continuous quality compliance's podcast

Welcome to episode 37 of Continuous Quality Compliance this is the last episode as I have recorded all the topics I think are relevant if you would like another topic covered which I have not then please email me [email protected]

Today I am talking about the different online platforms which can make your life easier.

For meetings there is zoom. Add Otter.AI https://otter.ai/ (https://otter.ai/)

to that you can then download the audio and get the transcript all you need to do is tidy it up it is great for meetings obviously get permission of the people before you record.

If you record video for your business Subly is good for adding captions https://www.getsubly.com/ (https://www.getsubly.com/)

I also like Viddyoze for adding some brilliant graphics and having awesome animated videos . https://app.viddyoze.com/ (https://app.viddyoze.com)

I bought this when it was on offer on Appsumo https://appsumo.com/ (https://appsumo.com/)

I added these to the introduction of my CQC online application course. It is fun too.

For planning there are many platforms such as Trello, I use my Outlook Calendar for all meetings whether personal or business so I know when I am free. I use Office 365 which enable me to use their booking app to make bookings.

For social media there are many ways to schedule you need to find the one that works for you. You do a good CRM I use HubSpot https://www.hubspot.com/ (https://www.hubspot.com/)

and Mailer lite https://www.mailerlite.com/ (https://www.mailerlite.com/)

now so I can do campaigns and send bulk email to members of the Association of Business mentors rather then typing each address every time also meets GDPR as no one can see other emails.

My other favourite platform is Canva I now have the Pro it is so good for creating documents cards , flyers etc. The free is great any I used it for may years free. The pro version allows you to store your brand colours and fonts and save them up and you can resize documents easily .

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)

Welcome to episode 36 of Continuous Quality Compliance

Today I am talking about… planning your year so you are on track to comply with the standards.

Planning is key to meet compliance otherwise you will do activities and not evidence or you will not do the right type of activity to meet compliance. I plan in December for the year ahead. It is strategy then I break it down into 90-day cycles. I look at what can be delegated .

What you should be looking at is what audits need adding or even taking away look at the frequency of audits sometimes you have to do them more often if you find issues and noncompliance every time or if you consistently are complaint you could reduce the frequency. If you have changed process you would want to audit that.

You will also want to audit tasks which are not part of compliance. For instance, look at your Sales and marketing how is you lead generation? Repeat clients, what is the best seller what add on can you have to stand out from others in the same marketplace.

Look at the Assessment framework what do you need to achieve for Good once you are working closely to that look at how you can Outstanding . For Outstanding you need to think outside the box be innovative use technology be engaged with your clients and staff. You also need to think about how you will sustain being outstanding. So Good may be more achievable. I believe in being realistic and reduce stress then try to go for Outstanding if it is realistically not going to happen.

Empowering your staff and training them is an important aspect of compliance getting feedback is important. If you have 10 or more employees, then it is good to look at a platform like Engagement Multiplier there is a link in the notes. https://www.engagementmultiplier.com/partner/tarunachauhan/ (https://www.engagementmultiplier.com/partner/tarunachauhan/)

You can do a free trial and still get a report which is useful. I have a client who loves using Engagement Multiplier it has helped them to meet so many criteria both for local authority and the CQC and it has given them an idea of what their employees think and they can address challenges and issues as they arise not when its escalated. I am a partner with them I only partner with organisations I trust.

By planning how you will meet compliance you will get more accomplished and have a clear idea of where you are headed. I see to many businesses trying to meet the standards without a clear plan. That does not work! I have been accredited for standards other than the CQC I was always working towards being inspection ready with evidence gathering being routine. Not something you rush around trying to gather because you have date for inspection. I made it easy to gather the evidence ensure it is part of business as usual and forms are not cumbersome.

When planning for the year talk to staff get ideas from them they will be engaged and help you because they will know what the plan is.

I work with business on my 12-month programme to support them to be inspection ready I look wider than just CC because your business is wider than CQC. There are different levels of service depending on how many audits I do.

Planning the year ahead is important otherwise it is kike starting a care journey and not knowing the destination. Make sure all staff know your values and what you need to focus on. The registered manager role is complex, and you cannot do it alone if you do because you are small you have to have a clear plan in...

Welcome to episode 35 of Continuous Quality Compliance

Today I am talking about Selfcare

I bet your thinking what has Selfcare got to do with Continuous Quality Compliance. Selfcare is important because you will be less productive and effective if you are not feeling good. If you are tired because you never stop.

Are you the person who does not take a lunch break then reach for the nearest sugary treat?

