Leadership and Management

20th march 2019. Level 5 Diploma in Leadership and Management for Health and Social Care.

1.1 Hypothesis

Increased staff training in areas directly linked to CQC quality guidelines result in a measureable improvement in service user service satisfaction.

I am employed at a company that provides twenty-four hour residential support for people with severe mental health conditions. The CQC provide guidance on how to enable the service to run effectively, responsively and in a caring manner. CQC guidelines outline what would be required for an ‘outstanding’ service. This takes into consideration what service users would like from a service and what would result in the best outcomes for those receiving the service. By providing training in these specific areas, and creating an evidenced-based practice approach, I postulate the service user perception of our service will improve and satisfaction rates increase.

1.2 Area of Research:

I conducted research into service user satisfaction levels, relating to the Caring and Effective aspects of our service. At the beginning of the project staff knowledge levels were measured prior to receiving training, and again eight months later, to ascertain if improvements in practice theory had been assimilated. Service users also completed a survey relating to staff approach, specifying areas highlighted by CQC in their guidance. Training in these specific areas was then given to staff over an eight month period. Service user satisfaction levels were then measured again through a repeat of the previous survey to ascertain of there was any significant improvement in how individuals perceive staff approach (Caring) and the outcomes of interactions (Effective).

1.3 Aims and Objectives

I choose to research effectiveness of evidenced-based approaches for several reasons. In my role I was aware of recent changes to CQC guidelines and increased focus on the five aspects of our service delivery (Caring, Safe, Effective, Responsive and Well-lead). Central to my role within the company is to provide staff training, as this is an approach I strongly promote. Assessing the impact of evidenced-based practice in relation to CQC guidance was a good way of measuring the effectiveness of CQC guidelines, and the concept of evidence driven practice.

As CQC specify ways of working that should result in an ‘outstanding’ service I aim to ascertain if knowledge in these areas directly improves service user perception of their experience of the service. I will therefore explore the validity of evidence-based approaches in general practice. ‘’Providing services that are caring and evidence-based is essential in health and social care. There are many aspects that need to be implemented in order to show the Care Quality Commission (CQC) this is a primary factor’’ (Frankova, 2014, pg. 1)

The CQC works alongside the National Information Governance Committee (NIGC) to oversee the standards of care in health and social care settings. ‘’It has embedded at the heart of an organisation concerned with a whole spectrum of health and social care, with a role where information is seen predominantly as a means to deliver better care than the end itself’’ (Giles, 2015, pg. 8). By improving staff awareness of evidence-based approaches and communicating these to service users should therefore result in an improved experience of the service. As evidenced-based approaches are undertaken by CQC, and are a central expectation of the NIGC, I aim to validate this approach in my findings.

1.4 Ethical Considerations

I work with service users that have severe mental health conditions. I was aware that when undertaking this project I needed to remain focused on the central values that are facilitating my research. I have to remain open minded and honest about my findings, irrespective of the outcomes I achieve.

When initiating this project I was mindful of the service users’ needs and mental capacity. There are five service users that are currently subject to a Deprivation of Liberty Safeguard (DoLS), and due to their mental impairment would not have been suitable for this piece of research. They would be unable to provide consistent and measurable feedback and were excluded from this research project. To ascertain is a person has capacity the Mental Capacity Act 2005 outlines four questions that the individual must be able to achieve in relation to understanding and communicating information. These are: Can the person understand the information? Can the person retain the information long enough to make a decision? Can the person weigh up the possible outcomes of a decision? Can the person communicate their answer. The five service users accessing our service that are subject to DoLS legislation would not have been able to understand, retain and communicate information relating to the survey. For this reason their answers would have skewed the results and the information garnered would not have reflected the process of this research. Therefore those individuals were not included in the service user group in this research.

The mental health of some of our service users fluctuates and those involved in the study were spoken to when their mental health was stable and they were able to clearly communicate their perceptions of the service they receive. All service user who have capacity were offered a choice whether to participate in the research, and it was made clear that they were not obligated to do so. One service user declined to participate, and this choice was respected.

When carrying out the survey I explained to service users that any staff specific feedback will only be raised with the staff member if it related to a breach of safeguarding protocol, or they gave consent for me to do so. This provided service users with some anonymity so they could more freely express themselves, and any concerns they wanted to raise. When having these discussions I was mindful of the individual understanding the terms I was using and ensured each individual understood what I meant by ‘safeguarding’ concerns. I tailored my approach to each individual. As I have worked for the company for nearly two decades I know the service users well. I was mindful of communication styles and varying levels of understanding and capacity, and ensured these discussions were understood by all service users participating in the research.

All service users that took part understood that this initial survey would be repeated in eight months time, and were willing to repeat the process again in due course.

In relation to staff training I am aware of differing staff abilities and the varying degrees that people are comfortable with ‘academic’ training. I asked staff to complete a questionnaire regarding Caring and Effective elements of their role as support workers, to ascertain each individuals’ knowledge baseline. All staff will receive the same training in Caring and Effective approaches, and what this means in relation to practice and service user experience of the service. However communication and training styles will be taken into consideration. Individuals’ academic ability, their confidence, levels of resistance to training, etc. I tailored the training to each individual’s needs to ensure information is assimilated in ways suited to the individual. This aims at ensuring all staff have equal opportunities for learning and understanding the information I will be disseminating. Feedback was sought after each training session to ensure the information was pitched correctly and all staff understood the discussion topics and how to apply this knowledge to practice. The questionnaire staff completed was then repeated to assess changes in knowledge base in eight months time.

