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Beverley Grange Nursing Home Good

All reports

Inspection report

Date of Inspection: 19 November 2013
Date of Publication: 24 December 2013
Inspection Report published 24 December 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)

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 19 November 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, talked with commissioners of services and talked with local groups of people in the community or voluntary sector.

Our judgement

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

Reasons for our judgement

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on.

We undertook this inspection to follow up on previous areas of concern. At the last visit we found that audits were not fully completed and maintenance records were not in place.

At this visit the manager informed us that quality assurance questionnaires had recently been sent to people who lived in the home and to visitors; they were awaiting the return of these. One person who lived in the home told us they had received one of these questionnaires. This helped people comment on the standards within the home.

Audits had been commenced by the manager of different systems in the home and this included administration, training, health and safety and the kitchen; there was an action plan from previous audits. This helped ensure that systems were checked to ensure that they were to the required standard.

We saw that records were kept of the maintenance of systems in the home. Regular maintenance helps to ensure that people live in a homely and safe environment. Records included a five year electrical wiring certificate which recorded the safety of the electrical systems in the home and also a gas safety document. The provider confirmed that all recommendations from previous inspections of the gas system had been completed. Checks of the fire safety systems had been undertaken and these included the emergency lights and fire extinguishers. Maintenance checks had also been completed on hoists used in the home.

Records were kept of accidents in the home. The provider may wish to note that not all of these recorded that the manager had reviewed the accident or if any additional follow up action was required.

We saw there were risk assessments to help keep people safe; these were in relation to the environment and some of the equipment in the home. A Legionella risk assessment was in place and recent testing had taken place; the manager forwarded the outcome of this to the CQC. Risk assessments in relation to the use of bed rails were not place and the manager confirmed this was due to all bed rails being integral to the bed.

Records were also kept of any complaints made to the home including the actions taken and responses made.