3.4 Compare different approaches to audits within quality improvement

This guide will help you answer 3.4 Compare different approaches to audits within quality improvement.

Audits are essential tools for monitoring and improving the quality of care in adult social care settings. They provide an opportunity to evaluate current practices, identify gaps, and implement improvements to ensure compliance, safety, and high standards. However, there isn’t a single “one-size-fits-all” approach to audits. Different methods can be used depending on the aim of the audit, the stakeholders involved, and the areas being assessed.

In this guide, we compare several approaches to audits commonly used in adult social care.

Internal Audits

Internal audits are conducted by members of the organisation, such as team leaders, managers, or designated quality assurance staff. These audits are planned and executed by individuals familiar with the service’s policies, procedures, and context.

Key Features:

• Carried out by in-house staff.
• Focused on self-assessment and continuous improvement.
• Can be scheduled routinely or be ad hoc (e.g., in response to an incident).

Strengths:

• Internal audits allow the organisation to identify and address issues proactively before external scrutiny occurs.
• They’re cost-effective as they don’t require external professionals.
• Auditors have an operational understanding of the service, which saves time and increases the relevance of findings.

Limitations:

• There is a risk of bias, as staff may overlook or underreport issues to protect the organisation.
• Auditors may lack the objectivity necessary to challenge longstanding practices that require change.

Example:
An internal health and safety audit could assess whether equipment checks are up to date or if risks, such as trip hazards, are being appropriately managed in the care environment.

External Audits

External audits are conducted by independent individuals or organisations who are not part of the service being assessed. This could include regulatory bodies like the Care Quality Commission (CQC), commissioned consultancy firms, or accreditation agencies.

Key Features:

• Performed by auditors with no prior involvement in day-to-day operations.
• Focused on compliance with external standards and legal/regulatory requirements.
• Often occur less frequently than internal audits, such as annually or biannually.

Strengths:

• They provide an impartial, objective assessment of care quality.
• Findings carry weight due to the independence of the auditor, giving credibility to the results.
• Useful for accountability to stakeholders, such as regulators or funders.

Limitations:

• External audits can be expensive, particularly for smaller organisations.
• They may focus heavily on compliance rather than continuous, person-centred improvement.
• Auditors may lack detailed context or understanding of operational challenges, leading to less practical recommendations.

Example:
A CQC inspection typically reviews key areas like safety, effectiveness, and responsiveness. An “Outstanding,” “Good,” “Requires Improvement,” or “Inadequate” rating is shared with the public.

Thematic Audits

Thematic audits focus on specific areas of care or organisational performance, such as safeguarding, medication administration, or infection control. These audits can be internal or external, depending on the organisation’s needs.

Key Features:

• Narrow focus on a single topic or theme.
• Can involve targeted observation, data collection, and stakeholder feedback.

Strengths:

• They provide a deep level of insight into high-priority or challenging areas.
• Help services respond to emerging concerns, such as addressing rising complaints about a particular aspect of care.

Limitations:

• Limited scope means other important aspects of care may be overlooked.
• Relevance depends on how well the theme is chosen; if poorly selected, audits may not address the underlying issues affecting overall quality.

Example:
A thematic audit may focus on medication errors following a pattern of complaints or incidents involving missed doses or incorrect prescriptions.

Peer Audits

Peer audits involve colleagues from outside the immediate setting or organisation assessing the service. This could include a sister site within a larger organisation or professionals from a partner provider.

Key Features:

• Auditors are skilled professionals but work in a different service or context.
• Combines external insight with professional expertise.

Strengths:

• Provides objective feedback from professionals who understand the social care sector but are not directly influenced by the organisation’s policies.
• Encourages shared learning between services, as good practices can be exchanged.
• Peer auditors often have hands-on experience, which can make their recommendations more practical and relatable.

Limitations:

• There could still be slight bias if peers hesitate to provide negative feedback to colleagues.
• It may lack the robust independence of external audits.

Example:
One residential care home within a care group may perform a peer audit of another home, reviewing areas like person-centred care planning and staff training.

Spot-Check Audits

Spot-check audits are unannounced audits designed to observe and assess practices as they happen. They can be part of either internal or external assessments. The aim is to gain a real-time view of the service without the preparation or adjustments that might occur during planned audits.

Key Features:

• Conducted without prior notification.
• Focus is often operational, such as observing staff interactions, environment cleanliness, or adherence to routine procedures.

Strengths:

• Allows a genuine picture of day-to-day operations without the influence of preparation.
• Identifies real-world strengths and gaps in practice that might not be evident during planned audits.
• Useful for validating whether previous corrective actions have been sustained over time.

Limitations:

• Staff may feel scrutinised or stressed by the “surprise” nature, which might create tension with management.
• Can miss issues that are not visible on a particular day or shift.

Example:
A spot-check audit might assess whether personal protective equipment (PPE) is being used correctly during a shift.

Self-Audits by Teams

In a self-audit, care workers or teams review their own performance and processes. Team discussions, reflective supervision, or simple checklists are commonly used during this type of audit.

Key Features:

• Conducted by staff for their own team or role.
• Focuses on identifying strengths and areas for development from a frontline perspective.

Strengths:

• Empowers staff by involving them directly in quality improvement.
• Encourages reflection and accountability without external pressure.
• Can highlight practical challenges quickly and efficiently.

Limitations:

• Self-audits are prone to bias, as staff may unintentionally minimise or avoid reporting weaknesses.
• They rely on honesty and transparency, which may vary across teams.

Example:
A self-audit may involve a care team using a checklist to review compliance with person-centred care plans at the end of each week.

Comparing Approaches

Each approach has distinct benefits and challenges. Choosing the right one depends on the organisation’s goals, available resources, and priorities.

Audit Type	Strengths	Limitations
Internal	Cost-effective; proactive	Potential for bias; less objective
External	Impartial; credible assessment	Expensive; may lack practical context
Thematic	In-depth focus on specific issues	Overlooks wider service performance
Peer	Shared learning; sector expertise	Less independence than external audits
Spot-Check	Real-world insights; unfiltered	Stress for staff; one-off snapshot
Self-Audit	Empowers staff; quick adjustments	Prone to bias; dependent on honesty

Final Thoughts

Different approaches to audits serve different purposes, and many organisations combine multiple methods to achieve a comprehensive picture of quality and performance. For example, internal audits may be regularly scheduled to monitor operations, while an external audit provides accountability to regulators. Thematic or peer approaches might address specific challenges, and spot-check audits confirm daily practices. When deciding which approach to use, it’s important to match the method to the issue being assessed to make the process meaningful and impactful.