1.5 Literature Review

The CQC sets out a clear mandate for service providers, and stipulates ways in which services can demonstrate that they are Caring and Effective. The emphasis is on staff understanding their role in providing a service that is effective in it’s outcomes, and can also communicate a caring approach. The NIGC, in partnership with the CQC, has specifically focused on evidenced-based practice in all aspects of inspecting and facilitating the provision of a good standard of services within social care settings. ‘’The NIGC has placed validation of information at the heart of new CQC inspection regime, providing increased confidence in…information’’ (Giles, 2015, pg. 13). The way in which CQC inspects services, and the expectations of service providers, has changed recently with the introduction of the Key Lines of Enquiry (KLOE). This separates all aspects of the service and it’s objectives into five categories (Effective, Safe, Responsive, Caring and Well-lead), which can be assessed by inspectors more efficiently. More directive approaches are outlined as a way of working towards providing an ‘outstanding’ service. Some of these elements are practical, but many rely on some theoretical knowledge and a deeper understanding of how to more efficiently meet service users’ needs. Managers have a vital role in ensuring the service meets these criteria. However in the company I work for most of the day-to-day work is carried out by support workers. Therefore there is an obligation on the manager to properly train staff in these approaches and how to provide an effective, caring and responsive service, as they deliver the majority of the social care provided. Evidence-based practice (EBP) underpins most approaches in the medical profession and this has been extended out to social care models of service delivery. This is reflected in the CQC’s focus on knowledge and understanding of social care staff in providing a high standard of care. Most pioneering advances in a multitude of practice fields is a direct result of acceptance by practitioners that EBP should be the basis for practice (Biesta, 2007).

There is copious amounts of research into the validity of Evidence-based approaches and it’s effect on improving standards of practice. Green states;

‘’the purpose of theory is seen not as offering universal explanations or predictions, but rather as enhancing understanding of complex situations. Such understanding will inevitably need to be sensitive to specific contextual factors, and would necessarily draw on the experience of practitioners’’
(Green, 2000, pg. 125).

It is the combination of understanding theory and how it applies to practice, alongside support worker experience, which improves outcomes for service users. The CQC attempts to place structured ideas and quantifiable outcomes within a person-centred framework. At times these two approaches may seem incompatible, but by adopting theoretical ideology within practice the care delivered can be more ‘Caring’ and more ‘Effective.’ Studies suggest ‘’clinically relevant research, clinical expertise and patient preferences produces the best evidence for ensuring effective, individualized patient care’’ (Rosewurm and Larrabee, 1999, pg. 317).

Despite much research supporting EBP there has been some debate on the nature of ‘evidence’, how this information is assimilated by practitioners and it’s overall level of effectiveness. In contrast to the research advocating for the positive influence of EBP other studies highlight other factors that impact on the effectiveness of this approach. EBP presents a broad term, and there are few specifics in the research regarding how practitioners link knowledge and theories to the practice they provide. Many factors can impact on an individuals’ ability to deliver high quality care, even with detailed training programmes in place. ‘’Research evidence is seen as one factor in a process of clinical decision-making’’ (Biesta, 2007, pg. 7), and how the individual interprets evidence and applies this knowledge in practice is an additional consideration. However Biesta goes on the explain the importance of instilling in practitioners an awareness of ‘ways of doing’ things. Biesta’s interpretation of EBP was a ‘’position of knowing, and not theory of knowledge’’, (2007, pg. 8). This approach incorporates reflective practice and draws on Rosewurm and Larrabee, and Green’s postulation that EBP is effective when aligned with clinical expertise and reflective decision-making skills.

Michie et al’s (2005) research emphasises the necessity to implement EBP effectively to achieve desired outcomes. They found that often the lack of understanding of the processes involved in changing people’s behaviour in healthcare represented a barrier to improved ways of working. In my research attention has been given to learning styles, possible staff resistance to change/new approaches, and managerial styles in promoting the most efficient ways of developing staff potential. Therefore how information is disseminated to staff is central to how useful this will be in application. Kitson et al (1998) outline specifics that may impact on the assimilation of training and knowledge; ‘’the level and nature of the evidence, the context or environment and the method…in which the process is facilitated’’ (pg.149), are all essential in the learning process. Many extraneous factors can impact on an individual learning the base theories. These can be overcome by understanding these barriers and working in ways that deliver training that enables staff to identify their concerns and engage with the learning process. Grol and Wensing, (2004) also identify some potential inhibitions that can prevent individuals’ development, such as ‘’lack of awareness, knowledge…social norms, leadership and facilities’’ (2004, pg. 57). However my research focuses on staff lack of awareness and knowledge from the outset by asking those involved to complete the questionnaire regarding Caring and Effective approaches. My role is to provide efficient leadership and the appropriate facilities for the training to be effective. The incorporation of reflective practice in the training I will provide also counters the notion that decision-making overrides higher cognitive functions and becomes ‘’reflexive…and based on limited rationality’’ (Webb, 2001, pg. 57). Central to this piece of research is the acknowledgement that there is a need to separate ‘facts’ from ‘values’ and enable staff to work from a reflective, considered stance.

