Chapter 51 – Michael McCarthy (D3SOP11)

Quality in Social Care

Professions such as social care, social work, community development and healthcare fall under the umbrella term ‘human services’ (Dalrymple & Burke 1995; Healy 2005; Banks 2006; Molly 2019). The field of human services approaches the goal of meeting human needs through a multidisciplinary knowledge base which focuses on the prevention and remediation of issues in order to work towards improving the quality of life of people who require service provision (Banks 2006; Lundy 2004).

Quality as a proficiency in social care work addresses some of the most complex and uncompromising human and social issues (McCann et al. 2009). Problems include poverty, child abuse, domestic abuse and homelessness. Social care work takes place in many settings including residential, in wet shelters, in hospitals, in nursing homes, in the prison service and in addiction services (Fanning & Rush 2006). Social care work is not an ordinary job but a profession which requires specific knowledge and skills.

Quality Social Care Frameworks

Social care is much more than care giving and the role of social care workers is to plan and provide for the care of marginalised individuals and groups in society of all ages and backgrounds (Molly 2019). This refers to building relationships with service users based on trust and positive mutual regard. It concerns working as part of a team and adopting a working in partnership approach to care, which leads to liaising, planning and co-ordinating services and service provision alongside other agencies (Walsh et al. 1998). This is what we mean by inter-agency working. For example, Table 1 illustrates various services that service users may need in addition to their existing support needs.

Table 1 Quality support planning

Support planning as part of a quality assurance framework enables the social care worker to explore in depth the needs and wants of the individual. In this respect, a support plan covers a wide array of needs including: housing, finances, mental and physical health, addiction issues, education, training and employment and life skills development (Powell 1992; Share & Lalor 2013).

In striving for quality improvement, what do we do to advance support plans, aftercare plans or any other type of support mechanism in helping vulnerable individuals and groups to reach their goals and full potential?

It is necessary, apart from the relational aspects of social care work, to have quality administrative systems in place. This is paramount in order to be able to stand over work that is evidence-based and person-centred, and to ensure that all social care workers are accountable for their words and actions. In the next section we will discuss quality assurance in social care and what this means in practical terms and we will differentiate between quality assurance and quality improvement.

What is the difference between quality assurance and quality improvement in social care?

Quality assurance measures compliance with standards and policies based on service user safety, quality of life, the rights of service users, ensuring that service users are treated with dignity and respect at all times and in employing an appropriate balance of interdisciplinary working^[1] and inter-agency working^[2] when required (HIQA 2018).

Quality improvement focuses on processes and systems utilised to improve both the quality of social care work and accountability (Loshin 2007). For example, systems used to enhance employee growth, potential and career advancement, performance management tools, annual employee appraisals, regular supervision of staff and management and the use of in-house databases to safely store and record relevant, concise and factual information regarding daily service user interactions (HIQA 2017).

Quality improvement systems that capture service user experience and daily interactions with social care workers should be case noted in a timely fashion. This provides a history of the work and will also be useful to relief staff members or new staff members joining the organisation. This is because they will be able, following a detailed handover from the team or their predecessor, to get a full picture of how the work has been progressing and it will assist them in mapping progress made and work yet to be done. As part of any quality improvement process this is essential for quality evidence-based practice.

In residential services any quality-based interventions or related quality-approved organisational incident or accident reports should be compiled as soon as possible after an event in order to ensure accuracy of the information. If a particular incident has been traumatic for an employee or a number of employees and service users; seeking support from a peer mentor or member of the team is important. Social care leaders should ensure that if an employee is upset post- incident, that they can have time off if required, access to counselling supports, and informal supervision should be provided between formally scheduled supervision meetings.

In the aftermath of a challenging behaviour incident, the service user should be given an opportunity to discuss their concerns and what occurred from their point of view (Wood & Long 1974; Tolan & Guerra 1993; Smith & Kirby 2004).

Depending on the organisation, as part of quality in training, therapeutic crisis intervention techniques may be employed as part of quality in training (TCI 2021). Such training may be useful in helping service users to identify and reflect on what triggered their behaviour, as follows:

• In remediating the situation.
• In returning the person to their normal state prior to the event (base line) and in helping to avoid further emotional or violent outbursts or situations in which challenging behaviour is more or less likely to occur.
• This will be dependent on all potential triggers (music, loud noises, a history of violence, not getting along with other service users and staff members) or circumstances based on emerging or known patterns of behaviour and the service user’s support needs.
• Improving quality is about making social care practice safe, client-centred, effective, efficient and fair.

