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Archived: Westbourne House

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Inspection report

Date of Inspection: 8 September 2014
Date of Publication: 30 September 2014
Inspection Report published 30 September 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 8 September 2014, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services.

Our judgement

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

The provider had 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

The homes manager had been in post for a number of years and was registered with CQC.

There were procedures and processes in place to monitor and ensure the home was providing an effective service and to monitor quality of the service.

We saw evidence of regular audits by the manager and senior staff within the service to check the quality of service. These audits were still being developed and staff had been delegated specific audits to complete. These included daily ‘walk around ‘observation audits, medication, health and safety, infection control and premises audits. Actions resulting from these audits were recorded.

We saw audits by the provider where they had spoken with people who used the service and staff and commented about the running of the home. The provider visited most days and recorded these visits. People said they knew the provider and saw them most days. People said, “he [provider] always speaks to me and asks me if I’m okay, I can tell him if I’m not.” This meant the provider had systems in place to monitor the home which included their involvement in the monitoring of the service.

People who used the service were asked for their views about their care and support and these were acted on. We saw evidence the provider carried out annual satisfaction surveys. The last survey however was in 2012. The manager said they would be undertaking another survey this year.

People said they had regular ‘resident meetings’ were any issues or concerns and plans for the running of the home were discussed and acted upon. We saw minutes of these meetings.

We saw minutes of staff meetings which took place every two or three months or more frequently if required. The minutes we saw had included discussions on training, general care, incidents, updated policies and procedures and best practice. Staff we spoke with told us they were always updated about any changes and new information they needed to know.

People we spoke with told us they were happy with the service and had no concerns or complaints. People knew how to make a complaint if they were unhappy and said they would tell the manager. They commented, "I see [named manager] most days, they always ask about me and if I am worried about anything, I’m happy though.”

We found a policy and procedure was in place for handling complaints to ensure any complaint was responded to appropriately. The policy included time scales for responses and the contact details of relevant organisations such as the local authority should people wish to raise concerns directly to them.

We checked the complaints, comments and compliments record and found there had been no recent complaints about the service.