So far from being clear-cut the concept of EBP is also dependant of extraneous influencing factors. However, the strength of research in favour of EBP suggests positive outcomes on practice can be achieved by adopting this approach and being mindful of other considerations. Despite there being peripheral factors that are not completely within my control (staff resistance to change/training, differing learning capacities, differing levels of understanding, etc.) the overwhelming evidence in research suggests that EBP is effective and CQC/NIGC adaptations of these concepts into their approach, validates this project. Various measures to limit the impact of these external factors have been put in place. Training will be delivered in a manner mindful of these individuals differences. The staff knowledge baseline questionnaire should demonstrate improvement in staff understanding and awareness that is measureable and reflects the research results.

2.1 Evaluation of Data Collection Methods:

There are many methods of data collection and analysis and the following are some examples of data collection approaches:

Qualitative: This data is descriptive and presented in a wider format. These approaches can be more time consuming for the researcher, e.g. interviews and observations that require the researcher to extract relevant information.

Quantitative: This date is numeric and results from research can be scored, counted and measured. E.g. Number of interventions by staff, amount of weight lost/gained, number of outpatient appointments, etc.

Primary Data: This is data collected by the researcher for a specific purpose. It is new data garnered from personalised research projects.

Secondary Data: This information is sourced by the researcher, and was initially gathered for another purpose. This type of data can be used by the researcher to support their hypothesis , research or findings.

Nominal Data: This type of data is neither numerical nor quantitative, but used as a way to label or identify variables, e.g. gender, age, hair colour, etc.

Original Data: This type of data can be ranked and ordered, e.g good to bad, satisfied to unsatisfied.

Interval Data: This is numerical and can be ordered or measured along a scale, with each point being equal distance from the other, e.g. temperature.

The data I have collected is quantitative in nature. My research adheres to the criteria outlined by Connect2Care and Edexcel Pearson assessment guidelines. I have applied VARCS to all my data findings to ensure quality and reliability as required.

Valid: The data I have collected will be relevant to the aims and objectives of this research.

Authentic: the work I have produced is my own. It is original and has not been plagiarised.

Reliable: The data I collected demonstrates consistency, has not been falsified and is relevant to my research project and the objectives outlined initially.

Current: The knowledge, skills and practices are up-to-date and relevant to the research I have undertaken.

Sufficient: The data collected and evidence provided must meet the requirements of unit 43 in the Leadership in Health and Social Care course.

2.2 Critical Evaluation of Types of Research.

There are numerous ways to collect and analyse data. The method of statistical analysis chosen for any research project is dependant on the type of data being collected, and consideration is taken regarding how the data can be most clearly presented. The following examples demonstrate different approaches to data analysis:

Questionnaires and Surveys: This approaches asks the participant to answer questions in their own time with either tick boxes (multiple choice) or written answers. When devising the questionnaire or survey is it essential that consideration is given to the language used (terminology chosen), how it is presented and what multiple choice options are offered (to ensure clear feedback). This will enable the participant to understand what they are being asked and how to answer accurately. A questionnaire or survey is usually presented in paper form, but can also be completed electronically or verbally communicated, depending on the individuals’ needs.

Interviewing: This approach is usually presented face-to-face with the participants and involves a series of questions previously constructed. This ensures the required information is being gathered from the participant. The interviewer will record the answers, either in written form or via audio record, with the interviewee’s permission. The latter approach can be helpful to the researcher as it allows time for the researcher to replay the recording to make sure information used in their research is accurate. Consideration should be taken regarding where the interview takes place, time of day, etc. to enable the participate to feel comfortable answering the questions openly and honestly. It is helpful for the interviewer to allow suitable time for the participate to reflect on their answers, otherwise they may feel under pressure to respond quickly. This can result in less accurate and considered answers.

Focus Groups/Meetings: This involves multiple participants to meet and be interviewed together by the researcher. A series of questions will be pre-prepared around the research subject and participants discuss these and provide feedback. The researcher records this either in written form or via audio record, with all participants’ agreement. This approach can be useful as it eases the pressure on individuals to answer direct questions, and discussions can provide further information and expand the research focus. This approach is useful if resources or time limitations restrict the use of other methods. Focus groups can be effective in gathering a lot of information in a relatively short time frame. This approach is generally considered suitable for ten or fewer participants. Larger groups can restrict the opportunities for individuals to be heard, and may impact on the amount of valuable data collected, possibly altering the research findings.

Observations: This method of data collection requires the researcher to be in a ‘natural’ environment and document what they observe. This approach is used when the researcher is analysing reactions and behaviour in everyday situations. The observer should be organised and have a clear mandate for behaviour they are predicting will be observed. However this is a subjective approach and observations are reliant on the researchers’ interpretation of situations and behaviours observed, and this can dramatically impact on the accuracy of findings. Researchers should be as objective in their approach as possible, and try not to interpret behaviour to ‘fit’ a theory or hypothesis. Any environment will be impacted on by the mere presence of the researcher, which can also impact on the accuracy of the findings. Participants may adjust their behaviour as they are conscious of the researcher’s presence. However observations can be useful in monitoring general behaviour patterns.

