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Inspection report

Date of Inspection: 11 September 2013
Date of Publication: 1 April 2014
Inspection Report published 01 April 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 11 September 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We spoke with a visitor who told us that the staff at the home regularly asked them if they were happy with the level of care and answered their questions. They told us that if they had any comments then the manager was approachable and did her best to put things right.

We saw that people who lived at the home, their relatives, friends and care professionals were regularly asked about their opinion of the service. We sampled three forms from the latest survey. Only a small number were available as the forms had only been sent out the week before. The senior staff on duty told us that the results of surveys were shared in staff meetings and any complaints or suggestions for improvement were addressed immediately with the individuals concerned.

We saw that the home had regular meetings with the people who lived there to consult them and to respond to their suggestions. We saw that the home recorded when such suggestions had been put in place.

We saw that the home had a complaints policy and procedure and that people’s complaints were recorded with actions.

The manager told us about a range of health and safety audits which were carried out. For example, the home carried out regular maintenance checks, portable appliance tests and hot water temperature checks. The manager told us that the fire service carried out an annual visit to the home and that checks to fire fighting equipment were regularly made and recorded. Lifts and other equipment were regularly serviced. We noted that the home had scored five (the highest score) for kitchen hygiene at the latest environmental check. We saw records for regular checks on fire fighting equipment, the nurse call system, fire doors, fire alarm and emergency lighting. All were up to date with records of any repairs or improvements.

We saw that the home carried out a series of other audits. Senior staff told us that they checked medication each month to ensure staff were recording this correctly. We saw audits for infection control, bed occupancy, staff sickness, activities, training needs, untoward incidents and an audit on the number of times each member of staff recorded spending individual time with people which were referred to as ‘butterflies’. This meant that the home knew what improvements were needed. Systems were in place to ensure the improvements were monitored.

Care plans were regularly reviewed and updated to ensure that people’s up to date care needs were taken into consideration.

Staff told us that they were informed of required improvements in meetings and in daily handovers between shifts. Meetings were also used to canvas staff opinion and ask for suggestions about improvements.

We saw that health care and other professionals were consulted for their advice and that this was incorporated into care plans. This ensured that people benefited from specialist support when this was needed.