ASQ – Guidance for Providers Final - Durham · Section Page No Introduction 3 Completing the ASQ...

1 ASQ – Guidance for Providers Final


Contents Section Page No Introduction 3 Completing the ASQ 3 Core and specific service standards 4 Providing Evidence for the ASQ standard measures 6 Links to Outcomes Links to Regulators, Recognised Good Practice Guidance and Legislation

7 7

Rating the ASQ standard measures 9 Submitting the ASQ 9 Post-submission of ASQ 9 Validation of ratings Collation and analysis of information Outcome of the ASQ

10 10 10

Contact us 11 Appendix 1 – Suggested sources of evidence 12 Core standards: Standard 1 – Staffing and Volunteers 12 Standard 2 – Involving Service Users/Carers 15 Standard 3 – Safeguarding and Protection from Abuse 19 Standard 4 – Security, Health and Safety 24 Standard 5 – Needs and Risk Assessment 27 Standard 6 – Care and Support Planning

30

Service specific standards: Standard 7 – Health and hygiene (including infection control) Standard 8 – Medication Standard 9 – Nutrition and Hydration Standard 10 – Deprivation of Liberty Standard 11 – End of Life Planning Standard 12 – Transport Standard 13 – Supporting Unpaid Carers

33 35 37 40 42 43 45

Introduction


The Assessment of Service Quality (ASQ) is an annual self-assessment within a Monitoring and Review Framework which enables Commissioners to ensure that providers are delivering high-quality services and achieving successful outcomes for service users against core and service specific areas entitled “standards”. It offers providers the opportunity to showcase services and to demonstrate strengths in supporting people to meet their needs and fulfil their goals and aspirations. To gain maximum benefit from the ASQ, both Commissioners and providers should embrace it as a tool for improving service quality. Taking a partnership approach, the ASQ can be used to promote a shared understanding of services and create an environment in which informed planning of quality improvements can happen. The ASQ can be used as part of your organisation’s own self-assessment and action planning and should add value to your own quality assurance processes used to gather, record and evaluate accurate information about the quality and safety of the service offered and care and support delivered. Under the terms of your contract with Durham County Council (DCC), you must complete and submit the ASQ annually, the outcome of which will feed into a quality visit or full review of your service undertaken by DCC at a minimum of once every three years. Completing the ASQ In Part A of the ASQ, you must complete a snapshot of current practice against six core standards and a number of service specific standards depending on your service type. It is up to you to decide which service specific standards you complete but Commissioners may contact you if you have missed a service specific standard that they consider could be relevant to your service type. You must also identify areas for continuous improvement within your service, state how you intend to improve outcomes for service users over the next 12 months and highlight any areas of added value. DCC are keen to capture good practice examples of increasing social value under any of the sustainability themes: environmental, economic and/or social outcomes and you can also use this section to include any examples. In Part B of the ASQ you must confirm that relevant policies and procedures are in place and are current by completing a checklist indicating whether the policy and procedure is relevant to your service, is in place and has been reviewed within the last three years. It is not the intention of the ASQ to dictate the form your policies take. It is therefore acceptable that certain policies and procedures may be combined, for example a policy to cover diversity could include expectations regarding equal opportunities. It is also not the intention of the ASQ to dictate service standards set out in policies and procedures unless there is a statutory and/or contractual requirement. It is the expectation of DCC, however, that providers will ensure policies and procedures reflect current legislation (where appropriate), good practice and any relevant guidance. You will have four weeks from the date of request to complete your ASQ. For more information on how to submit your ASQ please see “Submitting the ASQ” below.


If you have more than one service or contract with the council please follow the guidance below:

1. If you have one service please complete one ASQ 2. If you have more than one service but service provision is exactly the same and there are no areas within a particular service you wish to

highlight please complete one ASQ 3. If you have more than one service and they are different service types, eg respite and day care, please complete at least one ASQ per

service type as per rules 1 and 2 above 4. If you have more than one service, service provision differs in places and/or there are areas within a particular service you wish to

highlight please complete an individual ASQ for each service Core and service specific standards The ASQ contains six core standards which all1 providers contracted with DCC will need to complete as a minimum. Depending on your service type, some providers will need to complete additional service specific standards which are relevant to your service. Core Standards Standard No Standard Description Standard 1 Staffing and Volunteers Staff and volunteers have the appropriate skills, knowledge and abilities to

maximise positive outcomes for service users Standard 2 Involving Service Users/Carers Service users and carers are empowered and supported to get involved and

have choice and control Standard 3 Protection from Abuse The welfare of people using, visiting or working at the service is safeguarded

and the provider proactively works in partnership to protect vulnerable people from abuse

Standard 4 Security, Health and Safety The security, health and safety and wellbeing of people using, visiting or working at the service is protected

Standard 5 Needs and Risk Assessment The needs and risks of people accessing the service are identified and addressed appropriately

Standard 6 Care and Support Planning There are plans in place which take into account people’s views, preferences and aspirations, are reviewed appropriately and address the needs and risks

1 If you are a provider of equipment, maintenance or handypersons services only, please ensure that you complete the “ASQ for Providers of Equipment, Maintenance or Handypersons Services” which will be provided to you separately by the Commissioning Service together with an accompanying guidance document. Providers of residential and nursing care for older people are currently exempt from this process.


identified through the assessment process Service Specific Standards Standard No Standard Description Standard 7 Health and Hygiene (including

infection control) The provider ensures that the service is kept hygienic and clean throughout and there are robust systems and processes in place to control the spread of infection

Standard 8 Medication People are supported to take their medicines when they need them in a safe and effective manner supported by qualified and competent staff who work to robust standards regarding medication management

Standard 9 Nutrition and Hydration The Provider ensures good management of nutrition and hydration which leads to a healthy diet, aids a service user’s recovery/rehabilitation and safeguards those at risk of undernutrition

Standard 10 Deprivation of Liberty The service has a clear process to identify people who may be deprived of their liberty, refers them to the Supervisory Body for a Best Interests Assessment under the DOLS regulations, implements the outcome and conditions within its care planning processes and reviews the arrangements in a timely fashion

Standard 11 End of Life Planning People’s wishes regarding end of life care are included in assessments and plans and are reviewed appropriately

Standard 12 Transport Providers ensure the provision of safe and appropriate transport for service users which is subject to robust risk assessment

Standard 13 Supporting Unpaid Carers Unpaid carers are supported in their caring role and also to have a life outside their caring role

Each core and service specific standard is broken down into a number of “standard measures”. For example: Standard 1 – Staffing and Volunteers Standard Measure 1.1 - A safe and robust process is followed when recruiting new members of staff and volunteers Standard Measure 1.2 – Disclosure and Barring (DBS) checks are in place and reviewed when appropriate and there is a process for managing positive disclosures