Case Studies: These involve collecting data from a secondary source. The researcher will analyse other research and extract relevant information to their study. This approach can be time consuming and should only be used if time is not limited. How accurate and valid the information being assessed is needs to be considered in line with VARCS guidelines (Valid, Authenticity, Reliability, Currency and Sufficiency).

Diary Entries: This approach involves researchers asking participants to keep a diary, either written or in audio, about the research topic. All participants are required to consent to this approach, as some of the information recorded can be sensitive in nature. After a specified period of time the information can be collated and analysed. The analysis and extraction of information from recorded or written entries then needs to take place. This method is time consuming and should not be used if time is limited. The accuracy of information may be altered by the participants’ knowledge that the entries will be read/heard and analysed. Information provided by the participants is highly subjective and therefore could be ‘made up’ or inaccurate. This can impact on the validity of the findings.

2.3 Data Analysis Tools:

There is a myriad of ways in which data can be collected, analysed and interpreted. The following are examples of data analysis tools.

Bar Chart:

This is a diagram whereby numerical values of variables are presented in a vertical and horizontal bar format. High and length depict measurements from research findings. The bars demonstrate a clear difference in value.

Image above given as a example of a bar chart on Google images. (sourced 28/01/19)

Pie Chart:

This is a circular chart that presents data as segments. Each segment is depicted by a different colour, representing a percentage of the data inputted. These segments can be used to demonstrate the different quantities of information.

Image above given as an example of a pie chart from Google images. (Sourced 28/01/19)

Line Chart:

This type of chart depicts data as a series of points, which are connected by a line. This presentation of information can be used to easily identify trends and patterns in the data collected.

Image above given as an example of a line chart via Google images. (Sourced 28/01/19)

Radar Chart:

These charts are utilised to present multivariate data, and creates a two-dimensional chart for three or more quantitative variables on axes. These variables start from the same point.

Image above given as an example of a line chart via Google images. (Sourced 28/01/19)

3.1 Sources of Support:

My position within the company is one of Service Manager and Clinical Lead. My responsibilities include the safe and effective running of the company at a staff level. I ensure that the service and staff are complying with the regulations of the CQC and other governing bodies. I am responsible for the twenty-two service users in our care and the staffing team of fifteen. My role is overseen by my line manager/director of the company. However I have a largely autonomous role and I am able to manage my time, which is not restricted on this project. Specified study days have been allocated throughout the year to enable me to complete the course materials and research project.

I work closely with service users and work in a one-to-one capacity with individuals on a daily basis. This has been extremely useful in having a positive rapport with all of the service users, aiding my ability to approach them and request their participation in my research. I was able to assess each service users’ capacity to complete the survey and provide feedback. Those lacking capacity and subjected to DoLS legislation were not included in the research, as this would have been both unethical and compromised the validity of my findings, in accordance to VARCS guidelines.

My role also encompasses the training and supervision of staff. This enabled me to measure the baseline of staff knowledge in the areas specified in the service user survey by incorporating the survey into staff training. The staff survey was given at the start of the research, and then repeated eight months later, following intensive training relating to topics central to CQC guidelines. The data from the two surveys were then compared. My position in the company, and my role as development facilitator, placed me in good stead to incorporate the survey into training without any disruption or resistance from staff.

3.2 Selected Research Methods:

The hypothesis states that adopting an Evidence-based practice approach to staff training, focusing specifically on Caring and Effective approaches should improve the standard of the service received by service users. This should then be reflected in service user evaluation of the service provided.

I used questionnaires and surveys in my research, which could be quantitatively scored. I used this approach because it could be formatted in a way that was easily understood by the service users and would not deter them from participating in the study, (refer to appendix 2). Historically more qualitative methods of conducting service user surveys have garnered little useful information and many service users have disengaged with this approach. Due to the on-going psychotic presentation of many of the service users participating in this research, asking them to write answers long-hand or asking for personal opinions can seem threatening to them, especially those with paranoid symptomology. Asking service users to tick boxes relating to satisfaction levels has garnered a more positive response and more willing participants. This will therefore provide more useful data. This methodology enable me to get consent to participate and carry out the research.

The questions were presented in clear language so all service users understood what was being asked. This approach allowed participants to give considered answers, increasing the validity of their responses. An opportunity to write any additional information was offered following each question. This enabled participants to express their views clearly if they felt restricted by the multiple choice options. This enabled me to assess the accuracy of the tick box scored provided.

To measure staff knowledge of Caring and Effective approaches currently being utilised I asked all staff to complete a question paper/survey, focusing specifically on aspects of Caring and Effective approaches, (refer to appendix 1). This provided me with a baseline of knowledge at the start of the study for each staff member. The questions in the staff survey/questionnaire married up to those in the service user survey, so I could measure any improvements to service user experience in relation to improvements made to staff knowledge of good practice. The data I have collected will be presented in bar chart form for easy visual comparison.

The question paper for staff was also repeated eight months later, following intensive training, which focused on areas relating to Caring and Effective approaches. Training was provided in the following areas;

• Values and Inclusion workshop (March).
• Culture Training – Anti-discrimination, Kindness and Compassion, (March).
• Care Planning and Person-centred approaches, (June),
• Care Planning and Person-centred approaches continued – (July).
• Approach, Inclusion and Anti-discrimination Workshop, (August). (Caring and Effective)
• Mental Capacity Act and Promoting Choice, (August).
• Reflective Practice, Symptoms and Active Listening, (September).

