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Inspection report

Date of Inspection: 6 January 2014
Date of Publication: 6 February 2014
Inspection Report published 06 February 2014 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 6 January 2014, observed how people were being cared for and sent a questionnaire to people who use the service. We talked with people who use the service, talked with staff and reviewed information given to us by the provider.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

We looked at how the provider obtained feedback from people, staff and other key stakeholders regarding the quality of the service. The people we spoke with said they did not attend residents’ meetings and that there was no organised feedback. They said that if they had any problems they would tell a member of staff and “they would usually fix it.” One person said that although the manager would always listen to their complaints and concerns nothing ever got done about them. However, another person said that when they had had a complaint it was sorted out quickly.

We asked the manger to comment on the claim by one of the people who use the service that they failed to respond to complaints. The manager said that she thought this was in connection with an issue regarding the telephones at weekends. They said that during the week calls to people who use the service would be taken at reception and then transferred to the person’s room. At weekends an automated system was used which meant the caller would be asked to key in the person’s room extension. One of the people had requested that this system be used all the time. The manager said that this was not necessary as there were at least three people in the reception area who could answer the phone.

We were given a copy of the provider’s most recent residents’ questionnaire and noted that this focused on activities. The questionnaire listed a range of activities and asked people if these had improved, stayed the same or had got worse. The manager said they had not analysed the results yet. They also explained that each year the questionnaire would focus on a different aspect of the service.

The staff members we spoke with said there were daily staff meetings at midday , and that the manager met with senior staff once or twice a month. They said the manager had an open door policy which meant that staff could talk to them at any time.

The manager said the home did not have regular residents’ meetings because they were getting feedback from people all the time. They said that with regards staff meetings, up until the previous September they had chaired weekly meetings, which were minuted. They had then decided to meet everyday at midday and that at present these meetings were not being minuted. They said that staff found the daily meetings very useful. They said there were also weekly meetings with the heads of care where the needs of individual people were discussed, and that these were recorded. They said they might consider minuting the daily staff meetings from now on.

We were given a copy of the minutes of the latest head of care meeting and noted that these consisted of short statements regarding the health and welfare of a number of the people who use the service. We were also given the minutes of one of the last weekly staff meetings that had been taking place up until September 2013. We noted that issues discussed included a new member of staff starting, training, feedback from residents, the role of senior staff, and changes in the kitchen.

From our conversations with staff and people who used the service, and from our review of feedback information we were satisfied that the provider was taking steps to ensure it obtained regular feedback from key stakeholders, much of it in an informal way. This meant that any concerns raised could be acted upon in a timely manner. However, the provider might find it useful to note that the daily staff meetings were not currently being minuted, which meant there was no record of any agreed action points or areas of concern.

We asked the manager how they regularly monitored and assessed the quality of the whole service. They said they did not have any recorded quality assurance material such as audit reports or records of regular management inspections. However, they said that they were in direct contact with the owner of the service every day and attended management meetings with the owner every