Did you know that sugar is addictive. It provides Dopamine and when we get the hit we want more. I know when I had a lot of high sugar treat during Diwali I wanted more. I weaned myself off it again. I don’t take sugar in my tea or coffee. I am also wheat intolerant so not eating biscuits is easier.

Selfcare is about giving your brain a rest it is like any other organ it needs a rest. Think of it like your smart phone and you have all the apps open. The battery drains quickly and things slow down. This is what happens to you if you do not take breaks. Research has shown that taking regular breaks makes you more productive. It helps you to come up with solutions to problems you have because your giving your subconscious the time to look at the problem and think of a solution.

Gut health is so closely related to brain and heart health. I was on a workshop the other week and a nutritionist did a session. What you eat impacts the whole body. Movement for your body makes a big difference. I myself have added daily walking to my morning t

routine. At first I thought I would hate it I need a purpose to walk so I used my mindset to say I was walking to work which is in fact my home office. That change means every morning after breakfast I go for a walk. I have noticed it has helped my digestion. It has helped with my Mental health and it helps me with topping up my vitamin D which is important for everyone. I also get to meet dog walkers and it lovely to exchange a smile or a hello.

My clients who I coach and mentor tell me the selfcare side of it really helps them The fact hat I asked them to ensure they had a lunch breaks has had an impact on their mental wellbeing and increased their productivity. We are not machines we need time out at regular intervals. We are not designed to be sedentary for long periods. Even stopping and doing breathing exercise or dancing to a favourite tune for 10 minutes will help.

We cannot give from an empty vessel leaders have to be effective if you are not looking after yourself what kind of lesson are you giving your employees? If the leadership do not take breaks the staff will feel obliged to carry on.

Give your brain a rest, be hydrated eat well and see your productivity increase. I do all these. I plan my meals and lunches I have greatly reduced my sugar. I exercise and have time for myself. I do have a hectic work as I run my own business I am regional head of the ABM I love cooking and use that to relax. Making sourdough is a mindful activity which I enjoy. Find what you love in downtime and plan in lunch breaks and have a short break after each task.

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)

Welcome to episode 34 of Continuous Quality Compliance

Today I am talking about Report Writing

Before you start writing consider....

WHO are you writing the careplan, treatment record for?

WHY are you writing it?

HOW do you record it?

What is written needs to be factual and correct. It also needs to meet the needs of different stakeholders.

Steer away from a tick box culture as this will not provide enough information .

What you record can be broken into 4 areas;

Times, places, people involved, events happenings /consultation

Good reports should be legible, in simple language jargon free as possible. Clear factual, accurate. /in chronological order, enough information

A good way to train staff on good report writing is to have a sample of a good report and one of a badly written one.

If you’re a medical professional registered with the GMC, NMC , HCPC they have standards for record keeping which should also be looked at and be part of the organisations policy o record keeping.

If it is not documented it has not been done.

Common problems are:

An absence of clarity

Inaccuracies

Spelling mistakes

Missing information

Failure to record action taken when a problem has been identified.

Good Record Keeping

Record keeping makes the continuity of care easier;

Record keeping promotes better communication and dissemination of information between members of the multi-professional team;

Helps to address complaints or legal processes;

Supports clinical audit, research, allocation of resources and performance planning;

Helps to identify risks and enables the early detection of complications;

Supports client care and communication;

Supports effective clinical judgement;

Supports delivery of services;

Helps improve accountability;

Shows how decisions were made relating to the patient’s care.

What I ask is when your are writing would you be happy for what you have written to be read in a court of law? Also read it out a loud you will see if what you have written does not sound right.

Good record keeping is also important as part of being a member of a professional body.

Reference: NMc, GMc Ausmed , HCPC

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)

Welcome to episode 33 of Continuous Quality Compliance

Today I am talking about… Data Protection

What do we mean by Data Protection?

The ICO The Information Commissioners Office describes it as;

Data protection is about ensuring people can trust you to use their data fairly and responsibly.

If you collect information about individuals for any reason other than your own personal, family or household purposes, you need to comply.

The UK data protection regime is set out in the DPA 2018, along with the GDPR (which also forms part of UK law). It takes a flexible, risk-based approach which puts the onus on you to think about and justify how and why you use data.

The ICO regulates data protection in the UK. We offer advice and guidance, promote good practice, carry out audits, consider complaints, monitor compliance, and take enforcement action where appropriate.

Data protection is the fair and proper use of information about people. It’s part of the fundamental right to privacy

Does it apply to me?

Yes, if you have information about people for any business or other non-household purpose. The law applies to any ‘processing of personal data’, and will catch most businesses and organisations, whatever their size.

The ICO expect is not prescriptive in its approach because that would not be tenable.