Providing Evidence for the ASQ standard measures You are required to provide examples of evidence which demonstrate that you meet the relevant standard measure either in whole or in part and which supports your RAG (Red, Amber, Green) rating for that particular standard measure (see below for more on rating your ASQ). Your evidence should draw on service user/carer experience, involvement and outcomes. Examples of evidence are provided in Appendix 1, however, these are for guidance only and should not be used as your only sources of evidence. You are able to include service information which is not funded by DCC but this should be clearly indicated. Each standard measure is categorised as “Essential” (E), “Important” (I) or “Good Practice” (GP) and this is indicated both in this guidance document and under each standard measure number within the ASQ. Definitions are given below: Category Definition Essential An absolutely necessary, indispensable element of the service without which the provider could not be assessed as

delivering an acceptable level of service to service users Important An element of the service which is of great significance and/or adds value to the service but is not essential to the

provider being assessed as delivering an acceptable level of service to service users Good Practice An element of the service which is advanced, innovative and/or adds value to the service but is not essential to the

provider being assessed as delivering an acceptable level of service to service users You are not expected to provide examples of evidence for every standard measure within each overall standard, however, you should ensure that you provide examples of evidence for all of the standard measures marked as “essential (E)” as a minimum. If you are unable to provide examples of evidence for any of the “essential” standards then you must propose action in the “Continuous Improvement” or “Improving Outcomes” boxes at the end of each standard as to how you will achieve compliance with that standard measure and in what timescale. You may also use these boxes to demonstrate how you intend to progress from one rating to another and to highlight priority areas for attention. If you believe that you have an area of “outstanding practice” which exceeds the definitions of “essential”, “important” and “good practice” as set out above, please tell us about it in the “Outstanding Practice” box at the end of each section. After service review, and with your permission, we may use this as beacon for other providers. Examples of your evidence should be clear and succinct and you should use bullet points where appropriate. A maximum of 500 words is recommended as an upper limit for each of your answers given in the free text boxes.


Complete policies and procedures should not be used as examples of evidence. You can, however, refer to the relevant policies and procedures and include short extracts to demonstrate compliance with the standard measure. Information you provide in the ASQ may be subject to Freedom of Information (FOI) requests. DCC, however, are able to exempt or redact information provided, for example, if that information could be commercially sensitive or include personal information. You do not need to submit any actual evidence with your ASQ, although you should ensure that all of your evidence is documented and accessible as it could be validated at a quality visit at any time or at service review. Links to Outcomes It is widely agreed that the quality of a service can be measured by the outcomes it produces for those people in receipt of that service. Whilst recognising the importance of processes, procedures and practice, the aim of the ASQ is also to allow providers to set out plans for continuous improvement over the following 12 months and to demonstrate how outcomes for service users will be improved. Each standard of the ASQ links to one or more high-level outcome headings from the Commissioning Service’s Outcomes Framework and these are clearly set out both in this guidance and under each standard heading in the ASQ tool. Details of all outcomes included in the Outcomes Framework can be found at www.durham.gov.uk/asq Links to Regulators, Recognised Good Practice Guidance and Legislation Although the ASQ reflects contract compliance and seeks to promote continuous service development and improved outcomes for service users, there are parallels with the expectations of regulators (CQC and Ofsted). The aim is for the ASQ to complement other regulatory frameworks, to enhance completion of all frameworks for providers and to avoid duplication of effort. For those providers who are regulated, links have been made within this guidance document where comparisons can be made with other regulatory requirements for ease of completion and where evidence may be used for both. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and advice to improve health and social care. In addition to the above, you may wish to refer to NICE social care guidelines which can help you demonstrate the quality of your services (www.nice.org.uk and click on “NICE Pathways” in the menu bar). The Mental Capacity Act 2005 underpins all of the standards contained in the ASQ. Consideration of the Mental Capacity Act should be referenced when providing evidence of the core standards and service specific standards. Suggested links to other pieces of legislation that you may wish to reference are listed in the guidance document.

http://www.durham.gov.uk/asq

http://www.nice.org.uk/


Rating the ASQ standard measures You must rate each individual standard measure by placing a “X” in the relevant box on the ASQ. Ratings should be applied as follows: Green Standard measure fully

achieved There is sufficient evidence to demonstrate that the service consistently meets the standard measure all of the time and all related outcomes are achieved for all service users all of the time.

Amber Standard measure partially achieved

There is sufficient evidence to demonstrate that the service is achieving the standard measure and/or identified outcomes for service users most of the time, however, it is unable to demonstrate it consistently meets the standard measure and/or related outcomes for service users all of the time.

Red Standard measure not yet achieved

There is insufficient evidence to demonstrate that the service is meeting the standard measure and/or identified outcomes for the majority of service users at any time.

N/A Standard not applicable The standard measure is not relevant to the service and could not be achieved even through continuous improvement.

Having a “red” rating is not always perceived as negative. Some of the standard measures may only be achieved through continuous improvement and can provide direction as to how services can be enhanced. The “not applicable” rating should only be used when a standard measure could never be relevant to your service, even with continuous improvement, and you should provide your reasons for why the standard measure is not applicable in the comments box attached to that standard. Submitting the ASQ This document should be completed on-line via SNAP (an on-line survey system). The link to SNAP is https://www.snapsurveys.com/wh/s.asp?k=149037537985 . If you are unable to complete the ASQ on SNAP, please contact the Commissioning Service at [email protected] or by telephoning 03000 266837. You will have four weeks to submit your ASQ from the date of request. Using SNAP you will be able to save your document as you work through it if you need to return to it later. You are able to use the “cut and paste” function in SNAP and you will be able to save a hard copy or print a copy.

https://www.snapsurveys.com/wh/s.asp?k=149037537985

mailto:[email protected]


As mentioned above, you do not need to submit any actual evidence with your ASQ. If we need further information we will contact you. The DCC Commissioning Team reserve the right, under the terms your contract, to undertake a quality visit at any time to validate your evidence and examples of evidence will be requested at service review. See below for further details. Post-submission of ASQ Validation of ratings Members of staff in the DCC Commissioning Team will validate your ratings based on the examples of evidence you have provided. The examples of evidence given and the RAG ratings in your annual ASQ will be collated and will feed into your service review which, routinely, will take place once every three years. Any of the events outlined in (2) below, however, can trigger a quality visit or expedite your service review. Collation and analysis of information Information from your ASQ will initially be collated within SNAP. Further analysis of information provided may be undertaken by the DCC Commissioning Team, for example, across service type, service user group or by location. Durham County Council is a data controller for the purposes of the Data Protection Act. We take our responsibility to protect your information seriously and we will use it in accordance with the legal requirements of the Data Protection Act 1998. The information you provide will be used for contract monitoring and service review purposes and we will only share information with your consent unless there are exceptional circumstances for doing so such as risk of harm to individuals or for the prevention and /or detection of a crime. Where information is used for analysis and/or to share good practice information that could identify your organisation will be removed. If there is any possibility that you could be identified, consent would be obtained before information is shared for such purposes. Outcome of the ASQ There are two possible outcomes from the ASQ. (1) No further action required


