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Inspection report

Date of Inspection: 4 September 2013
Date of Publication: 18 October 2013
Inspection Report published 18 October 2013 PDF | 88.74 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 4 September 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 carers and / or family members and talked with staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

The provider was using a number of different measures to assess and monitor the quality of the service. We spoke with the registered manager who told us there were a number of audits in place to monitor the quality of the service provided. Examples of audits we looked at included; equipment checks, hoist and sling checks, care plans, falls, weight loss, food safety, health and safety, infection control and training. An action plan was in place for any identified shortfalls. This showed us that systems were in place to monitor the quality of the service and to make improvements. We saw that action had been taken in relation to some people who had recently lost weight. Referrals had been made to the dietician, weekly weights had been put in place with increased observation and support at mealtimes. The manager told us that a number of outstanding actions on the action plan had been addressed following this inspection.

Although there was an action plan in place in relation to staff training the provider may find it useful to note that although some staff had undertaken dementia awareness training. This meant that people may not receive care from staff who are skiled to effectively care for people with dementia.

The people who used the service and relatives spoken with on the day of this visit told us that they could talk with the manager, provider or staff at any time to express their views and opinions. One person said the manager was, 'very approachable' and had an, 'open door' policy and they felt able to express their opinions and suggestions freely.

We saw there was a complaints policy in place and this was displayed in the reception area of the home. This ensured people were made aware of how to raise any concerns or complaints they may have. Three staff we spoke with told us they knew what to do if a person approached them with a complaint. The three relatives we spoke with told us, "I would speak with the manager if I wanted to make a complaint. She is very approachable".

We were told there had been a relatives meeting since the last inspection. One person told us, “We have had an opportunity to share our views and talk with staff at the meetings. I am looking forward to next weeks meeting". A further residents meeting was planned within the following week and three people we spoke with were aware of this.

We saw minutes of a recent staff meeting which confirmed meetings were held. It was clear this was a two way process for staff to raise concerns and for the provider to raise any issues.

We saw that accidents and incidents were recorded and reported and where possible action was taken to prevent a recurrence. For one person a pressure mat had recently been put in place so that staff could be alerted when they attempted to get out of bed during the night. This showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

We were shown that new policies and procedures had been introduced to the staff to help protect the health and safety of those who used the service and were employed by the service.

It was evident from equipment in the home that servicing took place on this. We saw servicing of fire safety equipment, hoists and electrical equipment. As raised at the last inspection the five year electrical certificate was not available. The manager told us there were plans to rearrange the electrical wiring test as the certificate could not be located. We have requested that a copy is sent to CQC following this inspection.