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Keychange Charity Rose Lawn Care Home Outstanding

All reports

Inspection report

Date of Inspection: 23, 27 May 2014
Date of Publication: 21 June 2014
Inspection Report published 21 June 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 23 May 2014 and 27 May 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 given to us by the provider.

Our judgement

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 home protected people who used the service and others who may be at risk, against the risks of inappropriate or unsafe care and treatment. We know this because there was an effective system in operation which was designed to enable the provider to regularly assess and monitor the quality of the services provided.

The home does not currently have a registered manger in post. We were told that the deputy manager was in day to day control at the home. The deputy manager was supported by the provider’s operations manager and a registered manager from one of the providers other homes. We saw the supporting manager was at the home on the second day of our visit. The deputy manager told us they felt very supported and could ring for advice at any time. This meant the provider had ensured the home was managed by a competent person with the relevant support in the absence of a registered manager.

Staff told us there was a positive atmosphere amongst the staff and confidence in the deputy manager. Comments included “X has done really well”, “X has made it 100% better”, “X has done a great job” and “We are working as a team”.

People living at the home told us they felt safe and would go to the deputy manager if they had any concerns. Comments included “I am very happy here, If I wasn’t I would speak with X, they would sort it out”.

At this inspection we found that communication between the staff had improved. The home had a handover folder where staff could document people’s information they felt relevant, an appointment diary and two communication books. We saw that the senior’s communication book passed on information regarding healthcare professional visits and medication changes. Staff told us “Communication is so much better,” and “Things are written down”.

We were told the provider’s operation manager visits the home monthly. The operations manager told us they visited regularly to ensure the home was running safely and to support the deputy manager. They would speak with staff and people living at the home, look at documentation and give feedback to the deputy manager. This was confirmed by the deputy manager and staff working at the home. The provider may find it useful to note there was no formal record of the operations manager’s visits. This meant the provider did not have an audit trail to demonstrate they were undertaking visits to monitor the home.

We saw records of a residents and relatives meeting held in February 2014. The records showed a good attendance of people living at the home and their representatives. People had been advised about the concerns raised by CQC and how the home were working to make the necessary changes. One person’s recorded comments were ‘it is good to hear all this, as she felt it was needed’. Other topics discussed included activities at the home, management arrangements and laundry. This showed that people were involved and the provider took note of reports prepared by the Commission.

We saw records of two staff meetings held in January 2014 and May 2014. The records showed there had been a good staff representation at both meetings. Staff had been informed of concerns raised by CQC and how they were working together to make the necessary changes. Topics discussed included management changes at the home, call bell audits, training, completing paperwork and staff sickness. Staff told us they found the staff meetings very good and were able to raise concerns. One person commented “we get to have our say and learn what is happening”.

The home identified, assessed and managed risks relating to the health and safety of people who used the service and others who may be at risk. Records showed the home completed a weekly health and safety audit. The audit looked at the environment, checked water temperatures, checked equipment and fire procedures. We found that maintenance concerns identified during the audit were recorded in the maintenance book to be actioned.

Where necessary the ho