If, after validation, Commissioners do not wish to check evidence in any areas of the ASQ then no further action will be required until the next annual ASQ or service review. Providers will receive confirmation of this via email. (2) Some action is required If Commissioners would like to take any further action following submission of the ASQ, for example, clarification about evidence provided for a standard measure or generally need to discuss any aspect of the ASQ then providers will be contacted by telephone or by email to discuss any further action required. A quality visit may be undertaken by the Commissioning Team at any time determined by factors including (though not exhaustive):

• Gaps in examples of evidence provided • Further discussion required regarding examples of evidence • Validation of evidence • Intelligence received about services • Contract compliance issues

NB: Safeguarding issues will be dealt with under existing procedures but may trigger a quality visit or expedite service review. (Further details relating to quality visits and service reviews is available from the Commissioning Service). An action plan may be requested setting out agreed actions between providers and Commissioners including clear timescales for improvement and can be requested with or without a quality visit having been undertaken. Contact us If you have any queries about the ASQ please do not hesitate to contact us by emailing [email protected] or by telephoning 03000 266837.

mailto:[email protected]


Appendix 1

Suggested sources of evidence Standard 1

Examples of Prompts/Links

Staffing/Volunteers Staff and volunteers have the appropriate skills, knowledge and abilities to maximise positive outcomes for service users

DCC Outcomes: Economic Wellbeing, Be Healthy, Stay Safe, Enjoy and Achieve, Make a Positive Contribution CQC Service Standards: Safe, Effective, Caring, Responsive, Well-led Ofsted Inspection Judgements:

Children’s Homes: Overall experiences and progress of children and young people living in the home, Children and young people are helped and protected (key judgement), Impact and effectiveness of leaders & managers Boarding and Residential Provision: Overall experiences and progress of children and young people living in the home, Quality of care and support, children and young people are protected, Impact and effectiveness of leaders & managers Independent Fostering Agencies: Quality of service provision, Safeguarding children and young people, Leadership and management

Relevant Legislation Mental Capacity Act 2005 Mental Health Act 1983 Care Act 2014 Human Rights Act 1998

Standard Measure

Suggested sources of evidence/guidance notes

1.1 (E)

A safe and robust process is followed when recruiting new members of staff and volunteers

• Interview assessments • References • Investigation into gaps of employment

1.2 DBS checks are in place and • DBS checks on all staff prior to commencement of employment and updated in accordance


Standard Measure


(E) reviewed when appropriate and there is a process for managing positive disclosures

with policies and procedures • Investigation of positive disclosures, eg risk assessments

1.3 (I)

Staff and volunteers complete a comprehensive induction before working with service users and, where relevant, carers

• Signed copies of induction records (organisational and service specific) • Up-to date job descriptions

1.4 (E)

There is a commitment to staff and volunteers’ professional and/or personal development (including training) appropriate to the service and nature of the role

• Statutory/in house training • Team meetings • Supervision and appraisal records

1.5 (I)

Staff and volunteers receive regular supervision and appraisal

• Structured supervision and appraisals undertaken on a regular basis in line with policies and procedures

• Supervision covering issues relating to workload, health, training, personal development and quality assurance with evidence of input and signatures from both parties

• Appraisals covering issues relating to workload, health, training, personal development and quality assurance with evidence of input and signatures from both parties

1.6 (I)

Staff, individually and collectively, have the skills, knowledge and experience to deliver the care and support services the service provides

• Statutory/in-house training • Guidance, coaching and awareness raising • Team meetings

1.7 (I)

Staff and volunteers have access to communication methods and events where they have time to reflect on practice and quality matters

• Signed handover records covering the needs/issues of all service users and practice and quality matters

• Effective communication between management and staff and volunteers • Guidance, coaching and awareness raising

1.8 (E)

Staffing levels are sufficient and appropriate to meet service user needs at all times

• Appropriate skill-mix • Training matrix • Staff rotas in line with the service’s prescribed levels

1.9 Feedback from staff and • Staff satisfaction surveys


Standard Measure


(GP) volunteers influences service development and planning

• Team meetings • Changes to service provision stemming from the above sources


Standard 2


Involving Service Users/Carers Service users and carers are empowered and supported to get involved and have choice and control

DCC Outcomes: Make a Positive Contribution CQC Service Standards: Safe, Effective, Caring, Responsive, Well-led Ofsted Inspection Judgements:

Children’s Homes: Overall experiences and progress of children and young people living in the home, Impact and effectiveness of leaders and managers, Children and young people are helped and protected (key judgement) Boarding and Residential Provision: Overall experiences and progress of children and young people living in the home, Quality of care and support, Children and young people are protected, Impact and effectiveness of leaders and managers Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Experience and progress of and outcomes for children and young people who receive short breaks, Quality of service provision, Safeguarding children and young people, Leadership and management


Standard Measure


2.1 (I)

Information about the service is available which will enable people considering accessing the service to make an informed choice as to whether the service is right for them

• Material available in different formats (eg easy-read), languages and from different sources (eg leaflets, website) publicised to potential service users and carers and agencies

• Service statement of purpose - setting out aims and objectives of the service, eligibility criteria, how to access the service, terms and conditions of service and description of service offered

• Eligibility criteria and application process actively promoted to relevant agencies and within the wider community


Standard Measure


• Reference to the principles of the Mental Capacity Act as they apply to this standard and how they are applied to choice and decision-making in accessing services

2.2 (I)

Relevant, up-to-date service information is given to service users and carers upon their commencement of the service

• Handbook in an accessible and appropriate language / format • Reference to the principles of the Mental Capacity Act as they apply to this standard and how

they are applied to choice and decision-making in accessing services

2.3 (I)

Service users and, where relevant, carers are treated with dignity and respect at all times, including giving them privacy when they need and want it and are treated as equals

• Certificated dignity training - reviewed/updated as appropriate • Dignity champions • Practical examples from care and support plans

2.4 (I)

Service users are encouraged and supported to maintain and/or develop their independence and have choice and control over day-to-day decisions

• Person-centred care and support plan which reflects personal preferences, likes and dislikes and daily routines

• Active and ongoing discussions with service users • Statement of rights and responsibilities includes the right to be involved in decisions • Reference to the principles of the Mental Capacity Act as they apply to this standard and how

they are applied to choice and decision-making in accessing services 2.5 (I)

Services users are encouraged and supported to participate in the wider community

• Feedback from service users, carers, families and/or advocates of specific initiatives that have expanded the service user’s skills, confidence and self-esteem

• Availability and accessibility of information on services, activities and opportunities for leisure, arts, sports, training, education and employment appropriate to individual needs