(Caring and Effective)
The training delivered was chosen specifically as it focused on areas relating to the service user survey and directly correlated with the Caring and Effective guidance form CQC.

The training was pitched at a level that all involved could understand, as there were varying degrees of academic competence. Feedback after each training session was sought to ensure the training was being pitched to the correct level, (refer to appendix 3). This enabled the opportunity to modify the training approach, and format of information delivered, if necessary. However the feedback was positive and the open discussion and ‘exploration of ideas’ approach was positively responded to by all staff. The workshops and more formal training sessions were discussion based to enable staff members to explore ideas and discuss them within the group. This enabled individuals who were more adverse to formal training to be engaged and supported throughout the process.

4.1 Results and Analysis

As predicted by my hypothesis there was an increase in staff knowledge demonstrated in the second survey they completed eight months after the initial questions were answered. There was also an improvement in the scores provided by service users in their repeated survey.

The scores in both the Caring and Effective categories were improved on in the staff survey, as depicted in the below graphs:

Staff scores for Caring Approaches:

Staff Scores for caring Approaches Continued:

All of the staff improved their scores on the questions relating to Caring approaches, as demonstrated by the above two graphs, except one staff member who scored the same on both surveys, (staff member 3). The smallest improvement was by one point, (staff members 4 and 5), the largest improvement was by ten points (staff member 2).

Staff Scores for Effective Approaches:

Staff Scores for Effective Approaches Continued:

As with the Caring scores all staff improve their scores in the Effective questions, except one member of staff who score the same, (staff member 6). The smallest increase was by one point (staff member 10), and the largest increase was by six points (staff members 2 and 4).

Comparison of Total Scores from Staff surveys for both Caring and Effective:

There was a greater increase in overall scores for the Effective questions, with a total increase of 32 points collectively. There was an increase of 24 points collectively for the Caring approaches.

There was a total of 15 points in each category that could be scored by the staff member, with a total scored marked out of thirty.

Staff reportedly found the ‘Effective category questions more difficult to answer, and this was reflected in their initial scores. This also allowed for the greater room for imporvement.

Staff scores for the Caring category collectively totalled at 110/150 in the first survey, and 134/150 in the second survey.
Staff scores for the Effective category collectively totalled 75/150 in the first survey and 107/150 in the second survey.

Service user Scores for Caring Approaches:

The greatest increase in service user scores for the ‘Caring’ categories came in the Respect and Choice sections. The training was designed so that these themes ran through most of the group sessions. Training relating care planning and the Mental Capacity Act ’05 focused on promoting choice and respecting the decisions service users make. The increase in the scores for these categories demonstrates that this training has been assimilated and communicated to service users via adjustments in staff approach.

Service User Scores for Effective Approaches:

The largest increase in service user scores for the effective categories was in the Care Outcomes and Quality of life questions. This is a positive finding and it reflects the training staff received. By increasing staff awareness of service user experience (symptoms, anti-discriminatory practice and inclusion training) the service user scores for quality of life and positive care outcomes then increases. There was also an increase in positive experiences relating to staff interactions, with an improvement in anti-discriminatory scores also.

Service Users Overall Scores for Caring and Effective Categories:

There was an increase in scores for both the Caring and Effective elements of the service received by service users. The greater increase was in the ‘Caring’ category with an increase of 16 points. There was an increase of 12 points in the ‘Effective’ category.

Service users scores for the Caring category collectively totalled 449/495 in the first survey, and 465/495 in the second survey.

Service user scores for the Effective category collectively totalled 325/363 in the first survey and 337/363 in the second survey.

4.2 Discussion.

My research was designed to assess the correlation between EBP and service user experience of the service provided. This research was based on the premise staff educated in theories, concepts, legislation and values relating to good practice, as outlined by the CQC and their overarching authority the NIGC, should result in better service user outcomes and service satisfaction. ‘’Implicit…is the belief that the implementation of good quality research is likely to have improved outcomes for patients and therefore important for quality patient care’’ (Kitson et al, 1998, pg. 150). I began by measuring staff knowledge levels regarding ‘Caring’ and ‘Effective’ concepts and practices. This coincided with service user surveys assessing their perception of staff performance and interactions.

The results demonstrated an increase in scores for both staff and service users in the two categories. Service user results reflected a larger increase in the ‘Caring’ scores, indicating that the biggest improvement for them was staff approach and their interactions with individuals. The Choice and Respect categories in the ‘Caring’ section had the largest increase in service user scoring. This is interesting as Respect and Choice were themes that ran through most of the training. Even in aspects of training attributed to the ‘Effective’ category (such as the Mental Capacity Act ’05) promotion of service user choice, and respect for individual’s decisions were central elements of the information disseminated. Although I provided training in both ‘Caring’ and ‘Effective’ values and approaches in the same session, (e.g. Anti-discriminatory Practice alongside values of Kindness and Compassion) the greatest improvement for service users was in staff’s ‘Caring’ approach. This contrasts the staff results, where a more significant result was measured in the ‘Effective’ sections. This might indicate that staff practicing in ways that provide a more effective service, with improved outcomes for service users, increases the perception of staff being ‘Caring’. For example, promotion of choice in particular is central to ‘Caring’ approaches, and also ‘Effective’ ways of working. It also suggests that it is more important to service users that they are supported by staff that adopt ‘Caring’ approaches, and is a clear indication of service user satisfaction levels. This makes sense from a psychological perspective. If service users believe staff to be ‘Caring’ throughout the process of meeting needs and achieving treatment outcomes, this will positively impact of their perception of the experience. Being spoken to respectfully, kindly, with compassion and with dignity seem to be the factors most associated with a positive experiences of the service.

