drawn up after each visit and was followed up at the next. The annual quality assurance report included lessons learned and an action plan. It was detailed and comprehensive and addressed issues that had been discussed. People benefit from a service that is committed to quality assurance and constant improvement.

Dom care- last (CIW) inspection Oct 2016

People feel they get reliable, good quality care. This is because the provider has a quality assurance monitoring system in place. From examining documents we found that the responsible individual and quality manager carried out a very detailed quarterly audit of the service. We talked with the quality manager about the methods they used to ensure people received a good service. We were told that client satisfaction surveys were carried out and we saw evidence of this. Feedback we read included comments such as, “The staff have done everything to help me feel safe,” “Any issue I have had has been approached really well and resolved quickly- I have not felt the need to make any formal complaints,” “Love it here, the atmosphere, nice people working here.”

People can be confident that they are safe because the business is well run, with due care and attention to minimum standards and regulations. They can be confident that if things are not right they will be addressed quickly. Management are competent and responsible.

St Johns House- last (CIW) inspection Sept 2017

People’s needs and risks are carefully anticipated and planned for. We sampled two people’s care documentation. Pre-admission assessments were completed by a clinical nurse specialist employed within the organisation. The assessments were thorough as they evaluated, amongst other areas, the reason residents were referred to the service, their psychiatric history, family history and the risks to themselves and/or others. They included discussions with the resident and were informed by input from health and social care professionals. Care plans were relevant and contained appropriate detail and there was a system for reviewing them regularly by a key worker, in line with regulatory requirements.

People’s risk assessments were reviewed at the same time as their care plans, which we considered was good practice. As referred to above, people’s wishes and views were sought and documented and they countersigned and dated their care documentation.

Again, we considered this was good practice as it demonstrated people were consulted regarding their care which helped promote a sense of ownership. We therefore judge there are robust systems to ensure the needs of people are properly assessed, planned for and reviewed.

National Collaborative Framework for Younger Adults commissioning (All Wales Framework)

As part of the National Collaborative Framework for Younger Adults commissioning (All Wales Framework) we have achieved and maintained a 3 Q  Quality Assurance rating  from their commissioning audits since 2016.

Being awarded a 3 Q is the highest rating achievable.

The 3 Q quality assurance rating system is a methodology of ranking providers services by applying a quality assurance rating system (QARS) - designated by the letter “Q”.

The Quality Assurance Rating is important as it forms part of the process on which the framework orders services - the placements with the highest quality assurance will be rated first This ranking enables commissioners to select the best homes and choose them first wherever possible. The Framework sets out in a Wales-wide agreement what the Welsh NHS and local authorities require from Care Homes when they place adult mental health and learning disabilities clients. The Framework is designed to help achieve value for money combined with quality standards and ongoing improvements in quality.

At the heart of the Framework is a set of six quality standards which Care Homes are required to meet, all of them with a focus on the resident’s experience.

Standards are measured by

1. Being safe -Incidents, complaints, and the Care Home’s responses to these.

2. Feeling at home -The cleanliness of the Home and the state of furnishings and décor.

3. Valuing each other- The mix of social activities - and checking with residents that they are engaging in the activities and making progress.

4. Being healthy- Whether physical health needs are met and recording when they are not.

5. Recover and stay well -The resident’s engagement with their own individual care plan and regular review of the plan with the resident.

6. Progress and move on- The right staff being in place supporting the resident to maximise their personal independence.

The Framework sets out the criteria which will be used to select a suitable Care Home for each individual client. This system is aimed at achieving consistency and getting the best result in terms of suitability for the client, quality, and value for money.

Six criteria are used in making the selection:

Care Home/Setting - what type of Care Home is required

Availability - what places are available in the locality where the placement is needed

Assurance Rating - how well the Care Home has scored in terms of quality(Q rating)

Price - best price available so that the commissioner gets value for money

Other costs - such as additional care required for the specific client

Essential requirements- such as single sexed or mixed