• Employment, education, volunteering and social and leisure activities outside of the service are covered in care and support plans

2.6 (I)

Service users and carers are made aware of the complaints procedures and how to use them and communication barriers are overcome where necessary

• Service users, carers and families know how to access and use the complaints procedure and feel supported and confident that they are ‘listened to’

• Service user satisfaction surveys • Information available in appropriate formats

2.7 (E)

Service users and carers have access to information on independent advocacy services

• All types of advocacy services to be considered, including informal, peer, representative and statutory including IMCA and IMHA

• Written processes


Standard Measure


and are supported to access them

• Information available in appropriate formats

2.8 (I)

Staff receive appropriate guidance, instruction and coaching in all aspects of handling and recording comments, compliments and complaints received from service users and carers

• Complaints Log records the status and outcomes to complaints and shows that appropriate action is taken within specified timescales and enables trends to be identified

• Examples of service development following comments, compliments and complaints • Outcomes of complaint investigations are fed back to complainants

2.9 (I)

There is a duty of candour to ensure that when something goes wrong service users and carers are told what has happened, provided with support where required and receive an apology

• Written processes • Records of events • Lessons learnt documented and changes implemented

2.10 (GP)

Regular assurance checks are made as to whether there is sufficient awareness of the complaints procedure and other systems for capturing service user and carer views and to identify what might inhibit service users and carers feeding back their views

• Review of procedures includes assessment of whether there is sufficient awareness and what might inhibit complaints

• Records of the review process demonstrate participation and consequent changes or improvements to both the complaints procedure and the service

• Practical examples of proactive consultation with service users and carers, families and relevant stakeholders

2.11 (GP)

Comments, compliments and complaints are proactively used in service development and planning with the involvement of service users and carers

• Records of the review process demonstrate participation and consequent changes or improvements to both the complaints procedure and the service

• Practical examples of proactive consultation with service users, carers and families • Examples of recent improvements made as a result of service user, carer or family member

feedback or complaint

2.12 (GP)

Service users and carers are involved in the review of policies

• Records of reviews demonstrate participation and consequent changes or improvements to policies and procedures and the service


Standard Measure


and procedures in general • Reference to the principles of the Mental Capacity Act as they apply to this standard and how they are applied to choice and decision-making for those unable to make their views known

2.13 (GP)

Service user and carer views are pro-actively sought through regular consultation and other clear and accessible systems and are used to influence service development and planning

• Service user surveys/questionnaires • Meetings and minutes • Comments box


Standard 3


Safeguarding and Protection from Abuse The welfare of people using, visiting or working at the service is safeguarded and the provider works proactively in partnership to protect vulnerable people from abuse

DCC Outcomes: Stay Safe CQC Service Standards: Safe, Responsive Ofsted Inspection Judgements:

Children’s Homes: Overall experiences and progress of children and young people living in the home, Children and young people are helped and protected (key judgement), Impact and effectiveness of leaders and managers Boarding and Residential Provision: Overall experiences and progress of children and young people living in the home, Quality of care and support, children and young people are protected, Impact and effectiveness of leaders & managers Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Experience and progress of and outcomes for children and young people who receive short breaks, Quality of service provision, Safeguarding children and young people


Standard Measure


3.1 (E)

Staff and volunteers understand and implement policies and procedures concerning safeguarding and protection from abuse

• Training records and signed evidence of staff and volunteers understanding policies and procedures (including whistle-blowing)

• Verification that staff and volunteers understand the principal features of policies and procedures and how they impact on their work

• Reflection on incidents that have occurred, lessons learnt and implementation of changes

3.2 Staff and volunteers receive • Certificated safeguarding training including how to recognise symptoms of abuse or neglect -


Standard Measure


(E) appropriate training in safeguarding and protection from abuse

reviewed/updated as appropriate • Competency assessments of staff • Training records and signed evidence of staff understanding policies and procedures

3.3 (E)

Staff and volunteers are made aware of and understand their professional boundaries

• Induction, supervision and appraisal and training specifically address the nature and limits of relationships between staff and service users.

• Code of Conduct • Information detailing advice and requirements in respect of employee responsibilities around

professional boundaries and financial issues

3.4 (I)

Information is provided on safeguarding and protection from abuse in various places and different formats

• Information is widely provided to service users, carers, families, staff and visitors which explains how to raise concerns and what to do when concerns are raised

• Information is available in different languages and formats • Information includes contact details for concerns and referrals • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may be unable to understand principles relating to safeguarding and protection from abuse

3.5 (E)

Proactive systems are in place to prevent, identify, act promptly and, where appropriate, escalate safeguarding and protection from abuse issues identified by staff, volunteers, service users and carers

• Appropriate recording system that documents details of all safeguarding incidents including decisions reached, appropriate action taken and lessons learnt

• Provider audits of safeguarding incidents and issues and lessons learnt • Examples of whistle-blowing

3.6 (E)

Staff and volunteers are aware of County Durham’s procedures to report safeguarding and protection from abuse issues

• Policies and procedures are publicised/shared in appropriate ways • Information includes contact details for concerns and referrals • DCC certificated training – reviewed/updated as appropriate

3.7 (I)

Service users and carers are aware of and have an understanding of the procedures for reporting abuse or neglect

• Service users/carers understand what constitutes abuse and know to whom they should report actual or suspected abuse or neglect

• One-to-ones with service users/carers, house meetings etc • Website


Standard Measure


3.8 (I)

Support (including advocacy) is available and offered to service users and, where appropriate, carers experiencing abuse or neglect and to their carers

• All types of advocacy services to be considered, including informal, peer, representative and statutory including IMCA and IMHA

• Service users confirm that they have been offered advocacy services when appropriate • Relevant documentation details involvement of advocate

3.9 (E)

An individualised behaviour support plan is in place where a service user exhibits challenging behaviour

• Individualised Behaviour Support Plan is in place, where appropriate, and should include: o any restrictive interventions that may be required and the reasons for these o name(s) of those consulted on possible interventions o procedure(s) to be followed if restrictive interventions are required o details of proactive strategies to be used eg Positive Behaviour Support o evidence of service user/appropriate other involvement in the Behaviour Support

Plan o evidence of multi-agency care planning which considers risk and Mental Capacity

Act principles • Following an occasion when a restrictive intervention has been used (whether planned or

unplanned) the following documentation is completed within 24 hours and forwarded to the organisations Health and Safety Manager / Service Manager :

• Accident, Incident, Ill Health or Near Miss report forms

3.10 (I)

Service users receive appropriate levels of proactive support to manage their own finances and/or maintain as much financial independence as possible including support being offered to their carers

• Needs and Risk Assessments/Care and Support plans • Service user files • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to manage their own finances or make decisions about their money

3.11 (E)

Where service users are unable to take responsibility for the management of their own finances, details are recorded on risk assessments, action is taken to minimise any risks and regular

