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Archived: Dean Wood Manor

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Inspection report

Date of Inspection: 12 August 2014
Date of Publication: 5 September 2014
Inspection Report published 05 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 12 August 2014, 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, talked with staff and reviewed information sent to us by commissioners of services. We talked with commissioners of services.

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 home had a manager in place who was currently in the process of registering with the Care Quality Commission.

We looked at the accident and incident log which was completed appropriately. Monthly audits of accidents and incidents were carried out, trends monitored, actions recorded, followed up and completed.

The complaints policy was up to date and available via posters on the wall and within the welcome pack given to people who used the service and their relatives. Complaints and compliments were appropriately recorded and followed up.

We looked at documentation of audits and checks which took place on a regular basis within the home. We saw evidence of monthly medication audits, hand hygiene audits, kitchen audits and a number of health and safety checks. All included identification of any shortfalls and actions to be completed. Fire drills were undertaken on a three monthly basis.

We saw a monthly management audit and quality monitoring report which included areas such as environment, care records, infections, pressure sores, health and safety, staffing, training complaints, accidents and safeguarding concerns. We were shown a home development plan produced by higher management to ensure any shortfalls identified were appropriately addressed. The plan included target dates. We saw evidence that issues identified had been addressed within the home to help facilitate continual improvement in service delivery.

There were regular relatives’ meetings which provided a forum for relatives to voice any concerns or put forward suggestions. We saw minutes of some recent meetings where a range of topics had been discussed.

We saw evidence of a recent relatives’ satisfaction questionnaire undertaken at the home. This included areas such as physical environment, health and well-being and daily life. Comments were welcomed and there was a section for relatives’ suggestions and complaints. Some people had indicated they were unaware of the complaints policy and we noted this was to be discussed at the next relatives’ meeting. Other comments included, “The staff are warm, friendly and approachable. They all work very hard and it is much appreciated”, and, “All staff seem very dedicated and caring people”. One comment mentioned a concern that had been raised which had been satisfactorily rectified in a timely manner.