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Archived: Bevan House

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Inspection report

Date of Inspection: 14 October 2011
Date of Publication: 14 November 2011
Inspection Report published 14 November 2011 PDF | 87.24 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 14/10/2011, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

We found that the registered provider had met the compliance action set at our last review of compliance however more could be done to improve the homes filing systems and to make them far more accessible.

User experience

On this occasion we did not speak to people about this outcome area.

Other evidence

At our last review of compliance we found that monthly quality audits were being carried out at the home however issues of concern were being dealt with by the management team and were not being reported to the proper authorities.

The improvement plan stated that the operations manager would complete the quality audit of the home and the acting manager would ensure any issues of concern was discussed with the management and effective decision was made in order that people who use the service receive safe quality care and support. The registered provider would action the internal audit and the acting manager would action the outcomes. Actions of previous audits were ongoing.

The operations manager showed us documentary evidence indicating that monthly audits were being carried out at the home. They were also monitoring the number of student hours worked. They told us that all issues of concern were being reported to the proper authorities. We suggested to the operations manager that they included a section in the audit report for issues reported to other agencies such as the Care Quality Commission or the Safeguarding team. They told us they were implementing a quality audit tool provided by the Safeguarding teams coordinator, this included care plan, medication and risk assessment audits.

The operation manager told us they had an electronic copy of the Care Quality Commission's Guidance about compliance, Essential standards of quality and safety, which sets out what providers should do to comply with the regulations of the Health and Social Care Act 2008. We advised the services management that a hard copy of this document should be available in the care home at all times for ease of referencing purposes.

At our last review of compliance we recorded that the operations manager and new acting manager found it difficult to locate all the records we requested during the visit. Both managers conceded that there was significant room to improve the services filing systems and to make them far more accessible.

During this visit the acting manager again found it difficult to locate some of the records and documents we requested. The advised the operations manager and the acting manager to consider reviewing the homes recording and filing arrangements as the current systems made it difficult to locate important information quickly.