Quality Assurance Policy and Procedure


To set out how Accessible Care intends to achieve continuous improvement in all services, reflecting national, local and Accessible Care priorities.

To ensure the consistent delivery of safe, effective care that results in a positive Service User experience.


The following roles may be affected by this policy: 

  • All staff 

The following people may be affected by this policy: 

  • Service Users 

The following stakeholders may be affected by this policy: 

  •  Commissioners 
  •  Local Authority 
  •  NHS 
  •  Family 
  •  Advocates 
  •  External health professionals


To describe the mechanisms Accessible Care has in place to confirm that the quality processes meet Care Quality Commission requirements as well as the needs the company, our employees, our Service Users and others key stakeholders. 

To highlight that Accessible Care promotes a culture where quality care as well as Service User and staff safety remain high priority. 

To emphasise that the provision of evidence-based best practice underpins all activity within Accessible Care and our processes are benchmarked against NICE guidelines and other best practice guidance. 

To confirm the commitment of Accessible Care Ltd. to quality and ensuring that robust governance processes exist within Accessible Care.


Accessible Care will ensure that there is effective governance, including assurance and auditing systems and processes. These will assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for Service Users. The systems and processes will also assess, monitor and mitigate any risks relating the health, safety and welfare of Service Users and others. 

Accessible Care is committed to ensuring that we continually evaluate and seek to improve our governance and auditing practice.

The organisation’s aim is to delivering safe, caring, efficient, high-quality Care services which fully integrates quality, performance and governance as detailed in our vision and values. 

Accessible Care recognises that a quality service is one that understands the needs and circumstances of each Service User, carer, the local community and staff members. We fully appreciate that a quality service ensures that Care services are accessible, appropriate, safe and effective for all and that this includes protected characteristic groups. We also believe that workplaces should be free from discrimination so that staff can thrive and deliver excellence. 

Accessible Care will anticipate and be responsive to the changing needs of our diverse Service Users and the changing needs within our local community. We are committed to providing the best possible Service User Care and valuing the professionalism of our staff. 

Accessible Care will ensure necessary resources are available to effectively monitor key performance indicators. This data will be used to inform management decisions which support delivery of quality services, ongoing quality improvement and business planning decisions.

Within Accessible Care, key individuals with the appropriate skills, experience, and knowledge will be identified to have responsibility for the following:

  • Implementation of quality procedures and systems
  • Meeting legal, regulatory and contractual compliance
  • Auditing of the service
  • Collation of data and information to monitor performance against agreed quality standards
  • Listening and responding to Service Users concerns, feedback and views
  • Listening and responding to concerns raised by Accessible Care staff and other key stakeholders

The Registered Manager has overall responsibility for:

  • Ensuring there is ongoing compliance with regulatory and contractual requirements
  • Ensuring compliance with policies and procedures
  • Ensuring there are sufficient numbers of staff with suitable skills, experience and knowledge to deliver safe Care and maintain a high-quality service
  • Reviewing and learning from accidents, incidents (including safeguarding), complaints and sharing this learning with staff
  • Seeking feedback from stakeholders
  • Acting on results of audits and reviews of the service
  • Developing systems of achieving continuous improvement
  • Collation, reporting and using data to inform stakeholders of the quality of the service
  • Promoting a supportive, transparent culture where Accessible Care can learn from any mistakes
  • Collaborative working with commissioners, Derbyshire County Council and CCGs to identify opportunities to meet the needs of the local community 


Accessible Care Quality Framework 

Accessible Care will embed a quality framework that includes: 

  • Clearly defined quality objectives that are specific, measurable, achievable and time sensitive 
  • Ensuring a person-centred approach to the Care for each Service User 
  • Enabling the Service Users, we care for to set their personal objectives and involving them in the review process 
  • Setting targets that are focused on meeting the needs of our Service Users, our business and other stakeholders 
  • An organisational structure that identifies who provides vision and direction within Accessible Care.
  • An implemented, up to date suite of policies and procedures that are evidence-based, reflect best practice, the needs of Accessible Care and dovetail with any contractual requirements with regular audit cycles to ensure compliance. 
  • Personal development plans, supervision, and appraisal systems for staff to ensure that they have the relevant skills knowledge and expertise. 
  • The use of effective communication tools to minimise any internal or external communication barriers.
  • An active internal and external audit process with outcomes feeding back into the quality cycle.
  • An infrastructure and resources that can support delivery of aims and strategic priorities.
  • The building of positive relationships with partners and others working in the sector to enable sharing of experiences and resources, to pool expertise and work in partnership for the best interest of Service Users.
  • A means of evaluating all activity on a continuous basis and using feedback gained to inform the development of services.

