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Archived: Kingsmead Lodge

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Inspection report

Date of Inspection: 4 August 2014
Date of Publication: 4 September 2014
Inspection Report published 04 September 2014 PDF | 89.46 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 August 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

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 using the service and others.

Reasons for our judgement

The provider had systems in place to assess and monitor the quality of the service. The team leader told us that both they and senior staff carried out frequent observations of staff performance in areas such as their moving and handling skills and when improvement was needed the matter was addressed immediately or at supervision. A member of staff confirmed that senior staff checked that they were doing everything to the required standard and advised them on how to improve if necessary. The manager told us that the daily notes of care staff were checked at each handover and a random selection of care records and medication charts were audited each month. In addition the pharmacist supplying the medicines to the home undertook annual audits to ensure that medicines were managed safely. We looked at the feedback from the last audit in April 2014 and noted that action had been taken for example in how the dose of ‘when required’ medicines was recorded.

Provider compliance assessments were carried out each month by the area manager. We looked at two recent assessments and saw that they included checks on care plans, risk assessments and service user involvement. We saw that any issues identified were included in an action plan and were monitored to ensure that they were addressed within the specified timeline. In addition the provider’s quality lead carried out an annual internal audit against the regulations. We looked at the last one completed in May 2013 and saw that action had been taken to address the recommendations for improvement. For example we noted that ‘service user’ meetings were now held on a regular basis and minutes were kept.

We saw that all electrical equipment was tested annually and regular safety checks were performed and recorded by the health and safety representative. These included monthly emergency lighting checks, fire extinguisher checks and weekly tests of the fire alarms. These checks helped to ensure the safety of people using the service.

People and their relatives were made aware of the complaints system. We saw that it was included in the Statement of Purpose available to all and information about the complaints procedure was also clearly detailed in an easy read format on notice boards and doors about the home. People we spoke with and their representatives told us they would talk to their keyworker or the manager if they had any concerns and were confident they would be listened to and the issue dealt with quickly and to their satisfaction. Records showed that there had been two complaints since our last inspection in June 2013. We looked at one from a relative about communication and saw that it had been dealt with in line with the provider’s policy. We noted that a communication diary had been introduced and additional training undertaken and the person concerned had been satisfied with the outcome. This meant that the provider took account of comments and complaints to improve the service.

There was an accident/incident reporting system in place and staff we spoke with were aware of the reporting procedure. We were told that staff recorded any event or incident and the manager was responsible for ensuring the necessary action was taken and the appropriate people were informed. The area manager told us that all incidents were discussed at the provider’s monthly policy group meeting and any identified trends or patterns of behaviour were addressed and appropriate changes introduced. We looked at one incident which had been fully investigated and saw evidence that the provider had learnt from it and had implemented the appropriate changes.

People who use the service, their representatives and staff were asked for their views about the quality of the service provided. The manager told us that the provider sent out quality assurance questionnaires to a random selection of relatives every two months and gave written feedback to them on the outcome and any actions taken. We did not have