Every organisation is different and there is no one-size fits-all answer. Data protection law doesn’t set many absolute rules. Instead it takes a risk-based approach, based on some key principles. This means it’s flexible and can be applied to a huge range of organisations and situations, and it doesn’t act as a barrier to doing new things in new ways.

However, this flexibility does mean that you need to think about - and take responsibility for - the specific ways you use personal data. Whether and how you comply depends on exactly why and how you use the data - and there is often more than one way to comply.

There are some terms used which it is useful to understand in this context.

What is ‘personal data’?

In short, personal data means information about a particular living individual. This might be anyone, including a customer, client, employee, partner, member, supporter, business contact, public official or member of the public.

It doesn’t need to be ‘private’ information – even information which is public knowledge or is about someone’s professional life can be personal data.

It doesn’t cover truly anonymous information – but if you could still identify someone from the details, or by combining it with other information, it will still count as personal data.

What is ‘processing’?

Almost anything you do with data counts as processing; including collecting, recording, storing, using, analysing, combining, disclosing or deleting it.

What is a ‘controller’?

A controller is the person that decides how and why to collect and use the data. This will usually be an organisation, but can be an individual (eg a sole trader). If you are an employee acting on behalf of your employer, the employer would be the controller. The controller must make sure that the processing of that data complies with data protection law.

In this guide, we generally use the term ‘organisation’ or ‘you’ to mean the controller.

What is a ‘processor’?

A processor is a separate person or organisation (not an employee) who processes data on behalf of the controller and in accordance with their instructions. Processors have some direct legal obligations, but these are more limited than the controller’s obligations.

What is a ‘data subject’?

This is the technical term for the individual whom particular personal data is about. In this guide we generally use the term ‘individuals’ instead.

the DPA 2018?

The DPA 2018 sets out the framework for data protection law in the UK. It updates and replaces the Data Protection Act 1998, and came into effect on 25 May 2018.

It...

Cybersecurity is important for every organisation. Staff need to be communicated on what cybersecurity is and the importance of it. Most cyber security is preventable as they are due to human error.

Here is a stat for you

Every 40 seconds a business falls victim to a ransomware attack, and rose to every 14 seconds by 2019.

Cyber security is about assessing and resolving issues in your organisation that could compromise your ability to keep information, intellectual property and sensitive data safe.

A Cyber security breach can also risk your reputation so its best to have measures in place which reduces the likelihood of a breach.

National Cyber Security Centre NCSC .

http://www.ncsc.gov.uk/ (http://www.ncsc.gov.uk/)

The NCSC website includes a wealth of information that’s easy to understand. It has many tools for organisations to use too.

Your staff are the weak point in your organisation’s defences. I recommend asking all

employees to complete the free cyber security training on their website , regardless of their level or experience. We are all vulnerable especially when we are busy.

Exercise in a Box is an online tool to help find out how resilient your organisation is to attack. It also lets you practice your response in a safe environment.

Action Fraud is the National Fraud and Cyber Crime Reporting Centre. If you become aware

of a successful cyber attack on your organisation, make Action Fraud your first point of contact.

Action Fraud also offer free services that stop you from visiting malicious websites and

protect you from email fraud whether at home or at work. I have used Action Fraud when I have had phishing attacks the more people report there more the attackers can be stopped.

It does not take long at all

To find out if your security details need changing visit the Have I Been Pwned website. This will tell you if one of your online accounts has been compromised in a breach, such as those which affected Canva and Adobe users. If your email is on the list, but your password hasn’t been changed in a long time, now’s a good time to change it. http://www.haveibeenpwned.com/ (http://www.haveibeenpwned.com/)

Disposing of old equipment

The NCSC has guidance on this on their website.

It is important to dispose of old equipment safely but also by ensuring all data on the hard drive has been erased. There are companies to do this. Make sure you go to a company which provides a certificate.

ask for a CESG certificate for your records and confirmation of the assets destroyed. These should be kept on file for several years.

Did you know the Air Ambulance provides this service? Here is the link https://theairambulanceservice.org.uk/ways-to-give/reuse-recycle/asset-recovery/ (https://theairambulanceservice.org.uk/ways-to-give/reuse-recycle/asset-recovery/)

You can download an audiobook and PDFs from the Met Police site to help you prevent fraud and cybercrime.

The Secure Book PDF features step-by-step guides to securing smart phones, zoom meetings and social media accounts (including LinkedIn).

You should have a password policy so staff don’t create easy to hack passwords. A good way is to use 3 random words which mean something to you and also symbols and numbers. Use password managers. It means staff only need to remember one very strong password and others are behind the password manager for different things they need passwords for For example I have LastPass Free.