• Transparent financial records which are up to date, accurate and signed by the responsible person and counter-signed by another member of staff

• Audits are undertaken either independently or by management • Invoice process


Standard Measure


audits are undertaken of financial records

3.12 (I)

Service users have financial involvement in shared household finances and any other collective pots of money, where appropriate

• Clear and robust policy • Discussion of funds at house meetings (minutes taken). Any type of “collective” finances

should be included • Notes on service user files

3.13 (GP)

Service users and carers are involved in reviewing policies and procedures around safeguarding and protection from abuse

• Records of the review process demonstrate participation • Service users confirm involvement in reviewing of policies and procedures

3.14 (GP)

Learning from safeguarding and protection from abuse instances within the service are proactively used in service development and planning with the involvement of service users, carers and other relevant stakeholders

• Appropriate recording system documents details of all safeguarding incidents, near misses and serious untoward incidents including decisions reached, actions taken and lessons learnt

• Provider audits of safeguarding incidents and issues and lessons learnt • Action plans detail targets, outcomes and timescales

3.15 (GP)

The service has a proactive and outcomes based approach to learning internally using information from a range of local and national safeguarding and protection from abuse reviews to inform service development and planning

• Outcome based approach means that internal learning improves safeguarding processes for service users and/or reduces safeguarding incidents

• Appropriate recording system documents details of all safeguarding incidents including decisions reached, actions taken and lessons learnt

• Provider audits of safeguarding incidents and issues and lessons learnt

3.16 (I)

The service is open and transparent and is committed to participating in a multi-agency approach to safeguarding and protection from abuse of children and adults

• Designated staff for safeguarding • Joint working with other agencies to promote safeguarding • Engagement with Multi-Agency Public Protection Arrangements (MAPPA) • Multi-agency working for specific cases

3.17 Accessible and clear information • Liaison with local authority safeguarding officers


Standard Measure


(I) sharing protocols are in place to ensure timely and appropriate sharing of information between agencies

• Information sharing protocols • Proactive engagement with safeguarding partnerships


Standard 4


Security, Health and Safety The security, health and safety and wellbeing of people using, visiting or working at the service is protected

DCC Outcomes: Economic Wellbeing, Be Healthy, Stay Safe CQC Service Standards: Safe Ofsted Inspection Judgements:

Children’s Homes: Boarding and Residential Provision: Overall experiences and progress of children and young people living in the home, children and young people are protected Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Experience and progress of and outcomes for children and young people who receive short breaks, Quality of service provision, Safeguarding children and young people


Standard Measure


4.1 (E)

Staff and volunteers understand and implement policies concerning security, health and safety

• Training records and signed evidence of staff and volunteers understanding policies and procedures

• Staff and volunteer induction • Verification that staff understand the principal features of policies and procedures and

legislation and how they impact on their work 4.2 (E)

Staff and volunteers receive appropriate training, in security, health and safety

• Certificated health and safety training - reviewed/updated as appropriate • Competency assessments of staff • Moving and handling training

4.3 (I)

Staff and volunteers understand the Lone Working Policy and use

• Policy and process setting out how risks are minimised


Standard Measure


it in practice • Lone working risk assessments • Verification that staff and volunteers understand the principal features of lone working and how

they impact on their work 4.4 (I)

Information is provided on security, health and safety in various places and in different formats

• Service users understand what constitutes health and safety concerns and know to whom they should report issues

• One-to-ones with service users, house meetings etc • Handbooks/Guides • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to understand security, health and safety matters

4.5 (E)

The service has a robust approach to assessing and managing security, health and safety risks that affect premises, equipment and people and action is taken on reported concerns

• System for undertaking risk assessments for equipment used in the delivery of care and support to individuals

• Assessments consider the risk to the service user, the operator and others who may be affected

• Risk assessments and inspections include participants, key findings and action taken

4.6 (E)

Premises and equipment are clean, secure, well-maintained, accessible and suitable for the purpose for which they are being used

• Servicing/maintenance information and reports • Fire equipment testing • Portable Appliance Testing (PAT)

4.7 (I)

Service users and carers, staff and volunteers are aware of the health and safety policies and understand how to report concerns

• Service user handbooks • Welcome packs • A system is in place to record and analyse significant incidents/accidents/statutory

notifications, which can identify trends and there is evidence that appropriate preventative action is taken.

• Reference should be made to the principles of the Mental Capacity Act as they apply to this standard and evidence provided as to how they are applied to those who may lack the capacity or ability to report concerns

4.8 (E)

Appropriate arrangements are in place to enable staff, volunteers and/or service users and, where

• Evacuation procedures or stay-put policies are clearly recorded and rehearsed at appropriate intervals to ensure all staff, volunteers and service users can comply safely

• Remedial action is taken to address any identified issues


Standard Measure


appropriate, carers to access help in a service user crisis or emergency

• Personal Emergency Evacuation Plans implemented and reviewed for each service user outlining how they would be evacuated in the event of an emergency. Any service user’s special requirements are planned for including a consideration of their mobility, number of staff needed to assist, any equipment needed and any mental health considerations

• 24 hour emergency number publicised widely

4.9 (GP)

Service users and carers and other relevant stakeholders are involved in security, health and safety risk assessments

• Documents illustrating that service users and stakeholders have participated in health and safety risk identification

• Risk assessment methodology setting out how stakeholders are involved • Assessments record the participation of service users and stakeholders • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to make decisions about security, health and safety risk assessments

4.10 (GP)

Service users, carers and other relevant stakeholders are involved in the review of policies and procedures relating to security, health and safety

• Assessments record the participation of service users and stakeholders • Minutes or other records of the review processes demonstrate participation • Service users/carers and stakeholders confirmed that they have been involved in the review of

policies and procedures relating to security, health and safety • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied those who may lack the capacity to be involved in reviews of policies and procedures relating to security, health and safety

4.11 (GP)

Review of information relating to security, health and safety is used to inform service development and planning

• Documentation of comments • Examples of service development following comments • Plans detailing service development • Business continuity plan


Standard 5


Needs and Risk Assessment The needs and risks of people accessing the service are identified and addressed appropriately

DCC Outcomes: Stay Safe, Make a Positive Contribution CQC Service Standards: Safe, Effective, Responsive Ofsted Inspection Judgements:

Children’s Homes: Children and young people are helped and protected (key judgement), Impact and effectiveness of leaders and managers Boarding and Residential Provision: Children and young people are protected Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Experience and progress of and outcomes for children and young people who receive short breaks, Safeguarding children and young people


Standard Measure


5.1 (E)

Clear eligibility criteria and means of prioritising applications are in place and widely available

• Eligibility criteria • Service information • Information is current, relevant, accurate and available in different formats

5.2 (E)

