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Inspection report

Date of Inspection: 20 May 2014
Date of Publication: 24 June 2014
Inspection Report published 24 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)

Not met 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 20 May 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by other authorities.

Our judgement

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

We asked how the quality of the service was measured and acted upon. Staff showed us a box for written comments and complaints about the service at the home’s entrance, but said that it was not generally used. There were no written comments or complaints evident at the time of our visit, and staff and managers we spoke with could not recall when they were last received. We asked to see the comments or complaints record and this was not available, but we were told there were no unresolved complaints. One person acting on another person's behalf told us they had discussed their concerns about oral hygiene with the manager but the matter was not yet resolved. Another person acting on someone's behalf said they had discussed concerns with the manager and these had been listened to and acted upon.

Staff told us they would raise any concerns with the manager, but had not had recent cause to do so.

People who used the service, their representatives and staff were not asked for their views about their care and treatment and they were not acted on. None of the staff or people we spoke to could recall being asked for their views about the quality of the service. Managers confirmed that there were no formal systems in place to obtain regular feedback and there were no current arrangements for group meetings or surveys. One person, acting on another's behalf, told us “management don’t like criticism.”

We were told by the provider that the most recent survey seeking people's views was carried out in 2012. We saw the results of the 2012 survey reported in the home's current brochure, and that it stated an intention to develop and improve social activities. Staff told us that there were fewer activities now than in the past and that there was no identified activities co-ordinator. Staff could not provide us with any examples of changes made as a result of previous feedback about the service. This meant that a proactive approach to seeking feedback about the service was not in place and that feedback had not been acted upon.

We asked what external professional and expert advice was sought in relation to assessing and managing risks to people who used the service. We were told that there were no formal arrangements to ensure this happened. We saw that up to date national guidance and expert advice was not referred to in the policies we looked at. However,

managers told us there was some work in progress with external agencies to review the service. We saw a report that demonstrated that in May 2014 the service was assessed by two officers from Enfield Council as part of their contract monitoring process. The Council had asked for four action points to be followed up and had made seven recommendations to improve the service. The Council had agreed timelines for action and there was evidence that while some work was in place towards implementing the recommendations these were not yet complete. Managers also showed us a report of an external health and safety audit conducted in March 2014 with a number of outstanding action points.

The Registered Manager showed us a range of standard operating procedures and policies to provide instructions for staff to follow, however, we saw areas where they were not being followed relating to infection prevention and control, staff training and supervision, and safeguarding.We asked to see evidence of any monitoring of the policies in practice, review, and amendments made to policies. None was available. The Registered Manager told us there was no system in place to ensure this happened, but that the policies were last reviewed in January 2013, and we saw the revised date recorded on the policies. Staff and managers we spoke with were not able to give us any specific examples of policy changes that had been introduced at that time. This could mean that their practice was not always taking account of up to date information, and that there were ineffective systems in place to identify, assess and