All significant incidents should be discussed by the team in order to put a plan in place, for example if a service user self-harms or attempts suicide. This can be traumatic and upsetting for the person, their family and for their key worker and other members of the staff team.

As part of quality assurance, a safety plan would need to be devised or updated depending on the history of events and level of risk management involved (Webb 2006). A social care team may need to take advice and direction from the person’s mental health team as part of this process (Francis & Armstrong 2003). Risk assessments as part of safety planning are very important when working with vulnerable individuals and groups (Bostock et al. 2005). Lone working risk assessments are also crucial because they set out what is appropriate and what is not acceptable when visiting people in their own homes or in their own accommodation within social care settings (HSA 2021).

Lone Working Risk Management

A good-quality lone working risk assessment should point to the following:

• Potential hazards, which include threatening, abusive or potentially violent situations which may lead to social care worker injury.
• Allegations made against social care workers by their service users in lone working situations of a verbal, physical or sexual nature.
• Objects, things or even animals used to carry out threats against a social care worker.
• Risk of infection from service user pets if they are untreated for flees.
• Risk of needlestick injuries.
• Blood splashes from a service user who has self-harmed.
• Effects of passive smoking on social care workers.

Note: If a social care worker is ill, they should cancel any pre-arranged meetings with service users and should not attend in person in case the service user contracts their cold or flu or vomiting bug. Cancelled meetings should be rearranged and where possible another social care worker should be given a handover in case they need to attend an appointment with a service user (HSA 2021).

Having a good quality assurance structure embedded in the organisational culture is significant because it can also help to reduce anti-oppressive practice (Hughes & Wearing 2007). This may be overwhelmingly positive if the correct practice is put into action and power differentials do not get in the way because it puts all service users first in any given situation (Payne 2005).

On the other hand, difficulties may arise when implementing quality anti-oppressive practice strategies because our training and work-based culture has become guided by national policy frameworks which in some cases may prevent social care workers from making common-sense decisions because of fear of reprisal (Healy 2005; Banks 2006).

This suggests that, due to a lack of personal autonomy, it is easier to look for consensus, reach for the standard operating procedure and consult the local policy rather than taking immediate action in the best interest of the service user (Rose & Palattiyil 2018). All social care workers need to be mindful of this.

As part of our duty of care we need to use our common sense, our general intelligence (IQ) and, most important, our emotional intelligence in order to be able to identify what is going on for an individual (Robinson & Clore 2002). This involves being able to read the emotions of the person and the environment. If one’s own emotions become heightened in a difficult situation the following self- assessment may help improve the situation:

• Reflect in the moment/self-acknowledgement of the atmosphere and potential risks in order to be able to remain calm.
• Scan and assess the situation quickly.
• Follow through with decisions that are logical and relevant to the situation.
• Offer support to work colleagues and service users.

Quality in planning and delivering policy

Quality improvement is not just about service provision; it is about planning and devising policies and procedures that social care workers can familiarise themselves with through regular training and supervision (Schön 2017). When there is consistency and people are working to the same high-quality standards in order to ensure best practice, it will help to remediate problems and will prepare social care workers to act with conviction when faced with difficult situations.

Quality improvement requires core social care training, such as child protection training and first aid training, being put in place. Planning for quality structures requires social care workers to develop and regularly utilise specific skills, such as active listening, emotional intelligence, resilience, empathy, tolerance and good organisational skills (Ruch et al. 2010).

Quality assurance in social care: how progress is measured and captured

Quality assurance in social care is about providing quality care and additional supports as required in assessing the quality of services provided. For instance, advocating on behalf of service users, attending appointments or accompanying service users to appointments or court appearances. It may mean sourcing appropriate referrals to other agencies in relation to the specific support needs of the service user at that time.

To measure outcomes, social care managers will collect weekly, fortnightly or monthly reports from social care workers (HIQA 2012). These will capture information regarding service users who are being supported depending on their specific needs through an actionable support plan. For example, housing is one of the main support needs of young adults who have left the care of the state. A young person will need assistance with move-on options and life skills development (finance, budgeting, apartment checks, education, training or employment) to get ready for eventual independent living. Other measures to assess the quality of service provision include risk assessments/safety plans that are in place for service users who may require mental health supports, and appropriate referrals are placed in liaison with the young person’s after-care worker and any other outside agencies that may need to be contacted for support purposes (Batini et al. 2009).

The quality of the key working process is another factor that can be assessed in terms of service users’ level of need and level of engagement with the supports offered (Share & Lalor 2013). Key performance indicator information ^[3] is then forwarded by local managers to the service manager or their equivalent (Parmenter 2007). For example, in a residential service, key performance indicator’s (KPIs) can keep track of service user ‘move-ins’ to the service and of successful outcomes in terms of service user ‘move-outs’ from the placement to longer-term stable accommodation.

