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Inspection report

Date of Inspection: 5 October 2012
Date of Publication: 19 October 2012
Inspection Report published 19 October 2012 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 5 October 2012, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with stakeholders.

Our judgement

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

Reasons for our judgement

At our inspection on 22 August 2012 we found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. The maintenance audits did not always record action taken to rectify issues and the complaints policy was not on display in the home. The provider wrote to us and told us they had recorded actions taken to rectify identified risks to health and safety, and that the complaints policy was displayed around the home.

When we inspected the home on 5 October 2012 we saw that action had been taken to secure the cleaning materials in line with the provider's control of substances hazardous to health (COSSH) policy and this had been recorded in the health and safety audit. The provider had taken action to ensure the fire doors all closed and this was recorded on the fire safety audit. We saw that the environmental audit had identified some issues, for example with broken furniture and that action had been recorded to confirm that these issues were addressed. However the provider may find it useful to note that not all of the actions taken to address identified problems were documented.

At our inspection of 5 October 2012 we also saw that the provider's complaints policy was now displayed in three places within the home, including beside the visitors’ signing-in book at the entrance of the home. We saw that the provider had conducted surveys of both relatives and people using the service in September 2012. The provider had taken action to address some of the comments people had made: for example a relative had complained that their family member was not always sat upright to feed and this had been recorded in the care plan and the manager told this person's bed had been changed for a more suitable one. Most of the responses received back from people using the service or their family members were positive, and people said they had no concerns. This meant the provider had a system in place to receive feedback from people and took account of their concerns and comments to improve the service.