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Requires Improvement to Good – Developing an Improvement Plan

by Mark Topps

There is often many articles and blogs written about how to achieve a Good or Outstanding Rating, but few guides that tackle and support providers to improve their rating from Requires Improvement back to Good. I am delighted that InvictIQ are supporting me with a four-part series aimed at upskilling managers and providers. Last week I explored some of the common challenges that care providers need to avoid, a quick dive into the rating system, and how to evidence your improvements as well as a 5-part visual infographic set outlining each of the CQC Key Questions alongside those common issues/pitfalls so you can get inspection ready (listed under Infographics).

In this week’s blog, I am going to look at how you create an improvement plan, set realistic and measurable goals, how to ensure your staff join you in any changes you make within the organisation and how to utilise feedback from those you support, their representatives and your team.

How to develop an improvement plan?

An improvement plan is a document that structures the areas for development and how you will implement/achieve them, however I always think in social care that you should take it one step further and add a section into the plan about the impact so you can use it as evidence for your next inspection.

Here are the high-level steps you should take:

  • Analyse the improvements needed and prioritise them. Ensure any relating to the safety of those in your care or organisation are prioritised, followed by any that will then have the greatest impact on the service quality and business performance.
  • Set yourself goals and objectives to meet these improvements and ensure there are deadlines to hold you to account.
  • Develop an action plan that documents the steps needed, the resources required to achieve.
  • Communicate the plan with all staff members and stakeholders to ensure understand and buy-in.
  • Monitor and evaluate

Ensure you do your research as this is a whistle-stop overview, and within each point is much more to explore.

How to set realistic and measurable goals for improvement?

Setting realistic and measurable goals is not as hard as it sounds and there are some simple things you can do. Firstly, you need to know what areas requirement improvement. If you are not aware of what improvements are needed, you can do this by:

  • Undertaking a SWOT analysis which identifies the strengths, weaknesses, opportunities and threats to your business.
  • Gather feedback from those you support, their representatives and your team.
  • Use the actions from audits.
  • Undertake a mock inspection

Now you know what requires improvement, you need to set out the vision of what you want to do to improve (ensure that they are realistic and achievable with the resources and constraints you have). You can create a headline goal, however under this you need to create clear specific and detailed goals and with measurable targets so that you can track progress (percentages and numbers are a great metric to use for this). It is important that you ensure each goal has clear deadlines for achievement and diarise review points along the way to review progress and adjust the goal, resources etc as needed based on feedback and performance data.

Here is an example of a realistic and measurable goal:

  • Headline Goal: Increase resident satisfaction with meal services.
  • Specific Goal: Improve the quality and variety of meals offered to residents.
  • Measurable Targets: Achieve a resident satisfaction rating of 90% or higher in the monthly meal service surveys.
  • Resources Needed: Staff training on meal preparation, more staff in the dining area and kitchen during main mealtimes and flowers and menus on the table.
  • Timeframe: Reach the satisfaction rating goal within six months.

Importance of involving staff in the improvement process and how to get their buy-in.

Without buy-in, you will not improve and any goals or objectives you have with fail. Staff want to give their feedback, they want to work for a company that is progressive, responsive and meets their needs as well as those of those they support so make sure you maximise on the feedback opportunities. Once you know the issues and/or improvements you want to make, ensure you communicate these transparently with the team, explaining the end result and associated benefits. You should at this point seek their feedback and input again so that they feel involved in the decision making and brainstorming sessions. You should acknowledge contributions and participation to foster encouragement of more staff doing the same.

Once you have gathered their feedback, you should document the areas of improvement on an improvement plan and subsequent action plans and re-communicate this to your team. Be open and ask them what support they feel they need to achieve these and regularly check-in to check of there are any new support needs (such as training, additional staffing, technology etc), to gather feedback on progress and to ensure they feel supported.

Like the other sections in this blog, this is a whistle-stop tour, and you should do further research into how to involve your staff and the tools required to do this effectively.

How to gather and utilise feedback from residents and their families?

Feedback plays a huge part of the new CQC Single Assessment Framework, and there are several ways in which you can obtain this. My top five are:

  • Surveys – you need to move away from the annual survey and introduce pulse surveys so that people can give their feedback on current happenings. It is better that you know about the niggles/issues etc and have time to put a plan together to overcome those than the CQC finding out during an inspection.
  • Suggestion boxes – these should be in communal areas, near the front door etc so people feel they have a chance to use one of them without others seeing. You should not force people to identify themselves as this will result in some people being put off.
  • Audits – Digital solutions such as Audit On Cloud by InvictIQ can support with this. Their AI powered Action Planning not only automates the process but also identifies gaps and areas of improvement in the specific Key Question or Quality Statements. 
  • Focus groups – you could organise a small group discussion to gather in-depth feedback.
  • Regular meetings – with staff, those you support and families. You should ensure people feel able to speak up and voice their opinions and concerns.
  • Observations / spot checks
  • Exit interviews – so many providers miss a trick by not doing these. Get to know why people are leaving your organisation (both staff and those you support).

Be sure to get feedback from everyone who comes into contact with your organisation, the people you support, their representatives and your staff team. The recently launched Survey/Feedback module within the Audit On Cloud platform by InvictIQ enables users to conduct surveys seamlessly while leveraging AI-powered sentiment analysis. This innovative feature not only facilitates the collection of feedback but also assists in understanding and categorising responses, allowing users to prioritise actions, especially in response to negative feedback. Additionally, automated reviews and key insights accompany each survey, enhancing the overall feedback management process.You can then utilise this feedback by developing an Improvement Plan and this resource to help you drive the continuous improvements to your organisation that are needed, whilst creating documentation that can be used as evidence in your next inspection.

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"Every success story is a tale of constant adaption, revision, and change."
Richard Branson
Evidence driven improvement
Mark Topps

Mark Topps is a social care leader who has worked in the care industry since 2004 and is currently working as a regional support manager. He regularly advocates, appearing on television, radio and podcasts and has started many campaigns for change in legislation and culture within the industry. Mark is the co-founder of The Caring View which is a social care podcast, YouTube show and free resource initiative for the sector. He also co-founded The Health and Social Care Club, which is an audio event hosted on LinkedIn. Mark is also the social media and marketing director at the National Association of Care and Support Workers.

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