A quality framework for care homes for adults and older people
Key question 2: How good is our leadership
This key question has four quality indicators associated with it.
They are:
2.1. Vision and values positively inform practice
2.2 Quality assurance and improvement is led well
2.3 Leaders collaborate to support people
2.4 Staff are led well
Quality indicator 2.1
Vision and values positively inform practice
Key areas include the extent to which:
vision, values, aims and objectives are clear and inform practice
innovation is supported
leaders lead by example and role model positive behaviour.
Very good
People benefit from a clear vision that is inspiring and promotes equality and inclusion for all. Leaders are aspirational, actively seeking to achieve the best possible outcome for people and this is shaped by people’s views and outcomes.
The aims and objectives of the care home inform the care and support provided and how people experience this. These are regularly reviewed and reflect the involvement of people who live in the care home and other stakeholders.
Weak
The vision is unclear; it lacks clarity, collective ownership and does not focus sufficiently on improving outcomes. There is no, or limited, evidence that equality and inclusion are embedded either within policies, procedures and plans or from observing staff practice. Staff’s awareness or knowledge of the vision, values and aims are minimal and do not inform practice
Very good
The culture encourages creative contributions from staff and people living in the care home. Staff are empowered to innovate and provide person-led care and support, fostering a culture of positive risk-taking. Learning from this is shared, including when things go wrong. In the spirit of genuine partnership, all relevant plans, policies and procedures reflect a supportive and inclusive approach. Leaders and staff recognise the importance of an individual’s human rights and choices, and embrace the vision, values and aims to support these being met.
Weak
Where improvements are needed, there is limited innovative thinking and staff do not feel confident in contributing to or implementing improvement. Staff are not able to adapt, or think creatively to meet people’s needs, outcomes and wishes
Very good
Collective leadership is evident, with capacity for leadership being built at all levels. Leaders ensure that the culture is supportive, inclusive, and respectful and they confidently steer the care home through challenges where necessary. Leaders are visible role models as they guide the strategic direction and the pace of change.
Weak
People do not have confidence in leaders. Leaders are not visible role models, and not well known to staff, people and relatives. Their leadership may lack energy, visibility and effectiveness.
Observation of:
experiences of people in the service
staff practices
communication and interactions
Discussions with:
people living in the care home
visitors, such as relatives, friends and carers of people living in the service
visiting professionals.
Sampling of:
policies and procedures
meeting minutes and action plans.
Consideration of:
how people quality assure what they do
how the improvement plans are developed, updated and shared
the services aims and objectives and how these inform practice.
Quality indicator 2.2
Quality assurance and improvement is led well
Key areas include the extent to which:
quality assurance, including self-evaluation and improvement plans, ensures standards of good practice are adhered to and drives change and improvement where necessary
leaders are responsive to feedback and use learning to improve
leaders have the skills, capacity and systems in place to identify risks, plan appropriate actions to address these and drive improvement.
Very good
Staff continually evaluate people’s experiences to ensure that, as far as possible, adults living in the care home are provided with the right care and support in the right place to meet their outcomes. People are well-informed regarding any changes implemented, and their views have been heard and taken into account.
Leaders empower others to become involved in comprehensive quality assurance systems and activities, including self-evaluation, promoting responsibility and accountability. This leads to the development of a dynamic and responsive improvement plan that details the future direction of the care home. This is well managed, with research and good practice documents being used to benchmark measurable outcomes.
Observations of staff practice are regularly undertaken to assess learning and competence. Outcomes from this are discussed through team discussions, reflective accounts or supervision.
People feel confident giving feedback and raising concerns because they know this is welcomed and responded to in a spirit of partnership.
Where things go wrong with a person’s care or support, or their human rights are not respected, leaders offer a genuine apology and take action to learn from mistakes.
Weak
There are some systems in place to monitor aspects of service delivery, however there is confusion and a lack of clarity regarding roles and responsibilities. Quality assurance processes, including self-evaluation and improvement plans, are largely ineffective. The approaches taken are not sufficiently detailed to demonstrate the impact of any planned improvement.
There is little effective evaluation of people’s experiences to ensure that their outcomes are being met. The lack of individualised care and support and limited aspirations to help people get the most out of life have a detrimental effect on people’s overall wellbeing.
