MENTAL HANDICAP VOL. 21 JUNE 1993

Implementing Quality Assurance Auditing Residential Services for People With Mental Handicaps

Elisabeth Watson Elizabeth Perkins David Louden Margaret Fenton

This article reports on the format and implementation of a quality audit, Monyhull Audit Technique for Environmental Evaluation (MATEE), to evaluate the quality of residential services for people with mental handicaps. It is suggested that the key to successful quality auditing lies in the way in which the system is operationalised. The audit must be ongoing rather than a ‘one-off event. The procedure needs to be clearly specified, important aspects of which should include positive monitoring, regular follow-up on objectives and maximal involvement of care staff. Some of the benefits of this type of quality assurance are discussed.

This article reports the results from a six month quality assurance project in the Learning Difficulties Programme of South Birmingham District Health Authority. The format and implementation of a quality audit, Monyhull Audit Technique for Environ- mental Evaluation (MATEE) are described.

The MATEE audit Carrying out the quality audit involves members

of an audit team spending at least a full day in each home observing what goes on. The audit team is made up of three people who are independent of the daily running of the home. The Quality Officer leads the team. Other team members might include people from within the programme such as a dentist, pharmacist, gardener, secretary etc. and people from outside the programme such as purchasers or Community Health Council representatives. Many team members have reported that participating in the audits proved a valuable experience. The team use the 85 page MATEE checklist as a guideline for their observations in the home. To complete

the checklist some questions have to be answered by a member of staff from the home whilst others depend on direct observations or checking records and other documentation.

Although the format of the audit will be described here, we believe that the success of the measure lies in the way in which it has been implemented. The MATEE checklist covers 50 topics listed under six main headings: unit profile, organisation, physical environment, the life-style of the residents, special needs and support services. There are also two appendices, a staff questionnaire and a structured interview for residents. The staff questionnaire asks such questions as whether staff feel that they have the opportunity to air their views in staff meetings. The interview with residents gives individuals a chance to comment on life in their particular home and any changes they would like to see made.

Heading each of the 50 sections is an underlying principle. Figure 1 gives examples of two of these. Each principle is then followed by a series of questions to determine whether or not the home

Section Underlying Principle

The building All residents are entitled to live in a setting which is as homely, private and domestic as possible.

Each home’s activities must allow all residents the opportunity to participate as much as possible in ‘normal’ daily activities.

Pattern of daily activities

FIGURE 1 Examples of underlying principles in MATEE checklist

LIZ WATSON and MAGGIE FENTON are both Quality and Research Officers for the Learning Difficulties Programme of South Birmingham District Health Authority. ELIZABETH PERKINS is the Programme Director and DAVE LOUDEN the Director of Nursing Services.

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MENTAL HANDICAP VOL. 21 JUNE 1993

fulfils the principle. Figure 2 illustrates questions for the section ‘Effective staff ratios’. Most items are scored yedno on simple rating scales. This yields a score for each section of the MATEE. Scores indicate in which areas improvements are necessary and allow each home to chart their progress on each section over time.

The MATEE procedure A checklist, by itself, might not be used effectively

to audit residences. It is, therefore, vitally important that there is a clearly defined procedure to follow when auditing.

A few weeks prior to an audit, the Quality Officer sends a letter to the home explaining the purpose of the quality audit and the procedure. This is followed by a visit to the home to answer any questions the staff may have. All staff are made to feel active participants in the whole process and encouraged to see the audits as a positive event. Since it was felt that announced audits can lead to excessive preparation for the visit, each home is told to expect an audit within the month but not when, exactly, it will take place.

During an audit, one member of the audit team completes the MATEE checklist, after consultation between the team on each question. The checklist guides the team through all areas of service pro- vision. This involves a visual inspection of the premises, both inside and out; checking policies, communication books and individual clients’ rec- ords; observing meal-times, including the quality,

Principle: ‘The staff on duty should be arranged around the needs of the residents, the number of residents in the home and the overall work load.’

~~ ~

1. Is the staff ratio highest when the number of

2. Do part time staff work only at times of highest

3. Are the staffing levels sufficient to meet the

residents or the work load is highest?

work load? YES /NO

YES /NO

work load of the home:

(b) During the night? (a) During the day? YES /No

YES i NO

4. Are staffing levels sufficient to meet the needs of the residents: (a) During the day? (b) During the night?

YES /NO YES /NO

5. Is the present shift system adequate? YES /NO

6. Do you think the shift system could be revised to give a better service? YES /NO

FIGURE2 MATEE questions on ‘Effective Staff Ratios’

quantity and presentation of the food; observing the residents’ activities, interactions with others, clothing etc. Information is gathered in such a way as to cause the least disruption to the daily routine of the home.

After the quality audit has taken place, the audit team meet to discuss their observations. Within a few days a report is prepared, which is then sent to the home for discussion amongst the staff, to the Nursing Officer, the Director of Nursing Services and the Programme Director. The format of the report is important and hence will be discussed in detail.