Internal Procedures
All Accessible Care locations will ensure that following procedures are implemented: 

  • Specific Care Worker Pathway to ensure staff are regularly supported and competencies are assessed from the on-boarding process and during the length of the year.
  • Specific Service User Pathway to ensure people’s requirements are regularly reviewed and feedback is gathered on regular basis.
  • Regular Service Users, Families and staff surveys, including an analysis report detailing a specific action plan.
  • Efficient Significant Events procedures, to ensure all incidents are recorded, investigated and sustainability is achieved.
  • Regular Compliance Meetings to identify Significant Events themes and trends and plan preventive and responsive actions. 
  • Regular Recruitment and Retention Meetings to assess capacity ensuring a successful workforce retention and deployment.
  • Regular KPI reporting to Accessible Care’s Regional Head Office and Group Head Office to identify trends and trigger points.

External Audits

Accessible Care is committed to:

  • Maintain annual external Health and Safety audits in all its locations.
  • Maintain annual external care audits in all its locations.
  • Maintain annual external quality audits in all its locations, ensuring ISO 9001 (Quality management systems) is renewed.
  • Maintain annual external anti-bribery audits in all its locations, ensuring ISO 37001 (Anti-bribery management systems) is renewed.

A training matrix is developed and all staff undergo training needs analysis.

Training and Development is given high priority for all staff within Accessible Care to ensure a knowledgeable and competent workforce.

An environment is created where staff are committed to develop and change practice and systems in the light of research, good practice and evidence-based care.

Accessible Care will review training materials alongside any published policies and procedures to ensure consistency and ensure that they dovetail.

Training is reviewed as part of root cause analysis and lessons learned when things go wrong.The Regional Operations Director will ensure mechanisms are put in place to ensure any gaps in training are closed.

Service Users

Accessible Care will ensure that all Service Users have a person-centred Care Plan that meets their needs, expectations and wishes, created where possible, before their Care starts.

Care Plans should be reviewed at least once a year or when requirements dictate. This is detailed in the location’s Service User Pathway.

Accessible Care must ensure that risk assessments and Care Plans are reviewed when needs change, when there is an incident, concern or near miss.

Service Users must be at the heart of any Care Planning and with their consent, family or someone who can advocate on their behalf will be involved. 

Accessible Care will ensure that Service Users know how to raise concerns, share their views and how to get involved with shaping service delivery. Accessible Care will listen and respond, documenting any action taken.

Accessible Care will audit consistency and reliability of Care and take remedial action where required.

Accessible Care will ensure that principles of privacy, dignity and respect underpin all Care delivery and this will be audited.


Recruitment is valued based and robust to ensure the right people are recruited for the right job. There is a formal induction process for all staff to ensure they are provided with the skills and knowledge to gain competence to fulfil their roles. Recruitment will ensure that all pre-employment checks are undertaken and documents are held in line with the Data Protection requirements.

Accessible Care will undertake workplace observations on every Carer at the Service User’s home to witness Care delivery at a frequency agreed by the specific Accessible Care location. This is detailed in the location’s Care Worker Pathway.

Accessible Care will ensure all staff have regular supervisions which will include a mix of 1:1 and group supervision at a frequency agreed by the specific Accessible Care location. This is detailed in the location’s Care Worker Pathway.

New staff should undergo supervision more frequently and where concerns arise about any member of staff, supervision frequency will increase
Priority should be given to training and personal and professional development with the need to attend mandatory training emphasised.


