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Inspection report

Date of Inspection: 12 December 2012
Date of Publication: 25 January 2013
Inspection Report published 25 January 2013 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 12 December 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, 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

We saw quality audit questionnaires that had been completed by staff and people who used and visited the service. These questionnaires had action plans attached where appropriate. Meetings occurred every three months. The information gained from these meetings was used to plan activities and redesign the menu. This meant that the views of people used the service were sought and that the feedback received was taken into account with service improvement planning.

The provider published regular newsletters to inform people who used the service of upcoming events. These newsletters also communicated important changes and celebrated staff achievements. Relatives we spoke with told us they found these very informative and beneficial.

The provider completed regular spot checks covering day and night shifts. These checks monitored the staffing levels, quality of care and the professional presentation of staff. No problems had been identified through these checks.

There was an appropriate complaints procedure in place. People we spoke with and their relatives were aware that they could raise concerns if they wished. There were no complaints for us to review.

Personal emergency evacuation plans were in place which provided information to support people who could not get themselves out of the building unaided during an emergency situation. This meant the necessary information was available in the event of an emergency situation.

We saw that fire testing procedures were recorded and were clear and up to date. This meant the provider ensured that people who used the service and the staff were protected and safe.

The provider may wish to note that during our inspection we found that care plan audits were not completed. We spoke to the provider about this who confirmed that an effective care plan audit was not in place. This meant that the provider had not identified that; mental capacity assessments were not being completed, some people had not received assessments of need and care plans were not always up to date.