Document Description: Test Mk 4
Document Number: TEST-0004
Issue level: 0001
Issue date: 08/04/2013 12:30:11
Approved By: Dale Town (consultant)

Care Plus Group QM1 Quality Manual

ISO 9001:2008

Version: / 2.0 (January 2013)
Name of originator/author: / Dale Town/ Lucie Johnson
Ratifying committee / Integrated Governance Committee
Date issued: / TBC
Review date: / TBC

Scope of the quality management system

The provision of adult health and social care services to people across North East Lincolnshire. Scoped services as follows

  • Drug Intervention Programme
  • Alcohol Intervention Programme
  • Roundabout Service User Involvement Group
  • Intermediate Care At Home
  • Rapid Response
  • Home Team
  • Telephone Triage Service
  • Beacon

This Quality Manual is approved by the following

Chief Operating Officer
Jane Miller
Chief Executive
Lance Gardner
Head of Service –Governance
Lucie Johnson

Clause exclusion/s and justification

No exclusions from ISO 9001:2008 claimed

Definitions

QMS: Quality Management System

Procedure: A documented practice in support of the services listed above

Quality Manual Index

ISO 9001 clause / Manual heading reference / Description
4.1 / QM 41 / General Requirements – overview of the QMS at Care Plus
4.2 / QM 42
QM 421
QM 422
QM 423
QM 424 / Documentation and record requirements
General
Quality Manual
Control of documents
Control of records
5.0 / QM 50
QM 51
QM 52
QM 53 / Management responsibility
Management commitment
Client focus
Quality Policy statement
5.4 / QM 54 QM 541
QM 542 / Planning
Quality (service) objectives
Quality management system planning
5.5 / QM55
QM 551
QM 552
QM 553 / Responsibility, authority and communication
Responsibility & authority
Management representative
Internal communication
5.6 / QM 56 / Management review
6.0 / QM 60
QM61 / Resource management
Provision of resources
6.2 / QM 62
QM 621
QM 622 / Human Resources
General
Competence, awareness & training
6.3 / QM 63 / Infrastructure
6.4 / QM 64 / Work Environment
7 / QM 7
QM71
QM72
QM73
QM74
QM75
QM76 / Service delivery (product realization)
Planning of Care Plus processes (Services)
Client / service user related processes
Service Design and development
Purchasing new services or service support products
Delivering Care Plus services
Control of monitoring equipment critical to patient care / service delivery
8.0 / QM 8.0
QM 81
QM 82
QM 821
QM 822
QM 823
QM 824
QM 83
QM 84 / Measurement, Analysis and Improvement
General
Monitoring & measurement
Client satisfaction
Internal Audits
Monitoring & measurement of service performance
Monitoring & measurement of service conformity
Non conformity controls
Analysis of data
ISO 9001 clause / Manual ref / How Care plus applies ISO 9001
4.1 / QM 41 / General requirements – overview of the QMS at Care Plus
An overview of the Care plus process approach and how clause 4.1 is applied within our organisation is illustrated below.












This approach is consistent with the Care Plus Board Assurance Framework illustrated below

4.2 / QM 42 / Documentation requirements
4.2.1 / QM 421 / General
This electronic quality system is made up of the following:
  1. Quality policy statement
  2. Quality Manual (level 1)
  3. Process and Procedures (level 2)
  4. Records (level 3)

4.2.2 / QM 422 / Quality Manual
This quality manual references how the Care Plus Group applies ISO 9001:2008.
4.2.3 / QM423 / Control of documents procedure QP01 (Policy document)
4.2.4 / QM424 / Control of records procedure QP02 (Policy document)
5.0 / QM 50 / Management responsibility
5.1 / QM 51 / Management commitment
The Care Plus management team evidence their commitment to continual improvement of both business performance and the quality system by;
  1. Continuously focusing the Care Plus team on achieving stakeholder requirements relating to statutory requirements and strategic business plans
  1. Establishing, and reviewing the quality policy and associated service performance
  1. Ensuring that strategic objectives are established implemented and measured
  1. Conducting management reviews – see QM 56

5.2 / QM 52 / Client focus
Client focus is maintained by ensuring the following:
  1. Client requirements and inputs are understood, defined and documented then converted into services. (see QM71 covering the planning of service requirements)
  1. The measurement of Client feedback and satisfaction measurement (see QM821)