Leaders do not use success as a catalyst to implement further improvements. They may fail to motivate staff and others to participate in robust quality assurance processes and systems. The lack of information regarding the rationale and need for improvement may inhibit change. Changes may happen as the result of crisis management rather than through robust quality assurance and self-evaluation.
Very good
Leaders learn from adverse incidents and complaints to improve the quality of care and support.
People are supported to understand the standards they should expect from their care and support and are encouraged to be involved in evaluating the quality of the service provided
Weak
There is a lack of analysis of incidents and limited efforts to learn from these.
People are either unclear how to raise concerns or make a complaint, or do not feel supported to do so. Complaints and concerns may not drive meaningful change when they could or should. Where things do go wrong, leaders may be defensive and unwilling to learn from mistakes.
Leaders do not understand or carry out their responsibilities under duty of candour legislation.
Staff feel anxious and defensive about making mistakes because there is a critical and punitive culture in the service.
Very good
Leaders demonstrate a clear understanding about what is working well and what improvements are needed. They ensure that the needs, outcomes and wishes of people living in the service are the primary drivers for change.
Leaders at all levels have a robust and clear understanding of their role in monitoring practice and identifying, directing and supporting improvement activities.
There are clear systems for monitoring standards of care including clinical and care governance. The pace of change reflects the priority of the improvements needed.
Weak
There is insufficient capacity and skill to support improvement activities effectively and to embed changes in practice. The pace of change may be too slow.
Oversight and audits of key functions are not in place or gather superficial data. Leaders are not proactive at ensuring quality care is in place.
Observation of:
experiences of people in the service
staff practices
communication and interactions.
Discussions with:
people living in the care home
staff
visitors, such as relatives, friends and carers of people living in the service
visiting professionals.
Sampling of:
policies and procedures
minutes of meetings and action plans for people, staff and relatives
complaint and concerns records, audits and outcomes
accident/incident records, audits and outcomes
manager’s overview of training, supervision, SSSC registration.
Consideration of:
quality assurance and oversight of relevant policies, procedures, records and outcomes – for example, medication, support plans, the environment how the improvement plans are developed, updated and shared
how the service gathers feedback and action take, including how this is built into induction and supervision
analysis / evaluations from participation methods/activities.
SCLD – Using scrutiny to drive outcomes and associated resources
Adults with incapacity: template policy for adult services
Leadership development activities – Scottish Social Services Council
Learning from adverse events through reporting and review: A national framework for Scotland 2019
NES quality improvement learning and tools
Care Experience Improvement Model (CEIM)
Quality indicator 2.3
Leaders collaborate to support people
Key areas include the extent to which:
leaders understand the key roles of other partners and their responsibilities
services work in partnership with others to secure the best outcomes for people
leaders oversee effective transitions for people.
Very good
Leaders identify and overcome barriers to enable people to gain real control over their care and support. A culture of joint responsibility and decision-making helps create a positive climate for partnership working. This considers each individual’s whole life including people’s physical, psychological, cultural, social, emotional and spiritual needs.
Because leaders have a sound knowledge of the key roles and responsibilities of partner agencies, they quickly identify when to involve them. Partner or multi agency working is supported by a clear strategy to facilitate working together so that people get the right support from the right organisation when they need it.
Leaders are confident in working across boundaries to support people and ensure they experience high quality care and support. Leaders recognise the benefits of sharing ideas and practice, not just within the care home, but further afield too.
Weak
Leaders do not ensure that care and support is provided in collaboration with people, their families, and the wider community.
Leaders have limited understanding of the roles that others from external organisations carry out which may benefit or provide additional support for people. There is no clear strategy and guidance to inform a collaborative approach. Leaders are not able, knowledgeable or confident at accessing local pathways for people. They may not work effectively with other organisations or know how to obtain specialist support when needed.
Leaders do not engage with the supportive functions available to them and do not make the required notifications to relevant bodies.
Very good
Where people are supported by more than one organisation, they benefit from well-coordinated care and support. Organisations work together, sharing information promptly and appropriately so that people experience consistency and continuity.
Where information is being shared between agencies for specific purposes, consent is sought and recorded. In situations where people are at risk of harm, leaders work within the boundaries of clear confidentiality policies. This may involve sharing information without consent, for example where is considered necessary to protect people from harm.
Weak
Leaders may not be confident at learning from other organisations to improve the services they provide or be willing to work with them.
