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Inspection report

Date of Inspection: 7 November 2013
Date of Publication: 3 December 2013
Inspection Report published 03 December 2013 PDF | 78.05 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 carried out a visit on 7 November 2013, observed how people were being cared for, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff and reviewed information sent to us by commissioners of services.

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 to regularly assess and monitor the quality of service that people receive. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

The provider’s quality assurance system included regular checks by the manager and independent checks by the provider. The manager’s checks included monitoring and analysing complaints, accidents, events and activities. The manager took action to resolve issues. For example, the manager had organised for additional bank staff to be engaged for staff holidays and sickness cover.

The provider had organised a welfare committee that visited the home every month. Committee members checked various aspects of the service and talked with people who lived there, to make sure they were happy with their care and support. We saw that people were supported to complete questionnaires about the food, their personal care, staff, the home and the choices they were offered. People had said they were happy living at the home. People we spoke with told us, “It’s alright here” and “The food is good” and “I sleep well. It’s not noisy at night”. This meant that people who use the service were asked for their views about their care and support.

In the records we looked at, we saw the manager regularly checked that senior staff reviewed and updated people’s care plans. The manager’s checks included checks that medicines were administered and recorded appropriately and checks that staff responded promptly to call bells. The manager made unannounced checks on night time care. The manager analysed the results of their checks and took action to minimise the risk of a reoccurrence.

We saw that when the manager identified a pattern of falls for one person, they had asked other health professionals for advice. Staff followed the advice they were given, which reduced the frequency of falls for the person. This meant that decisions about care and support were made by the appropriate staff at the appropriate level.

The manager’s regular checks included checking that senior staff regularly reviewed people’s plans of care. In the care plans we looked at, we saw that senior staff reviewed and changed people’s care plans when the person’s needs changed. This made sure that people continued to receive the quality of care they needed.