5.3 / QM 53 / Quality Policy
See the quality policy statement, see QMP01.
5.4 / QM 54 / Planning
5.4.1 / QM 541 / Quality (service) objectives
Care Plus strategic objectives are established and distilled down following periodic strategic reviews.
The strategic direction of Care Plus Group is encapsulated in the five year “Care Plus Group Strategic Plan” (initially entitled “Integrated Business Plan”). This plan is annually reviewed and refreshed by the Board of Directors and members of the Senior Management Team at a dedicated “away day” to allow for uninterrupted and structured discussion.
Inputs into the review of the strategic plan include current market analysis, consultation with wider stakeholders both internally and externally (including current and potential future commissioners) and the current and predicted financial picture of the organisation provided by the Finance Director.
Subsequent to the dedicated strategic planning session the results are recorded and utilised to produce a revised plan. Organisational priorities drawn from the strategic plan are distilled into key statements and communicated to all staff. Quality indicators of performance are dictated by commissioners and all of the objectives and priorities are mapped into the Heads of Service “Quarterly Performance Reports”.
The Care Plus Group Strategic Plan is where overarching organisational objectives are recorded for the whole organisation which are then communicated and cascaded throughout the group by various means including uploading of the document to the Intranet, Managers Meetings, Staff Engagement Events, informing personal objectives in the PDR of individuals etc.
5.4.2 / QM 542 / Quality management system planning
Planning of the quality system is completed as a result of the following inputs:
  • External CQC assessments
  • Internal CQC reviews
  • Care Plus service planning see 7.1 and 7.3
  • Management reviews
  • Internal audit findings
  • Complaint corrective actions
  • Preventive actions
  • Client feedback and satisfaction measurement
Changes made to the quality system are reviewed and controlled in line with the document, data and records control procedure, see QM423
5.5 / QM55 / Responsibility, authority and communication
5.5.1 / QM 551 / Responsibility & authority
The following Care Plus roles have the authority to shape and lead the Care Plus quality assurance programme
Chief Operating Officer
Chief Executive
5.5.2 / QM 552 / Management representative
The following management role also acts as Management Representative for the Quality management system.
Head of Service – Quality Assurance
Responsibilities are as follows;
Ensuring that service oversight and processes are established, implemented and maintained.
Reporting to senior management on the performance of the quality management system and any need for improvement.
Ensuring the promotion of awareness of client requirements throughout the Care plus.
5.5.3 / QM 553 / Internal communication
Staff members are considered a key resource, integral to the delivery of the highest possible levels of Care Plus service. Internal communication is facilitated by the following;
Council of governors
Staff Advisory Committee
Fortnightly newsletter emailed - All staff newsletters HR version managers
Care Plus Group Intranet rolling news items
Managers meeting – agenda no notes, incidents complaint, trend analysis reports applied
Staff engagement event - quarterly
The Staff Advisory Committee
Staff employed by the Care Plus Group automatically becomes a member of the Society which means they are able to give their views and vote on important issues for the organisation.
The Staff Advisory Committee is made up of staff members from across the Care Plus Group. The staff advisory committee meets on a monthly basis.
The chair of the Staff advisory committee is a nominated staff member a staff member. The chair supports all members of staff with any queries or issues.
5.6 / QM 56 / Management review
5.6.1 / QM 561 / Care Plus completes a formal management review to ensure the effectiveness of its services and supporting procedures. The management review is completed at a threemonthly frequency.
The Head of Service – Quality Assurance has responsibility for ensuring that the management review is scheduled. Invited members of the management team have a duty of care to attend and provide positive contributions during the management review session. Management review attendees are required to play an active role in the review of performance information provided at the management review and for reaching agreement on actions and resources required to improve service performance levels.
The management review agenda will as a minimum be as follows;
1)Follow up actions from previous management reviews
2)Quality policy review
3)Results of audits
4)Customer feedback
5)Service performance
6)Service conformity – DATIX stats
7)Status of preventive and corrective actions
8)Changes that will affect the QMS
9)Quality objectives review
10)Recommendations for service / QMS improvement
Management review records shall be retained by The Head of Service – Quality Assurance. Electronic records of competed management reviews shall be retained indefinitely.
5.6.2/3 / QM 562/3 / Management review input and output
Input = Performance information relating to agenda items referenced above in QM561
Output = Actions and tasks aimed at improving performance possibly tasks,
6.0 / QM 60 / Resource management
6.1 / QM 61 / Provision of resources
The Care Plus group has a policy of resourcing services and supporting the supporting QMS to meet statutory and best practice requirements.
Resource provision at Care Plus ensures the following;
The implementation, maintenance and continual improvement of services and supporting QMS
Improved service performance levels
Best practicably possible client outcomes
6.2 / QM 62 / Human Resources
6.2.1 / QM 621 / General
Care Plus staff performing work relating to any Care Plus service or QMS support activity shall be competent on the basis of appropriate education, training, skills and experience.
6.2.2 / QM 622 / Competence, awareness & training
Care Plus
a) Determines the necessary competence requirements for staff performing workrelating to any Care Plus service or QMS support activity.
b) Take action to resource and provides training to achieve competence requirements relating to statutory/ mandatory and best practice requirements.
c) Evaluates the effectiveness of the actions taken for the above