Following the second question paper the feedback from staff suggests they felt they were providing a better service if their performance improved in relation to ‘Effective’ outcomes. The increase in staff awareness regarding issues surrounding inclusion and anti-discriminatory practice significantly improved, as is reflected in the larger increase in staff scores for ‘Effective’ questions. The difference in service users having a larger increase in ‘Caring’ scores, and the staff having a larger increase in ‘Effective’ scores therefore requires some reflection and consideration. These two aspects of good service are inextricably linked, and improvement in one aspect of practice will therefore necessitate an improvement in the other.
In relation to staff training there were some considerations made regarding delivery and application, which may have impacted on the results garnered. Ideally the training delivered would have been separated into distinct categories for ‘Caring’ and ‘Effective’ values and approaches, and taken place over a longer period of time. This would have created an on-going reiteration of the underlying core values of ‘Caring’ and ‘Effective’ approaches. Training that makes overt links to CQC standards, and how these concepts and values relate to providing high quality care, could also be incorporated. Staff members’ individual learning styles and preferences could also provide meaningful ways of ensuring information is being assimilated. Staff presented with differing abilities to process information and then apply this to practice. This was demonstrated by some of the scores on the staff question paper for the ‘Effective’ questions. Some staff increased their scores significantly (staff member 2 – Ten points), but others by a much smaller margin, (staff member 2 – One point). The ability to initially understand the theories and concepts, and then apply these in a meaningful way to practice, which demonstrates a measurable improvement in practice, varies from each staff member. Some individuals will be naturally more adapt at linking theory to daily practice. This is a variable I was unable to control, but makes for an interesting discussion point and reflective consideration. The concept of resistance to change and difficulty in adapting new approaches also varies from each member of staff. This again will impact on the results in terms of actively applying the information learnt in training to interactions with service users. Therefore it seems there are many other factors involved in assimilating concepts in training and how this then informs practice. ‘’EBP consists of integrating evidence, clinical expertise and patient considerations, and then making a judgment on what to do’’, (Kazdin, 2008, pg. 149). Indeed how knowledge is interpreted and applied varies greatly. How decisions regarding treatment outcomes, approaches adopted, application of legislation, etc. are choices staff make based on many factors, including evidence-based theories/practices. Therefore a move towards Evidence-Informed Practice (EIP) theoretically seems more in keeping with my findings. This suggests multiple factors for improved performance that begin with the dissemination of knowledge and theory, but are applied alongside many other practice considerations. ‘’Empirical evidence is better regarded as one component of the mutual and consistently changing journey of client and practitioner’’ (Nevo and Solnim-Nevo, 2011, pg. 1178). This approach suggests there is an underlying base of knowledge that is only relevant when incorporated with clinical judgement and an understanding of the service user being supported. My research attempted to install a ‘’production of actionable knowledge’’, (Elliott, 2013, pg. 2) that staff can access and utilise to improve their practice. Given more time these other factors would make for further research and exploration.

Overall my research results support my hypothesis that more informed and educated staff are able to provide a better experience for the people accessing the service. This supports the CQC guidelines, and the ideology facilitating the NIGC that oversee the standards of care our service adheres to. This was reflected in the improvement in staff knowledge and how this resulted in improved service user survey scores and feedback.

4.3 Reflection.

I am using Gibb’s Reflective Cycle to consider this research process and the results garnered. Prof. Graham Gibbs published his book ‘ Learning By Doing’ in 1988 and he postulated that practitioners utilising a reflective framework would enable them to learn from their daily experiences and develop as practitioners. The cycle of reflection he created encourages practitioners to break down the stages of an event and consider these analytically, exploring ideas and emotions associated with the event. This was designed to aid the learning and development process. The stages of his cycle are: 1) A description of the event, 2) Reflection on the person’s feelings about the event 3) Evaluation of what took place, 4) Analysis, 5) Conclusion and 6) Action Plan.

Below is a reflective account of this research via Gibb’s reflective cycle. The action plan is outlined in the recommendations and uses, moving forward.

Description: As part of the accreditation for the Level 5 Leadership in Health and Social Care Diploma I completed a piece of research looking at staff training and service user outcomes in relation to CQC standards. The research project was relevant to my role, as staff training and service management as central aspects of my managerial responsibilities. I ensure our company is adhering to CQC standards and in delivering a high quality service. I chose to assess the possible correlation between staff training in CQC stated values and approaches and service user experience of the service they receive. This involved looking at staff understanding of how we demonstrate and communicate ‘Caring’ approaches, and how we deliver an effective service that improves the service users’ quality of life. Initially staff completed a survey asking them to list how they demonstrate aspect of ‘Caring’ and ‘Effective’ approaches, such as how they communicate compassion, kindness, dignity, etc. as well as how they measure how interactions have been ‘Effective’ and garner positive outcomes. These questions were scored, and the same survey repeated eight months later following intensive training. The two scores could then be compared and any improvement in knowledge measured.
Parallel to this service users were also asked to complete a survey measuring their perception of staff being ‘Caring’ and whether they felt outcomes achieved were ‘Effective’. Again this was repeated eight months later and the results scores and compared. The scores of both staff and service user results were then compared, to ascertain if the EBP training implemented for this research has been effective in improving service user experience of the service.

