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Archived: The Paceys

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Inspection report

Date of Inspection: 9 June 2011
Date of Publication: 1 July 2011
Inspection Report published 1 July 2011 PDF | 108.79 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 reviewed all the information we hold about this provider, carried out a visit on 09/06/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

The provider has systems and procedures in place for monitoring the quality and safety of the service they provide.

User experience

We have not spoken directly to people who use services in assessing this outcome.

There is a very strong commitment to quality assurance, monitoring and making improvements within the service. The provider uses a variety of ways of seeking the views of the people who use the service and tries to include everyone, no matter what their communication difficulties may be. As previously mentioned in this report they include questionnaires and surveys, a guests communication book and feedback slips after each stay.

Other evidence

In the provider compliance assessment (PCA), the provider assessed itself as compliant or almost compliant in all aspects of this outcome area. They said they want to make some improvements to the way the outcome of audits is fed back to people who use the service.

In the PCA the provider told us they had systems in place to make sure they monitor the standard of the service provided. They said they complete monthly reports on staffing, health and safety, quality standards, business plans and any positive and negatives that happen within the service in that month.

They also said they receive feedback from people who use the service each month through a ‘guest’s communication book’ and a document completed after each stay at the service.

They said they also meet regularly with people who use the service through a number of meetings. These include the ‘guest council’ and a self advocacy group within the organisation.

Other information also provided good and clear evidence of how they are compliant with this outcome. They said, ‘Quality questionnaires, are circulated at annually to establish peoples views on how we conduct our work, as a organisation, our communication paths Trust wide and our Service Delivery to the people we support. This information is captured and used to improve our service delivery. ‘My Stay’ feedback forms are sent along with post short break reports to give guest and their families the opportunity to feed back about the service. These are collected and reviewed and any actions are taken and fed back to guests and their families.

Information in the PCA also told us that the provider has systems in place to analyse accidents and incidents. And that there are systems in place to assess and manage risk. This includes monthly checks and audits.