Infection control is important in all types of premises. In a clinical setting even more so. I work with home care agencies. They should also look at infection control in their clients home for the benefit of the client but also for the safety of carers. They may not be responsible for cleaning but they should still have a say if it affects the client. Especially if you are looking after someone with low immunity.

There are many resources for clinicians to follow. For those who are nurse led. The guidance from the RCN is very good especially . The ebook is called. Essential Practice for Infection

Prevention and Control, Guidance for nursing staff CLINICAL PROFESSIONAL RESOURCE

Practice guidance are evidence-based consensus documents, used to guide decisions about appropriate care of an individual, family or population in a specific context.

With Covid it is even more important that good hand hygiene is followed. Hand sanitisers are available.

Safe handling of sharps and safe disposal of clinical waste is also looked at by inspectors. Decontamination of equipment , having that in an appropriate area is also important. I undertook a Quality assurance audit. The Salon/Clinic owner has the autoclave in the staff room right near the microwave. There was risk of cross commination. The staff room is also not the place for equipment of this kind. They also had cleaning fluid in an office on the floor.

There are many things to think of like spillage management

Managing accidental exposure to blood borne viruses. If this is something that can happen in the clinic then its really important to have a process for when the situation arises. A sharps injury protocol is important.

Risk management also places a part look at riskes and themn put in ocntrols that are approprute for your setting ine size does not fit all. At tiems I see small bsuisses copying what corporates do that is too big a jumpo. Different size companies need different levels of measaure that is right for their envirnoemt to keep infecton control at optimum.

Every practice should be following standard infection control precautions as a minimum

You need to also meet COSHH regulations in your premises. Staff need to trained in COSHH.

have a look here for Health Safety Training which includes COSHH and infection control basic awareness

I also recommend looking on the HSE website it is a really good resource. https://www.hse.gov.uk/ (https://www.hse.gov.uk/)

There are consequences for organisations not adhering to infection control.

https://www.tchauhanconsultancy.co.uk/online-training-health-safety/ (https://www.tchauhanconsultancy.co.uk/online-training-health-safety/)

Many organisations have not heard of infection prevention control which is another good resource. https://www.infectionpreventioncontrol.co.uk/ (https://www.infectionpreventioncontrol.co.uk/)

The resources should be used to aid you to write a infection control policy and processes that help you to look reduce infection control reduction.

Welcome to episode 30 of Continuous Quality Compliance

Today I am talking about… Recruitment for Directors

CQC are getting robust with their initial interviews and want to ensue that the Directors you have in place are fit for purpose. They have also asked for a Fir Director policy. What I have done for clients is to take what Regulation 7 tells us plus what Companies House recommend.

I work with a lot of New business owners so todays episode is for going to be talking about what the responsibility of a Director is ;

Directors' responsibilities

As a director of a limited company, you must:

· follow the company’s rules, shown in its articles of association

· keep company records and report changes

· file your accounts and your Company Tax Return

· tell other shareholders if you might personally benefit from a transaction the company makes

· pay Corporation Tax

· You can hire other people to manage some of these things day-to-day (for example, an accountant) but you’re still legally responsible for your company’s records, accounts and performance.

Unfit conduct’ includes:

· allowing a company to continue trading when it can’t pay its debts

· not keeping proper company accounting records

· not sending accounts and returns to Companies House

· not paying tax owed by the company

· using company money or assets for personal benefit

How disqualification works

The Insolvency Service may investigate your company (or you personally as a director of your company) if it’s involved in insolvency proceedings or if there’s been a complaint.

If they think you haven’t followed your legal responsibilities as a director, they’ll tell you in writing:

what they think you’ve done that makes you unfit to be a director they intend to start the disqualification process

how you can respond

You can either:

wait for The Insolvency Service to take you to court to disqualify you - you can defend the case in court if you disagree with The Insolvency Service

give The Insolvency Service a ‘disqualification undertaking’ - this means you voluntarily disqualify yourself and ends court action against you

You may want to get legal advice if you get a letter about disqualification from The Insolvency Service.

Apart from The Insolvency Service, other bodies can apply to have you disqualified under certain circumstances, eg:

Companies House

the Competition and Markets Authority (CMA)

the courts

a company insolvency practitioner

If you’re disqualified You’ll be disqualified for up to 15 years.