Feelings: The subject matter was an area of interest to me prior to undertaking this research project. I enjoyed reacquainting myself with Evidenced-Based Practice theories and providing training which was more discussion-based and fluid. Staff feedback from the training also reflected that they preferred this types of work-shop type training sessions. Following the initial survey completion I was surprised by how difficult some members of staff found completing the question paper. Some individuals were unable to explain how they communicate ‘Caring’ approaches. This was an unexpected finding as such concepts are central to adopting a person-centred approach. Staff reported finding the questions relating to ‘Effective’ approaches, and how we measure outcomes for service users receiving services and their experience of these, the most difficult to answer. The extent to which some staff members found linking good practice approaches to underlying value frameworks was surprising. The staff demonstrate professional and positive values when working with service users, so I had not anticipated the difficulty in explaining how these values are expressed in practice. Reassuringly, following the second question paper eight months later this understanding seems to have improved greatly, especially in relation to ‘Effective’ approaches.

I also found that the focus of the research shifted from primarily person-centred values to anti-discriminatory practice, which I had not foreseen. The feedback from service users regarding indirect discrimination was unexpected, but enabled me to reflect on an increase in empathy towards service users, as a result of the inclusion, reflective practice, symptoms and anti-discriminatory training, had a large impact on service user satisfaction levels. Although I had not anticipated this finding it has been very useful in re-focusing my staff training goals and preparing for future work.

Evaluation: My research resulted in a significant outcome and demonstrated how training specifically designed to focus on EBP approaches, in relation to CQC standards, improved service user satisfaction. My hypothesis was relevant to my field and specific to the responsibilities within my role. I gained more insight into how service users perceive the service we provide and what aspects of staff approach influence their concerns and negatively impact on this experience. This has enabled me to focus on the areas that need the largest improvement and adaption of staff approach.
I used surveys, as this was a good way of collecting data required in an ethical manner. Staff and service users were given adequate time to complete the surveys/question papers, so they did not feel pressured to answer and could consider their responses. The questions selected for the service user survey were chosen to provide a general perspective of key aspects of service user experience. They were clearly formatted with multiple-choice answers, which has a score attached. The staff survey questions were broader as I was assessing their knowledge rather than subjective experience. A score of each answer provided was then given, (max of 3 points per question). This resulted in measurable data and made analysing my findings clear and comparable. Service users were willing to participate and engaged in both surveys, and provided useful feedback on personal experience of using our service.

Staff engaged in undertaking the knowledge-based survey twice and every staff member improved their overall score the second time around. Despite anticipating some resistance to adopting a different training approach and asking staff to complete the survey during a training session, staff embraced their participation in this research and this seemed to motivate them to engage with the training and increase their scores. This approach was effective as all scores improved, some by a significant margin.

Analysis: On reflection there are some aspects of my research I could have changed or improved. If there were no time limitations I would like to have provided more specified training over a longer period of time, which should translate to a more marked difference in staff approach, and therefore be reflected more notably in service user feedback. The assimilation of information given in training can sometimes take a while to transfer into meaningful practice. The on-going reiteration of values, approaches and theories will have a longer lasting effect on staff approach.
The continuous fluctuations in service user mental health will also have had an impact on the results of this study, as individuals with more paranoid and anxious symptoms may interpret the questions on the survey differently depending on their mental health at the time. If I was to repeat the study over a longer time frame I would undertake service user surveys more frequently to gain a base-line of scores, to garner more accurate results. If time was not a factor I would also have like to deliver training that directly linked to each question on the staff survey. Most of the training sessions involved discussions regarding aspects relating to both ‘caring’ and Effective’ categories, as caring approaches are inextricably linked to effective outcomes, (refer to Selected Research Methods above). I assumed staff would be able to extrapolate the information that relates to ‘caring’ aspects of the role (e.g. kindness, compassion, values) and information that relates to the ‘effective’ aspects of the role, (Anti-discriminatory practice, Mental Capacity Act ’05, service user symptoms). Providing training that separates these concepts and focuses on theories and approaches underpinning either ‘caring’ or ‘effective’ skills might have garnered a larger increase in scores and further improved staff knowledge and how to apply this directly to practice, (EBP), and in turn improved the service user experience more notably also.

Conclusion: On reflection of this research project I have gained insight into both the service user experience of our service and staff understanding of their role within that service. The findings support the hypothesis that staff working from Evidence-Based Training will have a positive impact on the service it’s users experience. Despite methodological changes that could have improved the accuracy of these findings, if there was time to execute them (see analysis above), I was able to observe a clear increase in both staff knowledge base and service user experience, which will go on to inform how I approach staff training in the future and how I collect service user feedback.

