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Inspection report

Date of Inspection: 2 May 2012
Date of Publication: 29 May 2012
Inspection Report published 29 May 2012 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

Our judgement

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

User experience

Staff told us that accidents and incidents are always recorded in people’s diaries and in the daily record book. We found that the registered manager kept a record and analysis of all incidents and accidents. We saw that where common themes or causes were identified that the registered manager made appropriate changes and communicated the changes to staff. This meant that there was a system for reporting and learning from incidents.

People who lived at the home told us they had regular meetings to discuss things that affected them, like the catering and activities. We saw from records of the most recent meeting that people had agreed a list of activities they would like to try, such as French bowls, more board games and a karaoke. Actions agreed at the meeting included, “Staff to produce an activities plan each month and display it to encourage others to join in”. The registered manager told us that most meetings with people who live at the home are spontaneous and informal. We saw notes the registered manager had made following a discussion and agreement with one person about keeping a duplicate key on site in case the person loses their door key. This meant that the provider took people’s views into account when planning how best to support them.

People we talked with told us they knew they could make a complaint to the manager if they were unhappy with anything. We found that some people who lived at the home had complained about the noise that other people made. Staff said, “One person often just needs our attention and this is how they communicate. We know their noise can be distressing to other people so we go to them quickly and try to calm them, and can change staff if we need to”. People we talked with said that once they understood this person’s needs they no longer found their noise distressing.

Other evidence

We found that the provider monitored the quality of the service by conducting regular checks on the care provided. The service manager’s monthly check included a conversation with individual people who lived at the home and checking records to see that care plans and daily records were up to date and that risk assessments and care plan reviews were undertaken. We saw that the service manager also checked that the registered manager had an effective staff rota and staff supervision schedule and had accurately recorded and reported accidents and incidents. We saw that where the service manager had identified issues the registered manager had responded with an appropriate action plan. This meant that the provider monitored the quality of service provision.

We found that the provider had implemented a central recording system which included staff signing-in and out and a handover sheet. We found that staff had used the book consistently to record changes in people’s health and behaviour, health professionals’ appointments and general information, such as, faulty equipment. We saw that seniors used this central record to show that they had checked on medication records and checked for any hazards or risks on the premises during their shift. The care manager showed us how they used this central record to ensure that staff recorded and reported issues accurately by comparing records to people’s care and lifestyle diaries. This meant that senior staff monitored the quality of care and support given to people.

We found that the provider conducted annual surveys of people who lived at the home and of staff. We saw that the provider analysed the results of the surveys and compared them with survey results from the provider’s others homes in the group. We saw that people who lived at Mill Green thought that ‘staff’s attitude’ was the most impressive aspect of the service. We saw the provider had made a plan to improve those aspects of the service that people had said that were less impressive. For example, people had said that activities could be improved and the provider had planned to provide a ‘social activity plan’, regular exercise and wellbeing opportunities for people and to encourage and promote the role of volunteers to support services. This meant that people who lived at the home and staff were asked for their views about their care and treatment and their views were acted on.

We found that a complaints and comments book was available in reception for visitors and relatives to write in, but no-one had made a complaint in this manner for over year. We found that the registered manager had dealt appropriately with a complaint made by a member of staff. The registered manager had investigated what had triggered the complaint and then held a discussion with the member of staff to explain why the complaint would not be taken any further. This meant that the provider took account of complaints and comments to improve the service.