Quality in the Provision of Social Care

Quality care can be provided on a one-to-one basis or with smaller or larger groups of people in a social care setting. This requires using interpersonal skills, which is why it is relevant to have a good understanding of group dynamics (Kelly 2017). Essential as it is to get to know your service user group, it is just as imperative to foster and build good relationships with other social care workers and leaders who you work closely with in your organisation.

After all, how you as a social care worker develop quality practices in your vocation/career depends on the following:

1. The Quality of Education

• CORU (the Health and Social Care Professions Council) is the body responsible for regulating health and social care professions established under the Health and Social Care Professionals Act 2005. CORU’s role is to protect the public by promoting high standards of professional conduct, professional education, training and competence among health and social care professionals.
• In Ireland, the minimum requisite qualification to practice as a social care worker in the publicly funded health sector is a three-year Level 7 degree. Many social care professionals will complete a Level 8 undergraduate degree in social care and some will go on to do a Level 9 master’s in a related human services field.
• When a social care worker gains employment in their chosen area of social care the accessibility of good supervision, training and continuing professional development is crucial.
• Hands-on practical experience, education and training will help develop a person into a social care practitioner who is well rounded and balanced in their approach to care. This will aid the development of additional skills such as case management proficiency and the capacity to carry out the necessary administrative tasks to a high standard.

2. The quality and regularity of good supervision

• A social care leader is responsible for organising good supervision with their supervisee (Munsen 2002). A good supervision model guarantees the collective reassurance that CORU values, ethical codes and guidelines are uniformly adopted and explored as part of the supervision process (SCWRB 2019).
• Good supervision should not just be a line management exercise in which each service user’s case is discussed, problems identified or solutions offered. It should be much more than that; it should boost reflective practice.
• High-quality supervision practice should convey how excellent supervision identifies with employee satisfaction, commitment to continuing personal development and employee retention.
• Quality supervision should facilitate conversations that the social care worker might like to have not only in relation to the work but also in relation to their feelings or personal matters outside the professional sphere that might be presenting issues for them (Lynch & Happell 2008). For example, the break-up of a relationship can be emotional for an employee and they may need time off. At times when childminding is an issue, patience and understanding should be shown by the supervisor and a plan put in place until the matter has been resolved.
• Conflict with other social care workers may arise from time to time and supervision offers a unique opportunity for a supervisee to feel listened to and valued and to have their perspective on the situation understood (Matthew 2009).

3. The organisational culture and personal growth

• The organisation’s culture in relation to the perspectives of work colleagues about the nature of the work, individual and group case work and about their feelings and relationships with service users and their families (Schein 1993).
• The capacity to self-reflect and to develop as a competent social care worker through a process of self-awareness and reflective practice.
• To learn and demonstrate a willingness to accept constructive feedback that has been delivered in a respectful manner and to use this feedback positively in order to drive change.
• To become the best advocate you can be for the service user.

Quality Improvement and Task Fulfilment

The following key tasks/tools are useful in identifying how quality improvement works in practice.

• Case management: This may require holding a caseload of a number of service users, e.g., fifteen to twenty cases. The author previously worked in the family homeless action team assisting families who were living in emergency accommodation. As a case manager the work was both challenging and rewarding. To ensure that all service users’ needs were adequately met a joined- up case management approach was adopted. This involved carrying out family assessments and holding initial key working meetings in order to identify family support needs.
• Information gathering: Gathering and recording information in line with GDPR (General Data Protection Regulation) in order to understand what led to families becoming homeless; an understanding of the family dynamic; the needs of the children and the overall support needs of the family as a unit.
• Role fulfilment: Carrying out risk assessments, putting in place service user-driven support plans, arranging regular scheduling and attendance of key working meetings and assisting families in securing long-term stable accommodation. In this context, building good relationships with local authority staff is important, particularly as they are not coming at the work from the point of view of a social care worker. It is our role to highlight and explain the issues to workers in other agencies in order to advocate for our service user’s best interests. For example, helping a family or a young person to register their housing need, helping them to understand how the private rented housing assistant scheme works, preparing individuals to attend property viewings, advocating on their behalf with approved housing bodies or making referrals on their behalf to access courses, education, training, employment skills, family welfare supports or child support worker provision when required. Another example of case management is social care workers who work with young people over the age of eighteen who have previously been looked after by the state residential care system or through the Irish foster care system. This type of social care support is provided by after-care workers who may be employed by Tusla or by one of the NGOs that are funded by Tusla. Similarly, after-care workers will carry a varied caseload which will be assigned to them by their aftercare manager.
• Autonomy and accountability: Local policies as part of a quality standard framework should emphasise the need for social care workers to practise safely within ethical and legal professional boundaries (SCWRB 2019). This involves being able to identify the limitations of their role and to seek advice from their colleagues and managers when required. This is imperative in order that they can act in the best interests of service users by taking their views and perspectives into account and in allowing them to be involved at all times in decisions affecting their lives.
• Quality improvement: This will only succeed and be effective when local policies in line with national policy legislation are adhered to at the organisational level (SCWRB 2019). For example, candour and disclosure when somebody is at risk to themselves or others or the steps to take when there is a death in-service.
• Quality communication: This means being able to assess and manage situations in such a way that the process is clear to the service user. Communication styles may need to be modified from time to time (verbal and non-verbal communication) to suit the specific needs of the service user at the time.
• Cultural competence: Social care workers should also think carefully about language barriers, the culture of non-Irish service users or members of the Travelling community and the various physical and mental health needs of service users. Social care workers should be able to comprehend the importance of building and sustaining professional relationships with other workers on the team and to contribute to decision-making within an interdisciplinary team environment.