I am generally pleased with how the process of this project proceeded and how the results were documented. There were no major obstacles to my research and I enjoyed delivering the training. Staff feedback on the training was also positive and insightful, and has changed my approach to presenting training sessions. Discussion-based training proved most effective in engaging staff, as they report it to be less intimidating than activity/question-based training styles. As the improvement of staff scores indicate there is good reason to adapt my approach to delivering training.

Service users also reported having a better experience of the service as a result in changes to staff approach following training. This measurable increase has occurred in a relatively short time frame, and is a finding I aim to build on and continue to improve going into the new year.

4.4 Recommendations and Uses.

After completing my research the findings reinforced that CQC guidelines, when followed by staff educated in the regulations and approaches to enforce these, does create better outcomes regarding service user experience. This finding was significant and will direct this coming year’s approach to the annual service user survey. Prior to this research service user feedback centred around satisfaction levels relating to their environment, activities provided, etc. However gathering feedback from service users regarding the effectiveness of staff interventions and approach raised many issues not anticipated by the aims and objectives of this research. By assessing the ‘Caring’ and ‘Effective’ categories of the CQC Five Key Principles I was initially focused on person-centred intervention and approaches between staff and service users. However what became clear from the verbal and written feedback offered by service users was that there were underlying concerns regarding stereotyping and possible indirect discriminatory practice. The questions assessing ‘Caring’ approaches in particular allowed the service users to comment on staff interactions and how perceived negative attitudes towards people with mental health issues can be detrimental to their recovery and general well-being. Although this had markedly improved following the anti-discriminatory and inclusion staff training, and was reflected in both the staff scores and service user results, this feedback highlighted service user concern that I was previously unaware of.

As a result of this finding I have extended the training on anti-discriminatory/anti-oppressive practice, inclusion, communication and reflective practice, including the expectation that all staff keep a reflective journal to record events for discussion in supervision. This training has already be scheduled into this year’s staff training plan. This will serve to continue this trajectory of improvement regarding staff-service user interactions and will result in an improved service being delivered. The initial training session on anti-discriminatory practice, service user symptoms and Reflective practice has already taken place (15/01/19) and the staff feedback was very positive.

I will conduct another research project this year, which will be centred around staff peer appraisals, and will be qualitative in nature. Again it will centred around CQC standards of practice, but will be focused on colleagues writing about each others’ approach with service users and evaluating the outcomes achieved. This will link into the reflective practice journals staff will be keeping.

The research undertaken for this diploma will direct and inspire training and the type of service user feedback approaches utilised by the management for the foreseeable future.

Bibliography

Biesta G. (2007) Why ‘What Works’ Won’t Work: Evidence-Based Practice and the Democratic Deficit in Educational Research. Educational Journal 2007, Vol 57, Issue 1. https://doi.org/10.1111/J.1741-5446.2006.0024.x

Elliott J. (2013). Making Evidence-Based Practice Educational. British Educational Research Journal. Vol. 27. Issue 5 pg. 22.

Frankova H. (2014) What is Changing About How We Regulate? http://www.magonlinelibrary.com/dol/abs/10.12968/nrec.2014.16.8.459?JournalCode

Giles A. (2015). The Role of Information Governance Within English Clinical Governance: Observations Based Upon the Interim Report From the NIGC of Care Quality Commission.
Governance: An International Journal, Vol. 20, No 1, 13-20.

Green J. (2000). The Role of Theory in Evidence-Based Health Promotion Practice. Health and Education Research: Vol 15, Issue 2, pg. 125-129

Grol R and Wensing M. (2004). What Drives Change? Barriers to and Incentives For Achieving Evidenced-based Practice. Medical Journal of Austrailia, Vol.180, issue 6, pg. 57-60.

Kazdin A. E. (2008). Evidence-Based Treatment and Practice. New Approaches to Bridge Clinical Research and Practice, Enhance the Knowledge Base, and Improve Patient Care. The American Psycholoical Association. Vol. 63, No. 3. PG. 146-159.

Kitson A, Harvey G. and McCormick B. (1998). Enabling the Implementation of Evidence Based Practice: A Conceptual Framework. Quality in Health Care, 1998, 7: pg. 149-158.

Michie S, Johnson M, Abraham C, Lawton R, Parker D and Walker A. (2005). Making Psychological Theory Useful for Implementing Evidence-Based Practice: A Consensus Approach. http://qualitysafety.bmj.com/content/14/1/26.short

Nevo I. and Solnim-Nevo. V. (2011). The Myth of Evidence-Based Practice: Towards Evidence-Informed Practice. The British Journal of Social Work. Vol. 41. Issue 6. Pg. 1176-1197.

Rosewurm M. A. and Larrabee J. H. (1999). A Model for change to Evidence-Based Practice. Journal of Nursing Scholarship, 1999, 31:4 317-322.

Webb S. A. (2001) Some Considerations on the validity of Evidence-Based Practice in Social Work. The British Journal of Social Work, Vol 31, Issue 1, 57-79.

About the author

Research has been conducted by Nesta Chambers BSc Social Worker and Registered Manager for Great Glens. Nesta works closely alongside Service Users and Staff and is always looking to implement evidence-based practice. To this end she has undertaken two pieces of research - one focusing on the impact of animals in care. the second piece looks at how getting staff to work reflectively improves the lives of the people they are caring for.