You are here

All reports

Inspection report

Date of Inspection: 11, 12 September 2013
Date of Publication: 4 October 2013
Inspection Report published 04 October 2013 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 11 September 2013 and 12 September 2013, 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 staff, reviewed information sent to us by commissioners of services and talked with commissioners of services. We talked with other authorities.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

People who used the service and their representatives were asked for their views about their care and treatment and they were acted on. We saw that the provider encouraged family members and visiting professionals to make comments on the service provided. Relatives we spoke with told us that they were asked for their views on the service during review meetings they attended. They told us that that didn’t have any concerns about the service but if they did they would speak to the home manager.

People using the service were given the opportunity to make comments about the service during a monthly meeting with their key worker. We saw that comments received were positive and where suggestions were made by people these were acted on. For example, one person suggested that they would like to have a new exercise bike and this was arranged. The provider may find it useful to note that there was no formal process in place to gather feedback from relatives on a regular basis. If people did not visit the service they would not have the opportunity to comment on the service provided.

We saw that there were a range of audits and checks which senior staff carried out at the service. These included medication audits, health and safety checks, audits on personnel files, support plan audits, food hygiene checks and checks that people’s health needs had been attended to. We saw that where shortfalls were identified in practices actions were taken. For example, we saw that the registered manager signed monthly key worker reviews and actioned issues raised in these reviews. The home was visited regularly by the provider and the quality of the service provided was checked during these visits. The provider also told us that they spoke with people using the service during these visits.

We viewed the maintenance records for the home. This showed that maintenance issues identified by staff were reported and repaired in a timely fashion. Fire records for the home were up to date and recorded regular testing of the fire alarm system, fire equipment, emergency lighting, automatic door closures and fire evacuation drills.

We saw that a staff training matrix was maintained which ensured that staff training was being monitored and was up to date. Dates that staff were due to have their training updated were highlighted on the matrix and we saw that arrangements were put in place to renew the training before it expired. This meant that the provider had an effective system in place to monitor staff training.

There was evidence that learning from incidents and accidents took place and appropriate changes were implemented. We reviewed the incident and accident forms for the home and saw that these were signed off by the registered manger. When signing off forms the manager recorded any actions that needed to be taken to reduce the likelihood of incidents occurring again.