d) Ensures that its staff are aware of the relevance and importance of their activities and how they contribute to the achievement of service and quality objectives
e) Maintains appropriate records of education, training, skills and experience through application of the OLM training database.
6.3 / QM 63 / Infrastructure
Care Plus provides infrastructure designed to provide the required capability and capacity to meet client requirements. Infrastructure requirements are reviewed at periodic management reviews or between management reviews as required.
Care Plus provides and maintains the infrastructure to achieve conformity statutory and best practice requirements. Infrastructure at Care plus includes
a) Buildings, workspace and associated utilities,
b) Service equipment (both hardware and software), and
c) Supporting services (including transport, communication and management information systems such as system 1, DATIX etc.)
6.4 / QM 64 / Work environment
The work environment promoted and developed at Care plus is one of mutual cooperation and team work.
Serious consideration is applied to the work place ensuring that the effects of noise, temperature, humidity, weather conditions and lighting do not impede the process of meeting client requirements. Risk assessments and associated control measures are applied to all areas of business and service activity ensuring employee safety.
Changes and potential enhancements to our work environment are considered at routine management meetings as well as at formal management reviews. The viewpoints and inputs of all members of the team where practical are considered relating to work environment improvements.
7 / QM 7 / Service delivery (product realization)
7.1 / QM 71 / Planning of Care Plus processes (Services)
The applicable heads of service are responsible for ensuring that service processes are planned considering the following
a)Statutory and regulatory requirements and required service outcomes
b)Commissioner expectations and service specifications
c)National Institute for Health and Clinical Excellence Guidelines
d)Resources required to meet the above are planned and provided
e)The service process including statutory requirement is documented and controlled in line with the document control procedure
f)Records defined by the process are retained as prescribed by the process
g)The required verification, validation, monitoring, measurement, activities specific to the service and the criteria for acceptance including CQC are in place;
7.2 / QM72 / Client / service user related processes
QM721Determination of Care Plus service requirements
Each Care Plus service scoped under Care Plus QMS is planned using design control principles embodied in clause 7.3 of ISO 9001:2008. See the individual Care Plus service document for details of how services are planned.
QM722Review of service requirements
Each Care Plus service considers stakeholder inputs as key service requirements. See the specific documented Care Plus service for specific inputs.
QM733Communication arrangements with service users
Communication arrangements and records or communication are specified in the specific Care Plus service
7.3 / QM73 / Service Design and development
See the specific documented Care Plus service document for details
7.4 / QM74 / Purchasing new services or service support products
All Care Plus Group services adhere to the Care Plus Group Purchasing process – control policy (QPO5)
In addition detail regarding the purchase of approved services and products relating to the relevant scoped service can be found at PO1, PO2, PO3, PO4, PO5, PO6, PO7, PO8
7.5 / QM75 / Delivering Care Plus services
See the specific documented Care Plus service document providing requirements of cross reference to service requirements and records generated during service delivery.
7.6 / QM76 / Control of monitoring equipment critical to patient care / service delivery
See the specific documented Care Plus service document for details covering the control, traceability and calibration of equipment critical to service provision.
8.0 / QM 8.0 / Measurement, Analysis and Improvement
8.1 / QM 81 / General
Care Plus operates monitoring, measurement, analysis activities designed to facilitate the following
a) Demonstration of service conformity to requirements, statutory, best practice, CQC related etc.
b) To ensure conformity requirements referenced by this QMS including services.
c) To continually improve the effectiveness of the QMS including services.
8.2 / QM 82 / Monitoring & measurement
8.2.1 / QM 821 / Client satisfaction
Currently client satisfaction is measured through the following
Intermediate Tier - Patient Opinion surveys
Care Plus Group – User opinion survey provided via the Care Plus Quality and Performance Team
DIP Drug and Alcohol Interventions Programme – service evaluation questionnaire
Two way feedback is facilitated with the commissioners on a quarterly basis as a minimum
8.2.2 / QM822 / Internal Audit procedure QP03 (Policy document)
8.2.3 / QM 823 / Monitoring & measurement of service performance
Service performance for each Care Plus Group service is monitored by the Care Plus Quality and Performance Team. Performance issues are investigated in line with the Non conformity, corrective and preventive action procedure see QM8.3 and QM852/3
8.2.4 / QM 824 / Monitoring & measurement of service conformity
Service Conformity including CQC compliance for each Care Plus Group service is monitored by the Care Plus Quality and Performance Team. Non conformities are investigated in line with the Non conformity, corrective and preventive action procedure see QM8.3 and QM852/3
8.3 / QM83 / Non conformity, corrective and preventive action procedure QP04 (policy document)
8.4 / QM 84 / Analysis of data
The following sets of data are analysed by the Care Plus Group as a means of analysing service performance
DATIX data
CQC Internal assessments, and external where applicable.
User opinion statistics
Heads of Service “Quarterly Performance Report data’
8.5 / QM 8.5 / Improvement
8.5.1 / QM 851 / Continual improvement
The Care Plus Group shall seek to continually improve the effectiveness of the quality management system through the use of the quality policy, quality objectives, audit results, analysis of data, corrective and preventive actions and management review.
8.5.2/3 / QM852/3 / Non conformity, corrective and preventive action procedure QP04 (policy document)

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