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Inspection report

Date of Inspection: 28 May 2012
Date of Publication: 15 June 2012
Inspection Report published 15 June 2012 PDF | 48.06 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)

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 reviewed all the information we hold about this provider, carried out a visit on 28/05/2012, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Overall, the provider had an effective system in place to regularly assess and monitor the quality of service that people received. The provider was meeting this standard.

User experience

People who used the agency were asked for their views about the care and treatment provided. People we spoke with had been asked to contribute to the annual satisfaction survey. All of the people we spoke with knew how to raise concerns.

We saw the following comments had been received by the agency as part of the annual survey response from people: - “Carers are genuinely helpful and caring”. “Everyone is so helpful and cheerful”. “I am very pleased with the regularity and ability of all the carers”. “We are very pleased with TLC agency and would recommend it to others”. “I am extremely impressed with the standards maintained by the agency”.

People and their advocates told us that the agency “are very very professional. A very good agency”. “I have every confidence in TLC. No agency is absolutely perfect. They are here to do the best they can”. “The consistency of carers is pretty good”.

Other evidence

The registered manager told us that a staff satisfaction questionnaire was sent out in April 2012. This was confirmed by staff. The registered manager told us that she was currently evaluating the results of the staff survey, but initial findings were that the agency had improved in the last year. The registered manager told us that she intended to publish the results from the surveys undertaken in order to provide feedback to people who used the agency and staff.

We found that the agency had an audit system in place for monitoring the quality of the service. For example, we saw audits had taken place for missed calls, complaints and compliments, training and supervision. The registered manager told us that the Team Leaders audited the medication charts and daily records when they were returned to the office, although they did not have any evidence available to support this. This meant that the provider was regularly assessing and monitoring the quality of the services provided to make sure that people received appropriate care and treatment.

We found that there were shortfalls in the audit trail in some areas to show what action had been taken. For example, messages were recorded in a message log and there was a space to show the action taken, but this was not being completed. There were no recorded action points following meetings with staff. Two complaints records both in March 2012 had no outcome recorded. The registered manager acknowledged that this could be improved and that there was a need for a more thorough audit trail to make sure all action plans were created and followed up as required.

The registered manager showed us their self assessments against the 28 essential standards of quality and safety and the changes that had been made following a review of the standards. For example for safeguarding people from abuse they had now included a leaflet in the ‘Client Information Pack’ produced by the local authority about ‘Keeping Safe.