There is a lack of clarity about when to contact other organisations or professionals to help support outcomes for people. Information about people is not regularly shared when it is appropriate to do so, and where that will lead to improvements in their care and support. Where information is shared, consent may not have been obtained from the person or their representative
Very good
Leaders ensure that the process for moving into the care home is person-centred. People are made to feel welcome and comfortable at the care home. If they choose to move on to another setting, they are supported to do so.
Leaders ensure that commissioned services are delivered efficiently and effectively. They monitor the success and effectiveness of working with partner providers and other agencies.
If people move on from the care home, there are clear processes in place to ensure they get the support they need.
Weak
Leaders do not work well with other organisations. The lack of joined up working impacts negatively on people’s experiences.
People do not benefit from robust approaches to moving in, or moving on, from the care home. As a result, people experience disjointed or rushed moves, leading to uncertainty or distress.
Observation of:
experiences of people in the service
staff practices
communication and interactions.
Discussions with:
people living in the care home
staff
visitors, such as relatives, friends and carers of people living in the service
visiting professionals.
Sampling of:
policies and procedures
information sharing policy and practice
admission procedure, practice and experience of people.
Consideration of:
arrangements for multi-agency working and how these benefit people
links the home has to local resources and how these are used and accessed.
Quality indicator 2.4
Leaders collaborate to support people
Staff are led well
Key areas include the extent to which:
leaders at all levels make effective decisions about staff and resources
leaders at all levels empower staff to support people
leadership is having a positive impact on staff.
Very good
Leaders engage meaningfully with staff, people living in the care home, their families, and the wider community. They take a collaborative approach to planning and delivering care and support.
Leaders are skilled at identifying and delivering the right resources, at the right time. They intervene at the earliest opportunity to ensure that people experience high quality care and support.
Where relevant, registered nurses and other health and social care professionals are empowered to play a key role in leading care and support. This includes working in partnership with all staff to ensure people get the health care and support they need. This results in robust systems of care with clear lines of responsibility and professional accountability, including clinical and care governance.
Weak
Leaders lack the skills and knowledge to anticipate the type and level of resources needed for people. This has a detrimental impact and fails to prevent difficulties arising and escalating.
Leaders do not identify potential barriers which impact on people. This may mean that people living in the care home have little influence on decisions which relate to their care and support.
There is a lack of vision and creativity in identifying services which may meet the unique needs and outcomes of each person living in the care home.
Very good
Leaders model a team approach, acknowledging, encouraging and appreciating the efforts, contributions and expertise of others, while instilling a ‘safe-to-challenge’ culture. They listen to others and respect different perspectives. They recognise that people are often best placed to identify their own needs and outcomes and encourage staff to support this approach.
Leaders recognise the importance of sharing ideas in a relaxed and supportive environment. They tackle inequalities and encourage equal opportunities for staff and people living in the service. Leaders learn from successes which they use to implement further improvements
Weak
Staff are not empowered to help identify solutions for the benefit of people who live in the care home.
Communication and direction is lacking and the approach to improvement is not sufficiently detailed. The rationale for change is not always clear to staff, impacting negatively on people’s experiences. Leaders may fail to engage, or energise, staff leading to confusion and a lack of clarity of roles and responsibilities.
Equality and inclusion are not embedded within policies, procedures and plans. There is a lack of understanding that staff at all levels have an important role to play in delivering high quality care and support.
Very good
Leaders are able to adapt their leadership style and motivate staff to deliver high quality care and support. A healthy work life balance is encouraged, which impacts positively on staff and people who live in the care home.
There is supportive and visible leadership that enables staff to voice their concerns, share ideas and explore ways to promote resilience.
Weak
Opportunities to use initiative, take responsibility and influence change are limited. Staff seldom adopt leadership roles.
There is no, or limited evidence that professional learning is linked to organisational priorities. Leaders do not address a lack of collaborative working within the staff team.
Observation of:
experiences of people in the service
staff practices
communication and interactions.
Discussions with:
people living in the care home
staff
visitors, such as relatives, friends and carers of people living in the service
visiting professionals.
Sampling of:
policies and procedures
minutes of staff and team meetings
staff training records, appraisals, supervision and deployment
quality assurance policy, procedure, practice and outcomes.
Consideration of:
the improvement plan
feedback about leadership and support for staff.
Achieving effective supervision
Everyday leadership from the frontline
Guidance on development of policy and procedure
Leadership development activities – Scottish Social Services Council