Improvement support section

We are the Quality Improvement Support Team (QIST). Our team provides specialist quality improvement knowledge and skills to the social care workforce, provider groups and Care Inspectorate colleagues. We support, educate and enable others to improve how they help people who experience care in Scotland. Working collaboratively is key to how we work, whether that work is universal, targeted or specialist.  

Our wide-ranging experience of quality improvement helps us to have meaningful conversations with all partners. Using the Model for Improvement, including PDSA cycles, we enable services to develop, implement and reflect on their change projects.  

We work collaboratively with our scrutiny and assurance colleagues to ensure that improvements are made alongside existing inspection frameworks and services’ own self-evaluation processes. 

The involvement and equalities team is a multi-disciplinary team that shapes and guides the organisation forward to ensure quality improvement, co-production, equality and fairness are integrated into all our work across the organisation. These are not just nice to do’s, or add on’s, they support quality improvement.

Involvement and equality are at the heart of all we do and will drive us towards our vision for world-class care that is characterised by individuals receiving high quality care, experiencing positive outcomes and having their rights respected. The Care Inspectorate exists to further improvements in the quality of social care and social work, and we can only do that with the involvement of people who experience care, many of whom will have protected characteristics or face disadvantage and exclusion.

We believe that the people who use services are the experts in knowing what works for them and that using the information they share will ultimately strengthen the scrutiny and quality improvement work that we do. Their unique knowledge and skills lead to high-quality, safe and compassionate care which reflects the rights, choices and individual needs of people.

We have two important strategies the Involvement Strategy "Working Together, Improving Together” and the Equality, Diversity and Inclusion Strategy 2021-2025 which explain our work and plans in more detail.

To find out more about the safe staffing programme, you can visit their page on the Hub - please click here. 

To find out more about the early learning and childcare (ELC) improvement programme, you can visit their page on the Hub - please click here. 

Key things to remember

• The aim of improvement activity in your service is to make the care you provide better
• Improvement in the quality of care doesn’t happen by accident; it needs to be planned and structured and takes time
• Making improvements should benefit everyone
• Essentials for achieving successful improvements include a belief that there is always the potential to improve, strong leadership, support, adequate resources, a dedicated improvement team and making improvement everyone’s business
• A well-planned approach to improvement will give you a better chance of being successful and maintaining improvements
• The Model for Improvement is a tried and tested approach to achieving positive change
• Consideration needs to be given to how improvements will last in the longer term

Quality improvement is the term used to cover specific activities that can improve the quality of care. The aim of improvement activity in care services is to make the care you provide better. That might be safer (less errors, infections, falls), more effective, more efficient (less waste) or more person-centred (caring, compassionate, fitting with resident/family wishes). Quality improvement involves individuals, teams and organisations looking at how making changes to the way they work can improve care. Improving care is often about changing habits. Sometimes a small change can make a huge difference. Making improvements should benefit your residents, your staff and the organisation.

A structured approach to improvement

Project charter

A well-planned, structured approach to improvement will give you a better chance of being successful. The first step is to identify where changes can be made in your service to improve care.

The image below summarises a structured approach to improvement we recommend. The first step is to identify where changes can be made in your service to improve care.

The model for improvement

This model offers the following benefits:

• It is a simple approach that anyone can apply
• It reduces risk by starting small
• It can be used to help plan, develop and implement change
• It is highly effective

What is the model for improvement?

The model for improvement (Figure 2) provides a framework for developing, testing and implementing changes to the way that things are done that will lead to improvement.

The model consists of two parts that are of equal importance. The first, the ‘thinking part’, consists of three fundamental questions that are essential for guiding improvement work.

The second part, the ‘doing part’, is made up of Plan, Do, Study, Act (PDSA) cycles that will help you make rapid change.

What are the three fundamental questions for achieving improvement?

The three fundamental questions for achieving improvement provide a useful way to frame your improvement work.

1. What are we trying to accomplish?

This question helps you to be clear about what you aim to achieve with your improvement activities. What will success look like in your care home? How will things be different? It is crucial for everyone involved to have a clear understanding of your aims.

2. How will we know that a change is an improvement?

While every improvement is a change, not every change results in improvement. Without measurement it is impossible to know whether things have improved. Agree what information you need to collect to measure whether or not the changes you make are improvements.

