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Inspection report

Date of Inspection: 5 August 2014
Date of Publication: 9 September 2014
Inspection Report published 09 September 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 5 August 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

The provider did not have 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. This meant that the provider did not comply with regulation 10 (2) (c) (i) that requires the provider to protect service users who may be at risk through the analysis of incidents that resulted in, or had the potential to result in harm to a service user.

Reasons for our judgement

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. The registered manager (RM) had completed a survey since the last inspection to obtain the views of people using the service. The RM explained relatives had been involved to help and support people to obtain their views. We saw the completed questionnaires and comments which indicated a good level of satisfaction and suggestions had been made to improve the service. We enquired whether any changes or improvements had been made in response to the survey. The RM explained some people using the service had requested electronic beds to allow them to be more independent and that two of these beds had recently been purchased. Other changes included changes and additions to the menu choices.

We spoke with the RM and three members of staff to understand how they responded to incidents. Staff we spoke with were able to discuss what actions were required if an incident occurred and these reflected the providers local incident reporting policy which included completing an incident form and notifying the person in charge. We noted staff received annual training in health and safety management. We were able to see that incident forms had been completed and there had been no serious incidents reported in the past year.

The provider may wish to note that the documentation did not include information about what actions had been taken in response to these incidents and there was no evidence of learning from incidents / investigations took place and appropriate changes were implemented. We spoke with the RM about how the information from the incident reports was used. The RM confirmed that at present there was no trend analysis of data or systems in place to lean from incidents to improve the quality of care or evidence they had introduced preventative actions to minimise the risk of reoccurrence of incidents.

We noted some areas had recently been refurbished and there were systems in place to ensure the environment was safe for both staff and people using the service. Examples of this were infection control audits to ensure hand washing facilities and supplies were adequate in all areas of the home.

The provider took account of complaints and comments to improve the service. We saw there was information available to people and their families about how to raise a concern or make a complaint. The complaints file was empty. The RM advised there had not been any formal complaints. We spoke with people’s relatives who told us they felt the care and facilities were of a good standard and they had not had a need to complain. Staff we spoke with were aware of their responsibilities regarding handling people’s concerns.