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Archived: Haddon Court Nursing Home Requires improvement

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Inspection report

Date of Inspection: 23 June 2014
Date of Publication: 22 July 2014
Inspection Report published 22 July 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 23 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services. We reviewed information sent to us by other authorities and reviewed information sent to us by local groups of people in the community or voluntary sector.

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.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Our judgement

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

Reasons for our judgement

The home manager had worked for the provider as the area manager for a number of years. They were currently in the process of registering with CQC as the homes registered manager. Several people we spoke with told us they thought the new manager was "very good."

We looked at a sample of the service's policies and procedures, for example the health and safety policy. We found the policies and procedures to be detailed, clearly written and easy to understand. The policies and procedures had been reviewed and updated as necessary.

The home manager explained the systems in place to assess and monitor the quality of service provision. They confirmed that the internal auditing of the service covered many areas, for example, infection control, environment, medication, food hygiene and care plans. We saw evidence of the systems in place to demonstrate this.

The provider may find it useful to note where audits had been completed it was not always clear if any action had been taken to rectify issues found during the audit. For example, we saw a food hygiene audit carried out in May 2014. It listed a number of areas that required improvement. It was not clear if the actions had been completed and if so when and by whom. We also found 27 care plan audits that had been undertaken by a registered manager from a sister home. The audits showed the actions that needed to be completed to make sure information in care plans was up to date and current. The home manager confirmed to us that the actions required had been completed but confirmation of this could not be found.

The provider may also find it useful to note on the audits seen there was not always an action plan with a timescale of the action required to ensure improvement. This meant there was a risk that intervention and improvements may not be made within a reasonable timescale.

A complaints procedure was in place so that people could voice any concerns. We saw information about how and who to complain to on display around the home.

All people spoken with said they weren’t aware of any ‘residents meetings’. One person said, “That would be a good idea.” Another person who used the service told us the manager came to see them twice a week and this gave them the opportunity to raise any concerns they may have. Five people who used the service told us that everything at Haddon Court had improved in the last six months. One person also said, "Management is more easy going."

On the notice board we saw a ‘relatives meeting’ was planned for the end of the week. Staff told us relative meetings took place every ‘few months’ and we saw the minutes recorded at the last meeting in March 2014.

Staff told us that staff meetings were held frequently. Following the meetings staff were provided with a copy of the minutes of the meeting. This made sure that all staff were made aware of any discussions that had taken place and any actions they needed to take.

A 'Customer Satisfaction Survey' was completed in September 2013. Questionnaires had been sent out to people using the service, their relatives and advocates asking their opinions about such things as the environment, social activities, food and personal care and support. The survey showed that overall; the proportion of people who were very satisfied or quite satisfied was over 70%. A report detailing the findings of the 'Customer Satisfaction Survey' had been completed. The report incorporated an action plan detailing what changes would be made following listening to people's views.