You can do this in terms of the way in which your results or outcomes might be different (for example, the number of falls in the care home), how the care that your residents receive will be better (for example, the number of residents receiving yearly eye health checks), or how your processes might change (for example, the number of residents receiving a multifactorial falls risk screen within 24 hours of admission).

A key element of successful improvement is collecting data which can be measured to show what improvement has taken place. If this is done by front line staff they see the changes that matter to people. They will then be motivated and inspired to identify and make improvements which will last.

How do you know that your improvements are making a difference?

• Be clear about what it is you are measuring and that everyone is measuring the same thing in the same way
• Be specific about roles and responsibilities of those collecting the information. Who does it and when?
• Determine the frequency of data collection. Will it be collected daily and then displayed monthly? The data will need to be collected continuously over the life span of the improvement project
• Understand the current state by taking a baseline before you test any changes
• How have the changes you have tested impacted on your data? Is there any improvement?
• Continue to review the data throughout testing to understand if the changes you are testing are resulting in achieving your aim

3. What changes can we make that can lead to an improvement?

Finally, you need to decide what changes you will test to achieve the results you are looking for.

Consider:

• Ideas and tools available in this resource that can improve care
• Evidence you have from elsewhere about what is most likely to work
• What you and your team think is a good idea
• What other people have done that you could try

This is where you can adapt ideas or be completely creative. Remember that you know your own service best, so use your knowledge and experience to guide you.

Gather together as many ideas as you can. These will form the basis for the next step – your tests of change, otherwise known as PDSA cycles.

PDSA cycles

PDSA stands for ‘Plan, Do, Study, Act’. A PDSA cycle is sometimes referred to as a test of change. Once you have decided exactly what you want to achieve, you can use PDSA cycles to test out your ideas developed from the third question, ‘What changes can we make that will lead to an improvement?’

First ‘Plan’ your PDSA cycle - what, where, when and who. Think what information (data) you need to collect to learn whether or not your test is successful. Predict what you think will happen – reflecting on this later will help your learning.

The key is to try out your change on a small scale to begin with. You might, for example, like to run your cycle over one day, with one staff member or one service user. You can carry out a number of cycles to build up information about how effective your change is.

Taking this approach makes it easier to get started, gives results rapidly and reduces the risk of something going wrong and having a major impact. If what you try doesn’t work as well as you hoped, you can always go back to the way you did things before. When you have built up enough information to feel confident about your change, you can then implement it as part of the routine in your care service.

After you’ve carried out your Plan (‘Do’), the ‘Study’ part of the cycle gives you the opportunity to reflect on what happened, think about what you have learnt and build your knowledge.

Finally, you can move on to your next step – the ‘Act’ part of the cycle. Do you need to run the same cycle again, gathering more evidence or making some changes based on what you learnt? Or do you need to carry out further cycles to move your work forwards?

PDSA template

How do you move from testing things out to implementation?

If the data gathered from the tests of change is showing consistent improvement, set a date for implementation. Make sure all staff know about the change, when it will happen, how it will happen and where it will happen. Involve staff in your care home throughout the process.

Update written guidance and policies to include any new way of working if appropriate.

Further tweaks may be required during the implementation phase using PDSAs. Regularly review any data and processes to ensure improvements do continue.

Remember effort will be required to ensure improvements are maintained over time.

PDSA stands for ‘Plan, Do, Study, Act’. A PDSA cycle is sometimes referred to as a test of change. Once you have decided exactly what you want to achieve, you can use PDSA cycles to test out your ideas developed from the third question, ‘What changes can we make that will lead to an improvement?’

First ‘Plan’ your PDSA cycle - what, where, when and who. Think what information (data) you need to collect to learn whether or not your test is successful. Predict what you think will happen – reflecting on this later will help your learning.

The key is to try out your change on a small scale to begin with. You might, for example, like to run your cycle over one day, with one staff member or one service user. You can carry out a number of cycles to build up information about how effective your change is.

Taking this approach makes it easier to get started, gives results rapidly and reduces the risk of something going wrong and having a major impact. If what you try doesn’t work as well as you hoped, you can always go back to the way you did things before. When you have built up enough information to feel confident about your change, you can then implement it as part of the routine in your care service.

After you’ve carried out your Plan (‘Do’), the ‘Study’ part of the cycle gives you the opportunity to reflect on what happened, think about what you have learnt and build your knowledge.

Finally, you can move on to your next step – the ‘Act’ part of the cycle. Do you need to run the same cycle again, gathering more evidence or making some changes based on what you learnt? Or do you need to carry out further cycles to move your work forwards?