The needs of service users and any inherent risks are assessed on a consistent and comprehensive basis prior to a service being offered, or very shortly afterwards, as appropriate to the needs of the service user

• Choices, interests, aspirations and appropriate use of advocacy • Needs assessments – dated and signed by service user and staff member • Risk assessments - dated and signed by service user and staff member • Views, comments and any disagreements considered and documented • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the


Standard Measure


capacity to make decisions about risk and risk taking 5.3 (I)

Needs and risk assessments (where appropriate) should take into account information from other individuals (including carers, relatives and other advocates) and agencies who are involved in the service user’s care and support

• Evidence of involvement of other people/agencies with consent of service user where appropriate

• Information shared with others with consent of service user where appropriate • Needs and risk assessments owned by and developed with the service user in a format that

suits them, involving others as appropriate

5.4 (E)

Needs and risk assessments are reviewed periodically on a consistent and systematic basis

• Service users’ files showing that all needs have been reviewed with appropriate frequency and/or following a significant incident or change in circumstances

• Frequency of individual reviews reflects the needs and risks identified by the assessment process

• Views, comments and any disagreements considered and documented

5.5 (I)

Staff receive appropriate training in needs and risk assessment and are competent to carry out such assessments

• Certificated training on needs and risk assessment - reviewed/updated as appropriate • Statutory/ in-house training • Information sharing opportunities

5.6 (E)

Staff are consistent and proactive in identifying and reviewing changing need and risk

• Needs and risk assessments – dated and signed by staff member and other relevant parties • Views, comments and any disagreements are considered and documented • Needs and risk assessments reflect each service user’s changing needs and circumstances

and are well documented in assessments and other communications tools, eg handover notes

5.7 (E)

Needs and risk assessments and reviews encompass “appropriate risk taking”, involve service users and, where appropriate, carers and take full account of their views, preferences and aspirations

• Procedures state how people will be involved • Promotion of positive risk taking in staff induction, training programmes, management

practices, strategies, service information, person centred plans, organisational policies and procedures and evidence of compliance

• Audit trails and examples of how people are enabled to take positive risks towards independence and social inclusion

• Reference should be made to the principles of the Mental Capacity Act as they apply to this standard and evidence provided as to how they are applied to those who may lack the


Standard Measure


capacity to be involved in risk assessment and review processes or to make their views, preferences and aspirations known

5.8 (GP)

Service users and carers are involved in reviewing policies and procedures around needs and risk assessment

• Written procedures describe how service users/carer views are to be incorporated • Service users/carers confirm that they have been involved in reviewing policies and

procedures • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to be involved in reviewing policies and procedures around needs and risk assessment

5.9 (GP)

Reviews of needs and risk assessment procedures are used to inform service development and planning

• Reviews of needs consider how successful the service has been in assisting service users in realising their plans, targets or aspirations and this information is used to improve services

• Plans detailing service development


Standard 6


Care and Support Planning There are plans in place which take into account people’s views, preferences and aspirations, are reviewed appropriately and address the needs and risks identified through the assessment process

DCC Outcomes: Economic Wellbeing, Be Healthy, Stay Safe, Enjoy and Achieve, Make a Positive Contribution CQC Service Standards: Safe, Effective, Responsive Ofsted Inspection Judgements:

Children’s Homes: Overall experiences and progress of children and young people living in the home, Impact and effectiveness of leaders and managers Boarding and Residential Provision: Quality of care and support, Children and young people are protected Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Quality of service provision, Safeguarding children and young people


Standard Measure


6.1 (E)

Service users have outcome-focused care and support plans in appropriate formats that address identified needs and risks

• Care and support plans are person-centred and reflect a person's personal preferences, likes and dislikes and their daily routines

• The service offered is supported by individual outcome focused plans and goals which describe how needs will be met

• Care and support plans reflect what matters most to the service user • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to express their needs and understand aspects relating to risk

6.2 Care and support plans (where • Joint care planning arrangements


Standard Measure


(I) appropriate) should take into account information from other individuals (including carers, relatives and other advocates) and agencies who are involved in the service user’s care and support

• Service proactively seeks to engage other agencies in caring and supporting people • Specialist expertise is sought where required, when drawing up care and support plans • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to express their views on a service user’s care and support

6.3 (E)

Care and support plans clearly set out how identified needs and risks will be met and managed

• Care and support plans – dated and signed by staff member and other relevant parties which o describe how all identified needs will be met and o document the service user’s vulnerabilities, strengths and abilities in order to promote

independence, wellbeing, safety and quality of life • Care and support plans and reviews also address issues relating to capacity where this is

relevant and appropriate or has the potential to become relevant and appropriate • The care and support plan sets out in detail the action that will be taken by care and support

workers to meet the assessed needs, including specialist needs and communication requirements

6.4 (E)

Care and support plans are reviewed periodically on a consistent and systematic basis

• Care and support plans are reviewed appropriately, and/or following a significant incident or change in circumstances

• Notes of reviews record service users’ involvement • Evidence of involvement of other people/agencies with consent of service user where

appropriate • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to made decisions around reviews of care and support plans or make their views known

6.5 (I)

Staff receive appropriate training in care and support planning and are competent to carry out such tasks

• Training records and signed evidence of staff understanding policies and procedures • Information sharing opportunities • Guidance, coaching and awareness raising

6.6 (E)

Staff are consistent and proactive in identifying and reviewing care and support plans

• Responsive care and support planning • Involvement of service users and carers in a meaningful way • Procedures state that reviews can be initiated at any time by a service user and the right is


Standard Measure


explained within service users’ handbooks etc

6.7 (GP)

Service users and carers are involved in reviewing policies and procedures around care and support planning

• Training records and signed evidence of staff understanding policies and procedures • Care and support plans evidence service user and carer involvement with documented

signatures where appropriate • Involvement of service users and carers in a meaningful way • Reference should be made to the principles of the Mental Capacity Act as they apply to this

standard and evidence provided as to how they are applied to those who may lack the capacity to be involved in reviewing policies and procedures around care and support planning or make their views known

6.8 (GP)

Reviews of care and support plans are used to inform service development and planning

• Reviews of care and support plans consider how successful the service has been in assisting service users in realising their plans, targets or aspirations and this information is used to improve services

• Plans detailing service development


Standard 7


Health and Hygiene (including infection control) The Provider ensures that the service is kept hygienic and clean throughout and there are robust systems and processes in place to control the spread of infection

DCC Outcomes: Be Healthy, Stay Safe, CQC Service Standards: Safe Ofsted Inspection Judgements:

Children’s Homes: C&YP are helped and protected (key judgement) Boarding and Residential Provision: Quality of care and support; Children and young people are protected Independent Fostering Agencies: Quality of service provision, Safeguarding children and young people


Standard Measure


7.1 (E)

Staff and volunteers receive appropriate training in infection control

• Certificated infection control training - reviewed/updated as appropriate • Training records and signed evidence of staff understanding policies and procedures • Information sharing opportunities