The report usually begins with several positive findings about the service, with particular reference to recent improvements. This positive monitoring (Porterfield, 1987) acknowledges the efforts being made by staff. A list of prioritised recommendations for the service follow. Problems and needs high- lighted by the audit are made explicit and, where appropriate, some form of action is suggested. This results in a concise report, typically of three or four pages in length. Scores achieved on each section of the audit are appended to the report.

The Quality Officer, Nursing Officer, home staff and any residents or their relatives who wish to be involved then meet to discuss the report and set some objectives for change. Areas highlighted by the report as being in need of improvement are discussed and those directly involved decide upon appropriate action. This part of the procedure is very important; care staff must feel that any action comes from them rather than being imposed upon them from an external source. An action plan is then drawn up clarifying the goals to be achieved. People volunteer to carry out the actions by a certain date (who, will do what, by when) and another individual takes responsibility for following up on progress towards each objective. Finally, the group prioritise the goals on an action plan. Copies of the action plan are then sent to all those involved, the Director of Nursing Services and the Programme Director.

A final and vitally important part of the procedure is follow-up. After each audit, there is a three month follow-up period, during which time there are several checks made by the Quality Officer on progress towards each objective. The individual responsible is reminded of relevant objectives and praised for any progress made. After the three month period, a report on progress is drawn up. Another follow- up visit takes place six months later. Audits are repeated every twelve months and homes are encouraged to monitor their progress over time. In this way, the audit process is ongoing throughout the year, rather than being a one-off event. This introduces a culture of self-evaluation in each home which helps promote a quality service.

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FIGURE 3. The rolling programme of site visits

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MENTAL HANDICAP VOL. 21 JUNE 1993

The two Quality Officers meet regularly with the Programme Director and the Director of Nursing Services to discuss individual sites or problems and present any requests for resources. Feedback on previous requests also comes through these meet-

To ensure that all homes in the District are audited on a yearly basis, a rolling programme has been designed. A summary of this is shown in Figure 3. For each site, the initial visit, audit, action plan and follow-up take four months, represented on the plan by arrows. The subsequent six month follow-up is indicated by asterisks. Note the periodic gaps, when no new sites are audited, to allow the entire system to.be reviewed and any catching-up to take place. At the end of each audit year, when all sites have been completed, comments from each home on the quality of the support services are put together and a report produced for each service.

The audit system is, itself, monitored through the use of performance indicators (PIS). A three monthly report to the PI team indicates:

ings.

The percentage of audits completed to schedule in the three month period. The standard set is 100%.

The percentage of three month follow-ups com- pleted to schedule. The standard set is 80%.

The percentage of objectives achieved for each home by the three month follow-up. The standard set is 40%.

Discussion The MATEE quality audit is one way in which

quality can be regularly reviewed in terms of the impact of the service on the service-users lives and in a way that leads to practical improvements.

Auditing in this way offers several benefits. It gives some positive feedback to care staff on the good work they do, thereby boosting staff moral. It also offers care staff a way of identifying problem areas within the service. The audit provides the opportunity for care staff to raise issues with management that they might, otherwise, not feel able to discuss and thereby facilitates the flow of information between managers and care staff. Other advantages include providing feedback for managers and providing evidence for the improved allocation of resources. Finally, the audit introduces a continu- ous evaluation system which helps staff focus on the quality of service provision.

Although the MATEE audit has its limitations, it has, nevertheless, enabled the programme staff to introduce quality assurance to residential services for people with learning difficulties and it indicates a direction for the future service evaluation.

Acknowledgements Thanks to Dr Peter Sturmey for his supervision of this project.

Any correspondence should be addressed to Liz Watson, Monyhull Hospital, Kings Norton, Birmingham, B30 3QB.

The percentage of unmet objectives for each home that are due to resource limitations.

Results from the audits This system has been successfully implemented

in the Learning Difficulties Programme of South Birmingham District Health Authority. Quality Offi- cers work in close liaison with both care staff and managers to promote a quality service. Six months after the completion of the project, 17 residential sites have been audited. A wide range of goals have been achieved, many of which have involved making the best use of available resources. For example, by altering sleeping arrangements in dormitories to offer more privacy, enhancing personalisation, giving residents more choices, increasing community par- ticipation and hobbies and removing official signs outside community houses. To date, all homes have exceeded the 40% minimum standard for the number of objectives to be achieved by the end of the three month follow-up period. Most of the unmet objectives have been due to resource limitations.

REFERENCE Porterfield, J. (1987) Positive Monitoring: A Method

of Supporting Staff and Improving Services f o r People w i t h Learning Disabilities. Kiddermins- ter: BIMH Publications.

RESIDENTIAL HOME

The J.S. Autistic Society is a new registered charity and will be opening a

new registered home for adults with autism in Moseley, Birmingham. It is due

to open at the beginning of November.

For information or referrals, please contact the Care Manager on:

(021) 441 4417.

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