Are you policies and procedures fit for purpose?

We are increasingly seeing health and social care operators falling foul of their own policies and procedures during a regulatory inspection.

Many smaller providers purchase off the shelf policy and procedure systems, but never review or update the information contained within them. There is an expectation that all policies and procedures reflect best practice guidance for example references to NICE (National Institute of Clinical Excellence) guidance. Most providers of Care Management Systems keep the policies on their system updated. However, many providers use paper-based policies and procedures, but if they are not replaced with the latest version the guidance quoted may be out of date. Staff save a policy to their desktop, rather than search the master file & very quickly you may have an out-of-date copy in circulation.

We all know that we all like a form in the health and social care sector, but are the forms in use the forms in your policy system? If not, you are failing to meet your own policy. We appreciate that every health and social care business is different, and every provider has a mix of paper and electronic records, but the policies and procedures must reflect what you do. Therefore, if you have replaced a off the shelf form with your own, the same form reference number should be used and the old form replaced within the system with your own. Many of the off the shelf systems that allow staff to access policies electronically have provision for personalised policies to be uploaded, meaning the policy viewed by staff or inspectors is correct.

Within Health and Social Care is becoming more important than ever to carry out audits, identify issues and learn from them. Sometimes the purpose of the audit is forgotten or misunderstood. Audits can take place for many reasons and should not be a tick box exercise. Audits can be used to identify and resolve problems and consider if the policy that you are auditing against requires updating. When auditing, it is important that the person or area that you have audited receives timely and constructive feedback.   A follow up audit should be carried out to check that the expected adjustments have been achieved.  Audit questions should be prepared in advance to test out understanding of the area you are investigating. The responses received may trigger an audit in a related area, e.g., completing a Care Plan Audit may lead you to look at risk assessments, pre-admission information, fluid / dietary intake, outcomes for people, wound care etc.

You should prepare an audit schedule so that everyone in the organisation is clear when audits are due to take place. This helps demonstrate compliance.