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Inspection report

Date of Inspection: 13 November 2012
Date of Publication: 6 December 2012
Inspection Report published 6 December 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 13 November 2012, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

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 provider took account of complaints and comments to improve the service.

We saw evidence that people's views were listened to and complaints were acted upon. People who lived in the home told us they had their views sought and were involved in decision making.

We found a positive approach was taken to receiving feedback from people to enable service provision to be further developed. People we spoke to explained that they could speak to the manager about any concerns. One relative said, "My mother is happy here, she has nothing to complain about."

We saw that questionnaires had been sent out to people who used the service but these were not dated or could be traced to when the activity took place. The manager gave her assurances that the next questionnaire activity which is to be extended to relatives would be completed in December 2012.

We looked at staff files to see whether ongoing appraisals had taken place to ensure staff development needs were suitably monitored and assessed. We found that staff appraisals had not been completed up to date. However, the provider may find it useful to note that staff appraisals were not being kept fully up to date, which made it difficult for the provider to monitor the quality of the service people receive.

At the time of the inspection we attended a scheduled Ladies Committee meeting. Ladies committee consist of external stakeholders, ex general practitioner and appointed persons by board of trustees.

This committee met once every two months and reviewed the current and best practice for the people who use the service in respect of menus, decor within communal areas, complaints feedback and new resident entries. Committee members also visited people using the service on a monthly basis in between committee meetings to assist in improving the service where necessary.

We saw evidence of staff meetings that were held to support and encourage staff to report incidents or encourage engagement. Operational activities such as handover procedures, housekeeping, care plan, key workers and medication activity were discussed and recorded in the meeting minutes.