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Inspection report

Date of Inspection: 15 May 2014
Date of Publication: 11 June 2014
Inspection Report published 11 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)

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 15 May 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

We saw that regular audits were completed to monitor the quality of the service provided. These audits covered areas such as the environment, infection control and medication management. We saw appropriate action plans were devised if any concerns had been identified which meant that the provider was constantly monitoring, reviewing and improving quality.

There was evidence that learning from incidents took place and appropriate changes were implemented. We saw that incidents and accidents were recorded appropriately and changes were made to peoples care and treatment in response to incidents. We saw where people had fallen, the registered manager had contacted the Falls Prevention Team to review the support provided and reduce the risk of further falls and risk of harm. This meant the provider responded to changes in individual needs and the service provided.

We saw that health and safety checks were in place to protect the people who used the service or who visited or worked at the service. These included regular fire alarm and emergency lighting checks. This meant the systems were checked to ensure there were suitable emergency procedures in place.

There was a system in place to gain feedback from people who used the service. We saw that each month a topic was chosen and the registered manager consulted with people who used the service, visitors or professionals on that topic. We saw recently this had included gaining people’s views on the home and the environment. We found as a result of this survey, additional garden furniture had been purchased and a summer house was to be installed in the garden. This meant people’s views were acted upon. The registered manager told us where any concern was raised they would ensure improvements were made to the service provided.