7.2 (E)

Personal Protective Equipment is readily available to all staff, is easily accessible and ample stocks are maintained and used appropriately

• System to ensure that PPE is available and supplies are provided to all staff and replenished when necessary

7.3 (E)

Cleaning regimes are supported by well recorded details of tasks that are monitored by a

• Cleaning regimes are in place and recorded • Regimes identify a schedule of all tasks to be carried out • Schedules identify individual rooms, areas and communal areas


Standard Measure


nominated staff member • Where problems or omissions have been identified it is clear that they have been noted and actioned


Standard 8


Medication People are supported to take their medicines when they need them in a safe and effective manner supported by qualified and competent staff who work to robust standards regarding medication management

DCC Outcomes: Be Healthy, Stay Safe, CQC Service Standards: Safe Ofsted Inspection Judgements:



Ref Standard Measure Evidence to support standard measure and rating RAG

rating 8.1 (E)

There is a system/process in place for the booking in and out of medication

• Appropriate recording system for booking in and out of all medicines • All entries in the booking in/out system are signed by the member of staff

responsible • All entries in the booking in/out system are correctly dated

8.2 (E)

Medication Administration Records (MAR) are fully completed for all instances of medication administration

• All instances of medication administration are recorded on MAR charts • There are no gaps evident in the MAR charts • Appropriate initials, terms and abbreviations are used within the recording at all

times

8.3 (E)

Staff involved in the administration of medication have received appropriate certificated training and annual

• Certificated “knowledge-based” training in the safe handling and administration of medicines (eg NCFE)

• Documented assessment of staff competence to administer medicines following


Ref Standard Measure Evidence to support standard measure and rating RAG rating

competency checks observation by an appropriately qualified/competent senior member of staff and/or certificated competence in the form of an NVQ or equivalent

• Annual competence assessments for all staff in the administration of medicines 8.4 (E)

Medication is stored securely and appropriately with only authorised staff having access

• Daily monitoring and recording of temperatures • Medication stored away from food stuffs, cleaning products etc • Evidence of only authorised staff having access to medication


Standard 9


Nutrition and Hydration The Provider ensures good management of nutrition and hydration which leads to a healthy diet, aids a service user’s recovery/rehabilitation and safeguards those at risk of undernutrition

DCC Outcomes: Be Healthy, Stay Safe, Enjoy and Achieve CQC Service Standards: Effective, Safe Ofsted Inspection Judgements:




rating 9.1 (E)

The provider assesses the dietary and nutritional/hydration needs of service users and appropriate action is taken to meet the dietary needs

• Regular nutritional screening and assessment for all service users • Care plans are in place for nutritional needs and document any special dietary

requirements, allergies, risks and actions to minimise any identified risks • Identified issues communicated to kitchen staff

9.2 (E)

The service is aware of the personal preferences, likes and dislikes of service users and these are recorded

• Care plans / kitchen records document service users likes, dislikes and cultural requirements

9.3 (E)

Menus are nutritionally balanced and reviewed on a regular basis

• Menus have been assessed as to their nutritional value and nutritionally balanced (this could be from professionals such as a dietician or nutritionist or by suitably trained staff (e.g. Focus on Undernutrition Catering training) in the home)



• This is done annually or as menus are changed 9.4 (I)

There is recorded evidence that menus, including options, are discussed with service users and appropriate others and that those suggestions and comments are acted upon where at all possible

• Process for gathering feedback from service users and appropriate others on menus and the food which is available

• Discussion at service user meetings and content within service user/relative surveys

• Suggestions and comments about menus and food choices are acted upon where possible

9.5 (E)

Service users can access a variety of snacks and drinks at any time (including healthy and nutritious options) and information is provided to service users

• The service publicises the fact that a variety of snacks and drinks are available at any time, including arrangements for night times. For example in service information, handbooks and guides and / or on display

• Feedback from service users / relatives and staff confirms that snacks and drinks are available at any time

9.6 (I)

Menus are delivered in a variety of formats, including photographic, specific to individual need to ensure that all service users are able to make an informed decision

• Menus are available and are presented in clear, easy to read formats • Menus are delivered in formats which reflect the needs of individual service users,

eg, large print menus, photographic menus and photographic choice cards • Menus are displayed in appropriate areas such as dining rooms, noticeboards,

individual tables etc

9.7 (E)

Staff and volunteers involved in any aspect of food delivery receive appropriate training in food safety or food hygiene

• Certificated Food Safety Training (Level 1) or Food Hygiene Training • Training records and signed evidence of staff understanding policies and

procedures • Guidance, coaching and awareness raising

9.8 (E)

Staff and volunteers involved in any aspect of care of people with nutritional and hydration needs receive appropriate training in nutrition and hydration

• Introductory training in nutrition and hydration

9.9 (E)

Weight loss/gain is identified through regular screening and reviewed on a regular basis

• Signed and dated food and fluid charts are maintained where concerns are raised and contain sufficient detail to accurately monitor intake of food and fluid

• Food and fluid charts are implemented where concerns and risks are noted in relation to nutrition and hydration for individual service users. [This should apply when the individual is classed as '1' Moderate risk or '2' High risk when using MUST]



• Food and fluid intake charts record the amount offered and the amount eaten/drunk and amounts are documented in meaningful units


Standard 10


Deprivation of Liberty The service has a clear process to identify people who may be deprived of their liberty, refers them to the Supervisory Body for a Best Interests Assessment under the DoLS regulations, implements the outcome and conditions within its care planning processes and reviews the arrangements in a timely fashion

DCC Outcomes: Be Healthy, Stay Safe, Enjoy and Achieve CQC Service Standards: Safe, Effective, Caring, Responsive, Well-led Relevant Legislation Mental Capacity Act 2005* Mental Health Act 1983 Care Act 2014 Human Rights Act 1998 *The Mental Capacity Act 2005 provides a statutory framework for acting and making decisions on behalf people who lack capacity to make those decisions for themselves. Where this care involves depriving vulnerable people of their liberty in a care home, extra safeguards have been introduced, in law, to protect their rights and ensure that the care or treatment they receive is in their best interests.


rating 10.1 (E)

There is clear, recorded evidence that all care staff have received training, which is certificated, on the Deprivation of Liberty Safeguards – which reflects current legislation and best practice

• Statutory Training Records • In–house training • Supervision and Appraisal Records

10.2 (E)

There are clear processes to ensure potential and actual DOLS cases are dealt with appropriately and that issues relating to Deprivation of Liberty are identified and referred to the Supervisory Body where relevant. This

• Clear organisational knowledge and processes in place to ensure that actual and potential DOLS cases are dealt with appropriately

• Evidence that where there have been issues relating to a potential deprivation of liberty and any subsequent application for a DOLS, there is a clear process recorded to enable the appropriate decision to be reached and implemented