The Registered Manager should promote a culture that is open, honest, transparent, safe and caring. The Registered Manager will ensure that:

  • Staff are given the opportunity to take part in surveys that are anonymised, collated and used to determine trends.
  • Processes support a person-centred, ‘fair blame’ culture that actively encourages service Users and/or their family or carers and Carers to report their concerns.
  • Whistleblowing and Safeguarding Policies and Procedures are widely publicised and linked to County Council procedures.
  • A learning culture is promoted, with audit and investigation outcomes being disseminated to staff so that lessons can be learnt and measures put in place to ensure incidents don’t arise again.
  • Any audits that result in actions identified, will be implemented in a timely, supportive manner, using the change management approach.

Policies and Procedures

Staff can access policies and procedures via the interface. 

These should be made available to ensure a consistently high standard of quality care is delivered. 

Policies and procedures will be reviewed to ensure they meet the needs of Accessible Care and make amendments where required to meet local policy requirements.The Registered Manager must ensure the policies and procedures are implemented and embedded within Accessible Care and will undertake regular compliance audits.

All policy writers must keep up to date with any local policy or best practice changes and ensure these changes are cascaded to staff.

Reviewing of Policies & Procedures

Reviews of Accessible Care’s policies and procedures will be carried out on an annual basis or at any such time it is recognised that changes are required. Changes may result from employee, management and trade union feedback and/or from changes in legislation.

All reviews and amendments will be recorded.

It should be noted that:

  • The policies and procedures do not confer any contractual rights unless specified in an employee’s contract of employment.
  • The overall responsibility for the enforcement of all policies and procedures lies with Accessible Care’s senior management team.
  • Accessible Care will retain the right to review the policies and procedures at any time.

The reviewing of all policies and procedures will be the responsibility of Operations Managers, Head of Operations and the Regional Operations Director.


The Nominated Person or delegated other will undertake regular quality control audits and reviews of their service as dictated by the quality framework. These service reviews should include the following umbrella terms:

  • Financial transactions.
  • Health and safety .
  • Accidents and incidents. 
  • Safeguarding.
  • Compliments, concerns, and complaints.
  • Service User and staff feedback.
  • Infection control.
  • Care and safety performance, e.g. Care documentation, medicine management, nutrition, tissue viability.
  • Home visit spot checks.
  • Thematic audits and national audits will also be used to provide focused reviews of quality.

Results will be analysed and used to:

  • Develop action plans to enable achievement of improvement and result.
  • Steer the direction for quality initiatives and review of Accessible Care strategy.
  • Form supervisions, training and performance management where necessary.

This does not replace any additional, more frequent quality assurance checks that are completed as locally agreed by Accessible Care.

Corporate Social Responsibility

Accessible Care is a socially responsible business and we recognise the active role we can play in helping to build happier and healthier communities. Accessible Care will do this by:

  • Ensuring ethical purchasing with due diligence carried out on our supply chains.
  • Adhering to Modern Slavery and Human Trafficking Laws as part of our purchasing strategy.
  • Complying with local waste reduction and recycling requirements.
  • Striving to be a responsible neighbour in the community we operate by ensuring the safety and security of The Agency premises.
  • Finding and investing in technological solutions where possible, such as low energy lighting systems, that can help us use energy resources more efficiently.
  • Being a ‘champion’ of change, showing how much, we care about the need for a low carbon economy and reducing our carbon footprint by ensuring staff can keep car journeys to a minimum by careful rostering.
  • Motivating staff to actively care about the environment, giving them guidance and information to help them make a real difference.
  • Producing and reviewing specific Community Engagements plans, to collaborate with the wider community.


Quality Assurance: 

  • Quality assurance is the process of verifying or determining whether products or services meet or exceed user expectations.
  • Quality assurance is a process-driven approach with specific steps to help define and attain goals.
  • This process considers design, development, implementation, and evaluation.
  • It is essentially about learning what works well and striving to do it even better.
  •  It also means establishing what may need to change to meet a need.

Quality Framework:

  • A quality framework is a structure which defines Quality in practical terms for an organisation.
  • It sets out expectations in domains for quality and represents a single framework through which can be the evaluation, management, and improvement of the quality of the service.

Significant Events:

Significant Events are incidents that affect the delivery of care and must be investigated: 

  • Missed Visit. 
  • Medication Error. 
  • Accident, Incident or Near Miss. 
  • Complaint.
  • Safeguarding.