Policies & Procedures
Quality Audit Schedule v1.0
Document owner | Registered Manager / Director |
Approved by | Mrs. Tavleen Sharma (Registered Manager) |
Version | 1.0 |
Review frequency | Every 12 months or following any significant incident |
Next review date | 12 months from issue or earlier if required. Next formal review date: 01-04-2027 |
1. Purpose
The purpose of this Quality Audit Schedule is to ensure VCare Consultancy Services Limited maintains robust governance, quality assurance, safeguarding and compliance systems in line with:
- Care Quality Commission (CQC) Fundamental Standards;
- Health and Social Care Act 2008;
- Care Act 2014;
- South Gloucestershire Council commissioning requirements;
- safeguarding obligations;
- best practice within adult social care.
The audit programme supports:
- continuous improvement;
- safe service delivery;
- regulatory compliance;
- risk management;
- service user satisfaction;
- workforce development;
- organisational learning.
2. Audit Objectives
VCare’s audit programme aims to:
- monitor quality and compliance;
- identify risks and trends;
- improve service user outcomes;
- strengthen safeguarding oversight;
- ensure policy compliance;
- improve staff performance and competency;
- monitor contractual compliance;
- evidence effective governance during inspections and tenders.
3. Governance Responsibility
Role | Responsibility |
|---|---|
Tavleen Sharma – Registered Manager & Director | Overall governance oversight and audit review |
Ashish Sharma – Nominated Individual & Director | Strategic governance and compliance oversight |
Lisa – Scheduler & Compliance Manager | Audit coordination, compliance monitoring and reporting |
Manish Sharma – Operations & HR Manager | Workforce audits, recruitment and HR compliance |
Noorvir Singh – Care Coordinator | Care delivery monitoring and spot checks |
Gerald Mhlanga – Trainer | Training audits and competency monitoring |
4. Quality Audit Schedule
Audit Area | Frequency | Responsible Lead | Evidence / Monitoring |
|---|---|---|---|
Care Plan Audits | Monthly | Registered Manager / Care Coordinator | Care records, reviews, outcomes |
MAR Chart & Medication Audits | Monthly | Registered Manager | MAR charts, medication errors, competency |
Safeguarding Audit | Monthly | Registered Manager | Safeguarding logs, referrals, trends |
Incident & Accident Audit | Monthly | Compliance Manager | Incident reports, trends, actions |
Complaints & Compliments Audit | Monthly | Registered Manager | Complaints log, feedback analysis |
Staff File Audit | Monthly | Operations & HR Manager | DBS, right to work, references |
Training Compliance Audit | Monthly | Trainer / Compliance Manager | Training matrix, expiry monitoring |
Spot Checks & Field Supervisions | Monthly | Care Coordinator | Spot check records, observations |
Service User Satisfaction Reviews | Quarterly | Registered Manager | Surveys, feedback forms |
Staff Supervision Audit | Quarterly | Operations & HR Manager | Supervision records |
Infection Prevention & Control Audit | Quarterly | Registered Manager | IPC checks, PPE compliance |
Health & Safety Audit | Quarterly | Compliance Manager | Risk assessments, H&S checks |
Lone Worker Audit | Quarterly | Compliance Manager | Staff welfare and incident monitoring |
Risk Assessment Audit | Quarterly | Registered Manager | Service user risk assessments |
GDPR & Confidentiality Audit | Quarterly | Nominated Individual | Data protection compliance |
Recruitment & Safer Recruitment Audit | Quarterly | Operations & HR Manager | Recruitment records |
Equality & Diversity Audit | Quarterly | Registered Manager | Complaints, workforce monitoring |
Environmental Sustainability Audit | Quarterly | Nominated Individual | Carbon reduction measures, sustainability |
Business Continuity Audit | Six-Monthly | Directors | Emergency preparedness |
Policy Review Audit | Six-Monthly | Registered Manager | Policy review schedule |
Duty of Candour Audit | Six-Monthly | Registered Manager | Incident communication reviews |
Governance & Compliance Review | Quarterly | Directors | KPI review, regulatory oversight |
CQC Notification Audit | Quarterly | Registered Manager | Notification records |
Mental Capacity Act & Consent Audit | Quarterly | Registered Manager | MCA assessments, consent records |
Quality Assurance Review Meeting | Monthly | Senior Management Team | Audit outcomes and action plans |
5. Spot Checks and Observations
VCare will complete regular spot checks and observations to monitor:
- professionalism;
- dignity and respect;
- medication practice;
- infection control;
- communication;
- safeguarding awareness;
- moving and handling;
- person-centred care;
- documentation standards.
Spot checks may be announced or unannounced.
6. Audit Reporting and Action Plans
Audit findings will be:
- documented formally;
- reviewed by management;
- assigned action owners;
- monitored for completion;
- escalated where risks are identified.
Action plans may include:
- additional training;
- supervision;
- competency reassessment;
- policy review;
- safeguarding escalation;
- disciplinary processes where necessary.
7. Service User Feedback Monitoring
VCare will gather feedback through:
- telephone welfare calls;
- review visits;
- surveys;
- compliments and complaints;
- direct discussions.
Feedback outcomes will contribute towards service improvement planning.
8. Training Compliance Monitoring
Training compliance will be monitored monthly through the Training Matrix.
VCare aims to maintain overall mandatory training compliance above 90%.
Training audits will review:
- expiry dates;
- competency assessments;
- refresher completion;
- induction compliance;
- specialist training requirements.
9. Environmental Sustainability Monitoring
As part of quality governance and social value commitments, VCare will monitor:
- paper reduction initiatives;
- digital working;
- travel efficiency;
- sustainability actions;
- environmental impact reduction measures.
VCare has invested in a fully electric Tesla Model Y for operational use, completing approximately 15,000 business miles since July 2025 in support of carbon reduction objectives.
10. Governance Meetings
Audit findings and quality trends will be reviewed during:
- monthly governance meetings;
- supervision sessions;
- management meetings;
- quality assurance reviews;
- safeguarding discussions.
The organisation will identify:
- trends;
- recurring risks;
- learning opportunities;
- improvement priorities.
11. Continuous Improvement
VCare is committed to continuous improvement through:
- audit monitoring;
- reflective practice;
- staff engagement;
- service user involvement;
- safeguarding reviews;
- incident analysis;
- lessons learned.
The organisation promotes a culture of openness, accountability and learning.
12. Related Policies
This schedule should be read alongside:
- Risk Management Policy
- Safeguarding Policy
- Incident Reporting Policy
- Medication Policy
- Complaints Policy
- Lone Worker Policy
- Infection Prevention & Control Policy
- Duty of Candour Policy
- Workforce Development Strategy
- Data Protection Policy
13. Review
This Quality Audit Schedule will be reviewed:
- annually;
- following regulatory changes;
- following serious incidents;
- following safeguarding investigations;
- following CQC inspections;
- following local authority feedback.
14. Declaration
VCare Consultancy Services Limited is committed to maintaining effective quality assurance and governance systems that promote safe, responsive and person-centred care.
The organisation will continue to strengthen compliance, safeguarding and continuous improvement arrangements through proactive auditing and governance oversight.