• Empowerment: Social care workers should endeavour to empower service users to reach their goals and to manage their own wellbeing as much as possible (Anuradha 2004).
• Quality managerial frameworks: Social care workers should be able to produce documentation that is concise, factual and objective (HIQA 2018). This will involve applying digital literacy skills or other technologies such as the use of email or synchronised online meeting forums such as Zoom or Microsoft Teams. These are particularly pertinent in the current COVID-19 climate.
• Quality safety measures: Social care workers should have the capacity to gather all relevant background information regarding service users’ history, health and wellbeing. For example, conducting needs assessments; seeking a social history or placement reports.
• Assessment techniques: Social care workers should be able to implement assessment techniques and to subsequently record a detailed assessment. For instance, family assessments for homeless families before they secure long-term, stable emergency accommodation. This is essential for building relationships with families who are only able initially to access emergency accommodation on a night-by-night basis. In this regard, advocating with the relevant local authority is essential in order to have their assessment and required paperwork finalised as part of their local authority assessment. At the point where it has been accepted that they are homeless, the family is eventually placed in longer-term emergency accommodation in which they will gain access to a dedicated case worker or child support worker if required.
• Risk factors: Social care workers should be able to recognise significant risk factors and to use this information to devise a quality-based risk management strategy in order to arrive at reasoned decisions when making interventions or when discontinuing interventions in favour of something new if previous strategies have failed to yield positive results.
• Quality of practice: Social care leaders need to comprehend the absolute necessity to monitor and evaluate the quality of social care worker practice through quarterly in-house audits in preparation for HIQA or Tusla audits. This is useful in order for social care workers to be able to critically evaluate their own individual practice as a case worker/key worker/after-care worker/team leader against evidence-based standards. This is further advantageous in terms of implementing changes and improvements to both standardised tools and relational-based practice based on the results and findings of review meetings and audits.
• Health and safety: Social care workers should be able to carry out and participate in and engage service users in fire safety checks at least twice a year. They should also carry out regular building checks to mitigate against possible damage that may be caused by hazards in the workplace. This also involves doing regular room or apartment checks in residential services to ensure the safety of both service users, visitors to projects and to employees.

References

Anuradha, K. (2004) ‘Empowering families with mentally ill members: A strengths perspective’, International Journal for the Advancement of Counselling 26(4), 383-91.

Banks, S. (2006) Ethics and Values in Social Work. Basingtoke: Palgrave Macmillan.

Batini, C., Cappiello, C., Francalanci, C. and Maurino, A. (2006) ‘Methodologies for data quality assessment and improvement’, ACM Computing Surveys (CSUR) 41(3): 16-18.

Bostock, L., Bairstow, S., Fish, S. and Macleod, F. (2005) Managing Risks and Minimising Mistakes in Services to Children and Families, SCIE Report 6. London: Social Care Institute for Excellence.

Dalrymple, J. and Burke, B. (1995) Anti-Oppressive Practice: Social Care and the Law. Milton Keynes: Open University Press.

Fanning, B. and Rush, M. (2006) Care and Social Change in the Irish Welfare Economy. Dublin: University College Dublin Press.

Francis, R. and Armstrong, A. (2003) ‘Ethics as a risk management strategy: The Australian experience’, Journal of Business Ethics 45(4): 375-85.

Healy, K. (2005) Social Work Theories in Context: Creating Frameworks for Practice. London: Palgrave Macmillan.