PDSA template

How do you move from testing things out to implementation?

If the data gathered from the tests of change is showing consistent improvement, set a date for implementation. Make sure all staff know about the change, when it will happen, how it will happen and where it will happen. Involve staff in your care home throughout the process.

Update written guidance and policies to include any new way of working if appropriate.

Further tweaks may be required during the implementation phase using PDSAs. Regularly review any data and processes to ensure improvements do continue.

Remember effort will be required to ensure improvements are maintained over time.

Useful links

Institute for Healthcare Improvement

Healthcare Improvement Scotland

iHub

IRISS - Improvement

NHS Education for Scotland

Scottish Patient Safety Programme

Social Care Institute for Excellence 

Quality Improvement Tools

Supporting older people to live active, healthy lives is a free online course consisting of 6 modules covering:

• the benefits of people experiencing care moving more in terms of their physical, mental and social health, 
• ways to think about helping blood circulation, stiffness, sore knees and continence and ideas for action.

The course is hosted on Turas Learn. It is particularly helpful for people who live with or work with frailer older people, although it is open to anyone in Scotland. If you complete all 6 modules, you can print a certificate.  

To find out more about the course and how to sign up to it, click here.

Click here for all quality frameworks. If you have any questions about these quality frameworks or toolkits, please email: methodology@careinspectorate.gov.scot

Support services (not care at home) quality framework and self-evaluation toolkit

We held a webinar on 21 April 2023 for people working in support services (not care at home). The webinar explained the changes made within the updated Quality framework for support services (not care at home), and also introduced staff to the self-evaluation toolkit which had emerged from the learnings of our previous work on Covid-19 Self-evaluation toolkit for key question 7 and from discussions with services and inspectors.

You can watch the video here.

Tools and guidance for support services (not care at home).

Support services (care at home including supported living models of support) quality framework and self-evaluation toolkit

We held a webinar on 1 June 2022 which explained the changes made within the updated Quality framework for support services (care at home including supported living models of support), and also introduced staff to the self-evaluation toolkit which had emerged from the learnings of our previous work on Covid-19 Self-evaluation toolkit for key question 7 and from discussions with services and inspectors. 

You can watch the video here 

Tools and guidance for support services (care at home including supported living models of support).

Joint adults and older people quality framework and self-evaluation toolkit

We held a webinar on 9 March 2022 for people working in care homes for adults and older people. The webinar explained the changes made within the updated Quality framework for care homes for adults and older people, and also introduced staff to the self-evaluation toolkit which had emerged from the learnings of our previous work on Covid-19 Self-evaluation toolkit for key question 7 and from discussions with services and inspectors.

You can watch the video here.

Tools and guidance for care homes for adults and older people.

Food Train/Eat Well Age Well, Dundee Health and Social Care Partnership and NHS Tayside have developed a new national training resource designed to support care at home staff with identifying if someone is at risk of becoming under-nourished, and how to support older people who may be struggling to eat and drink well at home. Malnutrition is largely preventable and treatable through early intervention and screening, and carers and care at home organisations can play a vital role in identifying malnutrition risk and supporting older people living at home.

The training is available online and consists of 8 videos and a workbook which cover topics such as what can cause malnutrition, how to spot signs and symptoms and simple tips to boost appetite. It can be completed by an individual care worker or used by a service provider as induction or on going training for a group of carers.

You can view the videos here
The workbook is available here

We have published Guidance for developing a policy for care at home services based on the NHS Scotland Pressure Ulcer Prevention and Management Standards (Oct 2020). These standards are applicable to both health and social care which includes care at home services.

We would encourage care at home services to take account of the standards and supporting guidance to put in place a robust approach to focusing on a preventative approach so that skin damage is picked up at and early stage and escalated.  

We are planning a webinar to support services to implement this guidance.  A date for this will be announced shortly.

This guidance was developed by the Care Inspectorate following a consultation event with a wide variety of health and social care professionals to consider the implications of these standards for care at home services.  From this event key areas of the standards were highlighted, and a draft policy guide developed to raise awareness of the areas care at home service should consider and support them to put these elements in place. Eight care at home services helped us to test out the guidance and their feedback was that it supported them in two ways. Firstly, for those services to develop a policy where none was in place, and secondly where a policy existed to use as a method of evaluation to ensure the content was in line with the pressure ulcer standards.