Quality & Compliance Magazine: Evidencing the inclusion of service users in their care

Topics covered: Ridouts professional advice

Any health and social care provider that has read the new legislation and CQC’s subsequent Guidance about Compliance: Essential Standards of Quality and Safety (the “Guidance”), will know that the entire ethos of the new regime hinges on the rights and experiences of the service user.

The language of the Health and Social Care Act 2008 and the linked regulations makes it clear that the way the service providers communicate with the service user and involves them in their care will be paramount when the CQC judges compliance.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (the “Regulations”) form the basis of CQC’s Guidance and will dictate what a provider must do to achieve compliance.

Outcome 1 sets out the importance of promoting “autonomy, independence and community involvement”. This theme is pervasive through the Regulations and CQC’s Guidance.

The need to prove that service users are offered independence and choice in their day to day lives can pose a challenge to providers. Most service users are given plenty of choice on what they eat, what activities they are involved in and how they spend their time, however, CQC are relying on providers to be able to evidence that these choices are given and provide such evidence during an inspection.

Many providers I have spoken to despair on how to create documentation on something that is done informally all day long, after all, staff in the sector are trained to put the needs of the service users first.

I am going to deal with two Regulations that require such inclusion and choice to be provided:
Outcome 1: Respecting and involving people who use services (Regulation 17)

The Regulation behind this Outcome requires that:

(2) …the registered person must – …..

(c) encourage service users, or those acting on their behalf, to –

……….. (ii) express their views as to what is important to them in relation to the care or treatment

(d) where necessary, assist service users, or those acting on their behalf, to express… views …..and so far as appropriate and reasonably practicable, accommodate those views;

(e) where appropriate, provide opportunities for service users to manage their own care or treatment;

(f) where appropriate, involve service users in decisions relating to the way in which the regulated activity is carried on in so far as it relates to their care or treatment;

This Regulation clearly shows that as far as is reasonably practicable, providers must involve service users in decisions relating to their care and to seek their views generally. This requirement appears to be at the very heart of what the CQC is trying to achieve with the new regime.

To evidence involvement providers should keep the minutes of any service user meetings on file. This will show the CQC that service users are given the opportunity to voice any concerns or feedback that they may have regarding the service. The same should be done for any relatives meetings.

Whilst evidencing such feedback opportunities is important, providers need to be able to show that the feedback has been acted upon to improve services. This will show the CQC that service users are having a direct impact on the way that their care is being provided. There is little value in recording concerns and doing nothing about them.

Some providers produce feedback forms or questionnaires for service users and their families. This allows service users who do not wish to discuss matters relating to their care in an open forum, to voice their opinion.

The most important element of seeking such views is how the provider deals with the information. Inclusion and involvement can only be shown where a provider takes proactive steps to improve the experience of the service user.

Outcome 5: Meeting nutritional needs (Regulation 14)

Where a provider offers food services to its service users, the Regulation behind this Outcome requires that service users are provided with:

“a choice of suitable and nutritious food and hydration, in sufficient quantities to meet service user needs”

Provision of choice in this respect can be exemplified in a number of ways.

Providers should actively seek the input of the service users on what they would like to see on the menu. This could be done in one to one meetings, during a residents’ meeting or via a questionnaire. Any results of such discussions should be kept on file to show the CQC that the needs and wishes of the service users have been sought and taken into account.

The CQC have produced guidance with the Royal College of Nursing to assist with compliance with Outcome 5. This can be accessed on the CQC website. The importance of choice is highlighted in the guidance and it details what CQC will look for in deciding if a service is compliant. Some points include seeing whether people are:

•    given an informed choice, i.e. using a menu, lists, verbal descriptions, pictures, photographs
•    people preparing food for themselves
•    a range of replacement meals being offered that include the provision of culturally sensitive   choices (for example, halal) and for reasons associated with special physical needs (for example, dysphagia).

Ridouts would recommend becoming familiar with this guidance.

Some providers conduct staff audits of menus. This allows staff members who have gotten to know the service users and their personal preferences, to have input on what they think service users would like to eat and drink. Obviously this would form the basis of the decision and further input would be required from the service users themselves.

Providers must also consider the specific dietary requirements of service users. These may be related to religion or merely a personal preference, however, this choice must be respected and clearly detailed in a care plan.

Under this Regulation providers should also be flexible on where service users prefer to eat meals. Some service users would rather eat in their rooms than in a communal dining area and whilst some providers may see this as anti-social, the service user’s wishes must be respected. Obviously, a preference like this should be marked in an individual’s care plan.

Flexibility should also be given to the times that service users wish to eat and also to food that is available outside of set mealtimes.

Those who provide domiciliary care services should take the same approach with their clients in terms of providing choice and allowing the service user to have maximum input on what they have to eat. This could involve


Services may find that they already provide service users with many of the opportunities listed above; however, providers must ask themselves if they have enough evidence on file to show that such steps have been taken.

The CQC will be concerned with the documents that providers have to hand to prove compliance, they will not be prepared to form a judgment based on the unquestionable goodwill and informal approaches of some staff.

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