• Readily available guidance for any staff responsible in the home, on the processes



should include the process for urgent and standard authorisations and the distinction between them

involved with deprivation of liberty applications • Where no application for a DOLS application has been made, the responsible

person has indicated the process used and utilised relevant supporting documentation

• Clear organisational knowledge and processes in place to ensure that actual and potential DOLS cases are dealt with appropriately

• Guidance to ensure that the home has access to the documentation required to obtain both standard and urgent authorisations

• Forms are readily available: (Form 1 for Urgent Authorisations and Form 4 for Standard Authorisations)

• Approved applications are recorded in the service users care file together with any identified conditions

• Clear process recorded to enable the appropriate decision to be reached and implemented

10.3 (E)

Where an application for Deprivation of Liberty has been considered and / or approved, this is included in relevant care planning processes relating to the service user, and includes any identified conditions applied by the Supervisory Body

• Implementation of conditions in care plans • Process for enabling reviews in a timely manner • Evidence to show that even with a Deprivation of Liberty in place, providers need to

ensure they are using the principles of the Mental Capacity Act with care being delivered in best interests and in the least restrictive manner


Standard 11


End of Life Care People’s wishes regarding end of life care are included in assessments and plans and are reviewed appropriately

DCC Outcomes: Make a Positive Contribution CQC Service Standards: Effective, Caring Relevant Legislation Mental Capacity Act 2005 Mental Health Act 1983 Care Act 2014 Human Rights Act 1998


rating 11.1 Service users are supported and

consulted about their preferences and advance wishes for planning end of life care

• Details of end of life care preferences and choices recorded on personal plans and assessments including advance decisions

• Relevant and updated end of life information (to include local service providers, referral criteria and support services, etc) for staff, service users and family members

• Clear, documented approach for supporting service user’s end of life wishes • Liaison with health professionals and use of palliative care standards

11.2 Staff and volunteers receive appropriate training in end of life care

• Service user files • Certificates • Training records and signed evidence of staff understanding policies and

procedures

11.3 Do Not Attempt Resuscitation (DNAR) forms are in place where appropriate

• Service user files • DNAR forms are reviewed whenever a person’s condition or wishes change • The complete DNAR form clearly records that the person is in agreement with the

decision, or if they do not have capacity to make the decision, that it has been agreed to be in their best interests

Standard 12




Transport Providers ensure the provision of safe and appropriate transport for service users which is subject to robust risk assessment

DCC Outcomes: Economic Wellbeing, Stay Safe, Enjoy and Achieve, Make a Positive Contribution CQC Service Standards: Safe Ofsted Inspection Judgements:

Children’s Homes: Overall experiences and progress of children and young people living in the home Boarding and Residential Provision: Quality of care and support Independent Fostering Agencies: Experience and progress of and outcomes for children and young people who are looked after, Quality of service provision



rating 12.1 (E)

Risks are identified regarding those associated with the use of transport, or whilst being transported including if a service user requires an escort whilst being transported

• Risk assessments • Care and support plans • Assessments and plans are reviewed regularly and where there has been a change

12.2 (E)

Documentation is in place and current in relation to insurance, vehicle records and training for drivers

• Current MOT certificate (where required) • Appropriate insurance to cover all liabilities • MIDAS training recorded on staff files and renewed as appropriate

12.3 (E)

Vehicles are inspected on a daily basis • Daily inspection logs to include checks of tyre pressure, lights, bodywork, glass, oil, water, seatbelts and equipment

• Logs are signed and dated by the person carrying out the inspection



12.4 (I)

Public transport is utilised where possible, when it is economically advantageous and when it can assist the service user in developing and/or maintaining independence

• Risk Assessments • Care and support plans • Assessments and plans are reviewed regularly and where there has been a change

12.5 (GP)

Transport is managed in innovative ways

• Transport season tickets • Car sharing schemes


Standard 13


Supporting Unpaid Carers Unpaid carers are supported in their caring role and also to have a life outside their caring role

DCC Outcomes: Economic Wellbeing, Be Healthy, Stay Safe, Enjoy and Achieve, Make a Positive Contribution Relevant Legislation Mental Capacity Act 2005 Mental Health Act 1983 Care Act 2014 Human Rights Act 1998

Ref Standard Measure Suggested sources of evidence/guidance notes RAG

rating 13.1 (E)

Carers are supported to access a break from their caring role when a need is identified

• Application forms from carers for breaks funding • Records of decisions made and amounts spent on breaks funding • Documents such as leaflets/newsletters publicising carer breaks

13.2 (I)

Carers are supported to gain or maintain employment or full time education

• Records of support provided to carers to help them to gain or maintain employment or education whilst carrying out their caring role

• Feedback from carers

13.3 (E)

Carers are provided with information and advice to assist them in their caring role, including their rights as a carer

• Examples of information (eg leaflets/newsletter articles) provided to carers about their rights, including their right to a Carers Assessment

• Examples of display information used by provider at forums, events etc • Feedback from carers

13.4 (I)

Carers are supported to access training or equipment to assist them in their caring role

• Examples of information (eg leaflets/newsletter articles) provided to carers about how to access training or equipment to assist them in their caring role

• Records of training provided to carers • Records of equipment provided to carers

13.5 (E)

Carers are provided with information or support to assist them in an emergency

• Examples of information (eg leaflets/newsletter articles) provided to carers about the support available to them in an emergency (eg Carers Emergency Support Service) and how they register for this service

• Examples of display information used by provider at forums, events etc • Records of referrals made to Carers Emergency Support Service

13.6 Carers are provided with information to • Examples of information (eg leaflets/newsletter articles) provided to carers about


Ref Standard Measure Suggested sources of evidence/guidance notes RAG rating

(I) support them to access health services for themselves

the range of services available for them • Examples of display information used by provider at forums, events etc • Specific records of cases where carers have been signposted to another

organisation to access services for themselves 13.7 (I)

Carers are provided with information or support to apply for benefits for themselves or the person they care for

• Examples of information (eg leaflets/newsletter articles) provided to carers with benefits advice with particular regard to a caring role

• Specific examples of support provided to carers to apply for benefits • Feedback from carers

13.8 (E)

Carers are protected from inappropriate levels or types of caring

• Examples of information (eg leaflets/newsletter articles) provided to carers about inappropriate levels or types of caring, particularly in respect to Young Carers

• Records of support provided to carers to protect them from inappropriate levels or types of caring


13.9 (GP)

Carers are provided with opportunities to share their views on local health and social care services

• Examples of carers having the opportunity (eg surveys, questionnaires, events, focus groups) to share their views on local health and social care services

• Examples of how local health and social care services have listened to such feedback and made changes to services to help carers


ASQ – Guidance for Providers Final - Durham · Section Page No Introduction 3 Completing the ASQ...

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