Plan for Home Support Regulatory Compliance utilising a Gap Analysis Tool
The Department of Health (DoH) released the Draft Regulations for Providers of Home Support Services in June 2022. These Draft Regulations set out the minimum requirements that public, private and not-for-profit providers of home support services will be required to meet to obtain a license to operate.
When the Regulations arrive, they will be supported by a number of Guidance Documents from the DoH and National Standards from the regulatory body, HIQA. These documents will set out high level outcomes as to what they expect to see in services and service provisions.
Whilst there are many uncertainties facing Home Support Services currently, regulation is undoubtedly on the way. Although the Regulations are still under review, we do have an idea of what the regulator will expect to see and the approach they might take, not only from the Draft Regulations, but also from looking at the regulatory frameworks from other sectors such as disabilities and aged care.
Now is the time to benchmark your service and ask key questions about your service provision as it stands. In this blog, we discuss why utilising a Gap Analysis approach is beneficial when facing new regulations or standards to help put you on the right path to regulatory compliance and service improvement.
Why take a Gap Analysis approach?
It is always favourable by regulatory bodies to see a proactive approach been taken by services to understand what the regulations mean for your service and the care and support it provides to service users.
When facing a new regulations or standards, HCI will utilise a Gap Analysis approach. A Gap Analysis is a method of objectively assessing the performance of a service to determine whether the requirements (in this case the draft regulations) are being met, and if not, what steps should be taken to meet them.
A Gap Analysis acts as a starting point, allowing you to identify where the gaps are so that you can develop an action plan to achieve compliance and service improvement. It will also help guide the allocation of resources and assist in identifying required training for staff to assure the quality and safety of care.
It is important to note that this is different from an audit, as an audit is a verification that the processes, which are already in place, conform to the requirements.
6 Stages for Gap Analysis
- Establish the Target
- Understand the Assessment Approach
- Analyse the current processes
- Detail the findings
- Rate the service’s level of compliance
- Develop a comprehensive, step by step action plan
Stage 1: Establishing the Target
As it currently stands, the target is achieving compliance with the Draft Regulations for Providers for Home Support Services. This is a movable target, as the Standards and Guidelines are yet to come. However, we do have a good idea of the areas we need to focus on and types of requirements that services will be expected to be compliant with.
It is also important, before you start to prepare a tool, such as an excel spreadsheet, to record your findings and action plans. Some of the key areas to include in the tool are the regulations, the findings, a compliance rating, any action plans, responsibility, timeline and the ongoing status.
Stage 2: Understand the Assessment Approach
When you are undertaking your Gap Analysis, it is important to consider what would the regulatory body expect to see and what is their approach when they go out to analyse services.
Presently, we don’t have any documentation from HIQA for home support services, but we do have documentation from other sectors such as residential services for disabilities or aged care. The two documents that are normally released for onsite inspections are the Assessment Judgement Framework and the Guidance for the assessment of centres. The Assessment Judgement Framework details the lines of enquiry and the Guidance for the assessment of centres details examples of evidence to be reviewed. HIQA Inspection reports are another type of documentation worth reviewing to understand the types of non-conformances that are trending in services.
When reviewing the lines of enquiry, consider the following questions:
- What will the Regulatory Body expect to observe?
- What will the Regulatory Body expect to be communicated to them?
- What documents will they expect to be available to them?
Stage 3: Analyse the Current Processes
Once you have identified your target, developed the Gap Analysis tool and gained an understanding of the assessment approach required, then you can embark on the Gap Analysis process. It is important to utilise a triangulation model which incorporates interviews, observation and documentation reviews.
The first step is to schedule the Gap Analysis. To do this you need to identify who the facilitators are, the regulations covered, the agenda and timeline for the observation and interviews and who are the required attendees.
Objectivity is critical and must be reflective of a regulatory body approach. As such, it is important to review beyond the paperwork. Information may be sourced from service user visits, observations, one to one discussions (with staff and service users if possible) as well as review of documentation.
When conducting observations and interviews, consider the following:
- Look for evidence of implementation
- Need to observe the processes being implemented.
- Be considerate of privacy, dignity and consent
- Speak to the staff that implement the processes on a day to day basis, not just the Line Managers
- Discuss with staff whether they know what to do when things go wrong not just when they go right do they know the escalation process?
Examples of documentation for review include:
- Governance records
- Strategic and operational plans, Team charts, Teams terms of reference, minutes, agendas, Statement of Purpose, business continuity plan, financial records.
- Service monitoring and measurement documentation
- Audit reports, KPI’s, annual review data, incident management records, risk registers, Quality Improvement Projects/Initiatives, external reporting information
- HR records
- Staff files, job descriptions, training plans, induction and ongoing training records, staff rotas , agency staff records, performance reviews, supervision records.
- Service user records
- Service user contracts, personal support plans/records of service provision, survey reports, complaint management records
- Supplier contracts and monitoring records
Stage 4: Detail the Findings
Once the onsite audit and the documentation review has been completed, it is now time to compare the current evidence of compliance with the expected evidence of compliance and identify the gaps.
Stage 5: Rate Compliance
The compliance rating applied during a Gap Analysis should be reflective of the Regulatory Bodies rating model, i.e.
- Not compliant (Red):The service has not complied with a regulation and considerable action is required to come into compliance. Continued non-compliance or where the non-compliance poses a significant risk to the safety, health and welfare of service users will be risk rated red (high risk).
- Not compliant (Orange): The service has not complied with a regulation and considerable action is required to come into compliance. Where the non-compliance does not pose a risk to the safety, health and welfare of service users, it is risk rated orange (moderate risk).
- Substantially compliant (Yellow): The service has generally met the requirements of the regulation, but some action is required to be fully compliant. This finding will have a risk rating of yellow which is low risk.
- Compliant (Green): The service is in compliance with the relevant regulation.
Stage 6: Develop the Action Plan
At this stage, we are looking to develop a comprehensive, step by step action plan to bring the current status to where we need to be to meet the regulatory requirements. We need to ensure that that individuals are provided with responsibilities not Teams. If it becomes a Teams responsibility, then it decreases the likelihood of the action being undertaken.
It is also important to set a timeline for implementation of the actions and from this review the open actions on a scheduled basis, e.g. as part of the Management Team meeting on a monthly basis. Incorporate this as part of the agenda items for the Management Team to ensure that it is monitored appropriately. Achievement or otherwise of open QIP’s should be documented in the Team Meeting minutes.
How can HCI help?
HCI has been working with health and social care organisations over 18 years, supporting them make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance.
We are currently working with a number of Home Support organisations to conduct Gap Analysis against the Draft Regulations for Providers of Home Support Services. We use our knowledge and understanding of HIQAs approach to develop a comprehensive report that will detail areas of good practice and areas of non-compliance against the Draft Regulations. This report can be used to support the development of a compliance plan that will put you in a good position as you move forward within the regulatory framework model.
For more information contact HCI at 01 629 2559 or email@example.com.