HIQA (Health Information and Quality Authority) (2012) ‘What you should know about data quality: a guide for health and social care staff’ in Guidance on a Data Quality Framework for Health and Social Care. Dublin: HIQA. Available at <https://www.hiqa.ie/sites/default/files/2017-01/Data-Quality-Guide. pdf>.

HIQA (2017) Information Management Standards for National Health and Social Care Data Collections. Available at <https://www.hiqa.ie/sites/default/files/2017-02/Information-management-standards- for-national-health-and-social-care-data-collections.pdf>.

HIQA (2018) Guidance on a Data Quality Framework for Health and Social Care. Dublin: HIQA.

HSA (Health and Safety Authority) (2021) Lone Workers. Available at <https://www.hsa.ie/eng/Topics/ Hazards/Lone_Workers/>.

Hughes, M. and Wearing, M. (2017) Organisations and Management in Social Work. London: Sage Publications.

Kelly, B. (2017) Group Work in Health Care Settings. London: Guilford Publications.

Loshin, D. (2007) Developing a Data Quality Strategy. Available at <http://www.beye-network.com/ view/3816>.

Lum, D. (2007) Culturally Competent Practice: A Framework for Understanding Diverse Groups and Justice Issues. Belmont, CA: Thomson Brooks/Cole.

Lundy, C. (2004) Social Work and Social Justice: A Structural Approach to Practice. Ontario, Canada: Broadview Press.

Lynch, L. and Happell, B. (2008) ‘Implementing clinical supervision: Laying the groundwork’, International Journal of Mental Health Nursing 17(1): 57-64.

McCann, J., Roiste, A. and McHugh, J. (2009) Social Care Practice in Ireland: An Integrated Perspective. Dublin: Gill & Macmillan.

Matthew, F. (2009) ‘Leadership and organisational strategy’, Public Sector Innovation Journal 14(1): 3-14.

Molly, M. (2019) ‘An exploration of social care workers’ experiences of emotional labour and professional burnout in domestic violence refuges’, Journal of Social Care 2(2): 1-23.

Munsen, C.E. (2002). Handbook of Clinical Supervision. New York: Howorth Social Work Practice Press.

Parmenter, D. (2007) Key Performance Indicators: Developing, Implementing and Using KPIs. New York: John Wiley & Sons.

Payne, M. (2005) Modern Social Work Theory 3rd Edition. London: Lyceum. Powell, F.W. (1992) The Politics of Irish Social Policy. New York: Edwin Mellin Press.

Robinson, M.D. and Clore, G.L. (2002) ‘Belief and feeling: Evidence for an accessibility model of emotional self-report’, Psychological Bulletin 128(6): 934-60.

Rose, S. and Palattiyil, G. (2018) ‘Surviving or thriving? Enhancing the emotional resilience of social workers in their organisational settings’, Journal of Social Work 1(2): 1-20, doi.org/10.1177.

Ruch, G., Turney, D. and Ward, A. (2010) Relationship-based Social Work: Getting to the Heart of Practice. London: Jessica Kingsley.

Sakamoto, I. (2007) ‘An anti-oppressive approach to cultural competence’, Canadian Social Work Review 24(2): 105-14.

Schein, E. H. (1993) Organizational Culture and Leadership. San Francisco, CA: Jossey-Bass. Schön, D. (2017) The Reflective Practitioner. London: Sage Publications.

Share, P. and Lalor, K. (2013) Applied Social Care: An Introduction for Students in Ireland (2nd edn). Dublin: Gill & Macmillan.

Smith, C. and Kirby, L. (2004) ‘Appraisal as a pervasive determinant of anger’, Emotion 4(2): 133-8. TCI Trainer Manual Activity Guide: System Overview (2021). New York: Cornell University.

Social Care Workers Registration Board (2019) Social Care Workers Registration Board code of professional conduct and ethics. Dublin: CORU Health and Social Care Regulator. Available at https://coru.ie/files-codes-of-conduct/scwrb-code-of-professional-conduct-and-ethics-for- social-care-workers.pdf.

Tolan, T. and Guerra, N. (1993) What Works in Reducing Adolescent Violence: An Empirical View of the Field. Chicago, IL: University of Chicago Press.

Walsh, J., Craig, S. and McCarthy, D. (1998) Local Partnerships for Social Inclusion. Dublin: Combat Poverty Agency.

Webb, S.A. (2006) ‘Risk’, Social Work and Society 4(2): 379-82.

Wood, M. and Long, N. (1974) Life Space Crisis Intervention. Austin, TX: Pro-Ed.