You can’t:

be a director of any company registered in the UK or an overseas company that has connections with the UK be involved in forming, marketing or running a company

other restrictions

There are other restrictions if you’re disqualified. For example, you might not be able to:

sit on the board of a charity, school or police authority

be a pension trustee

be a registered social landlord

sit on a health board or social care body

be a solicitor, barrister or accountant

If you look at all this you will see why it is important to have a robust process for incoming directors. You need to check them thoroughly and have a consistent process. When you are CQC regulated you also need to bring in the criteria of Regulation 5 . So, ensure that you are meeting both Companies house and CQC criteria.

It is something that benefits...

Welcome to episode 29 of Continuous Quality Compliance

Today I am talking about… Training and personal development

CQC ask for a training matrix. They wan to see that you are covering mandatory training. However it is important o note that as part of Regulation 18 Staffing. Staff skills and knowledge and development of staff appropriately. To me training should be looked at outside the box. Don’t assume that all training has to be either class room based or e learning. It should be a mix but also your staff will have different learning styles so the number one thing is to find out the learning style of staff. Why because they will learn better .

Also look at staff development broader then just today.

What do I mean. Well for instance in one organisation I am working with we have been discussing succession planning. The senior staff have been with the company for over 20 years so there will come a time when they are ready to retire. If they want staff from within the organisation to apply for their roles they need to be thinking about succession planning so that other senior staff are taught relevant tasks. This needs to be done over a at least 18 months to 2 years’ time frame. I despair because in the NHS I have seen succession planning being none existent.

When you are promoting staff especially into management roles please ensure you give them the tools to do their job. I have had personal experience of being thrown into a management role with no experience and it was difficult. I ended up being bullied. I learnt the hard way how to manage I would not wish that on anyone. I blame my managers it was not even in the job advert. There was no training provided I had to ask for relevant training. I learnt a lot but at the expensive of my mental health. My husband found it hard seeing me crying night after night when I was being bullied. The next time I knew what to do. No, I did not leave the organisation because I had not done anything wrong. I actually was being supportive, but the team had been so used to managing themselves in a bad way they didn’t like having a manager.

So training is not just about mandatory training it is about give the staff the right tools to do their job and develop them so they wan to stay. If you can have a career path that is even better. Staff who feel valued will usually stay.

Training can be learning from journals, personal development books ,going to forums in the local area and imparting the knowledge. It can even be learning from films. So think outside the box when you consider training. If you want some ideas get in touch with me through the contact form on my website

For instance Home Instead Care collaborated with the local hospital to reduce hospitalisation after falls and also to reduce unnecessary calls. By working as a team both parties were able to help each other and more importantly their clients. It meant the trust training the Home Instead Staff on a traffic light falls assessment system which they used in hospital . This is what I mean about outside the box thinking. You don’t need to find the answers only within your organisation collaborate with other that you refer to and see how you can help each other. Case Studies can be found on the CQC website

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)

Welcome to episode 28 of Continuous Quality Compliance

Today I am talking about Audit.

Audits is something the CQC look for in your organisation. Audits are important for any organisation to audit hat their processes are working.

Audit is a quality improvement process.

The definition of Audit is measures current practice against a defined (desired) standard. It forms part of clinical governance, which aims to safeguard a high quality of clinical care for patients. For Social care take out the word clinical

To check that staff are doing what they should be for instance when you audit good record keeping. The areas you need to audit will be dictated by what the organisation does but also bear in mind what he CQC are looking for in terms of the KLOE.

Audits need to be reviewed as well so ensure that the person doing the audit is not the one who should be checking it . Also ensure staff have training in how to do an audit. I have found audits not always developed well. They should not be just tick box exercise that is not the reason for audit. Audit should show if something is working if it’s not then it should be analysed and there should be a way to look at how to improve things.

Audits can look at:

Structure of care

Process of Care

The Outcome of Care

The aim is to find out how the present provision compares with the desired standard. This information can then be used to plan improvements in the service.

The standards are the CQC Standards here . Audit is cyclical but please schedule it so you don’t do all audits in one go. Have then schedules over a period of 12 months. Look at frequency some you will only need to do annually. Some every 6 months, some quarterly, and weekly. These should be appropriate to your organisation and the audit requirements of the topic.

NICE has some audit tools especially for Clinical audit use those if appropriate I am a great advocate of not re-inventing the wheel.

If you are not sure of what audit need to take place then have a look at the patient/client pathway look at the patient journey and documents journey then look at which areas would be good to review. Remember you know that he areas that CQC ask about need audits but you also need to think of audits appropriate to your organisation.

Audits are about improvement and when you need to make changes you need to account for time who needs to be communicated etc, do staff require further training or refresher etc. Audits are not about blame they are about understanding that processes are working effectively.

http://www.tchauhanconsultancy.co.uk/ (www.tchauhanconsultancy.co.uk)