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Archived: Mount Avenue

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Inspection report

Date of Inspection: 30 April 2014
Date of Publication: 3 June 2014
Inspection Report published 03 June 2014 PDF | 91.33 KB

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

Not met 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 30 April 2014, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with commissioners of services.

Our judgement

The provider did not have an effective system to regularly assess and monitor the quality of service that people received. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

Reasons for our judgement

At our last inspection in November 2013 we made a compliance action in this outcome area because we found a number of issues which had a moderate impact on people who used the service.

At this follow up inspection we found the provider had made improvements.

There was evidence in one of the care records we looked at that reviews had been carried out on the person’s care plans and risk assessments. However, when changes were identified this was not reflected in the care plan. This matter is addressed under the heading ‘records’ later in the report.

Feedback questionnaires had recently been completed by people who used the service and staff. These were in the process of being analysed by the manager. We saw the feedback was mostly positive. However, people’s views had not been considered regarding what areas of their home should be given priority in the redecoration plan.

There was no robust system in place to effectively identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

We saw a spot check audit had been carried out in April 2014 by the manager. The manager confirmed this was the only audit that had been completed since the last inspection. The audit did not cover areas such as care records, which meant there was a risk they would not reflect people’s current needs. We found there was no cleaning schedule in place which meant there was a risk that the home would not be kept clean and tidy. A cleaning schedule was introduced on the day of our visit.

We found there was no formal system in place to review the decoration and upkeep of the home. The manager informed us medication audits were carried out but not documented. We found accident and incidents were documented. However, there was no evidence to show these were audited by the manager to identify any patterns or trends to ensure any issues were identified at an early stage.