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Archived: Ayrshire House Good

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Inspection report

Date of Inspection: 22 May 2013
Date of Publication: 21 June 2013
Inspection Report published 21 June 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)

Not met 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 22 May 2013, 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 staff, reviewed information given to us by the provider and talked with commissioners of services.

Our judgement

The provider had not got an effective system to regularly assess and monitor the quality of service that people received. The provider had not got an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

People who used the service had not been asked for their views about their care they received. Whilst we saw people who used the service had monthly meetings with staff, this was generally an opportunity to discuss and agree what social activities people wanted to do. We saw in the care files we looked at a copy of a service user questionnaire, this was part of the services internal quality and monitoring system. However, the questionnaires viewed were dated 2011. The registered manager told us they had not sent a further questionnaire since this time. This means that the provider cannot be assured that people are happy with the service they are receiving.

There was limited evidence that learning from incidents / investigations took place and appropriate changes were implemented. We looked at the accident book and whilst accidents and incidents were recorded, there was nothing to show if or what action had been taken to reduce further accidents reoccurring. Another example of this was we saw the registered manager had done regular medication audits. We saw they had identified missing care workers signatures on medication records. We asked the registered manager what action they had taken in response to what they found. They were able to tell us what they had done and would do if this became a reoccurring theme, however, we did not see that this had been recorded anywhere.

We saw the services complaints procedure. We saw there had not been any recorded complaints in the last year. The complaints procedure was not written in easy read language. This meant people with communication needs may not have fully understood what the complaints procedure was or how to make a complaint.

We looked at various health and safety documents, we found policies and procedures in relation to health and safety were missing. We discussed this with the owner and registered manager who agreed further work was required to develop and implement these.

We saw there was a business contingency plan that stated it had been revised in 2012, we saw it had not been dated or signed by either the owner or the registered manager. However, the owner signed it before we left.