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Archived: College Green Rest Home Good

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Inspection report

Date of Inspection: 18 June 2014
Date of Publication: 24 July 2014
Inspection Report published 24 July 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 carried out a visit on 18 June 2014, observed how people were being cared for, talked with people who use the service and talked with carers and / or family members. We talked with staff and reviewed information given to us by the provider.

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 evidence of internal audits that had been completed by the provider. Individual care plans were reviewed every other month or earlier if necessary. Medication was checked on a monthly basis which helped ensure people who used services had received the correct type, and amount of medication. We saw a kitchen audit had been completed in April 2014. We also saw the results from several external audits. Liverpool Community Health had recently completed an infection control audit and awarded an overall 85% positive rating. The provider addressed the shortfalls that had been raised and when the audit was repeated, a 95% rating was received. The last pharmacy audit was in April 2013 but the provider told us, "That`s because we have changed pharmacists and we are now waiting for an audit."

A complaints procedure was in place at College Green Rest Home and there was a copy within the information booklet that people received when they were admitted to the rest home. The provider told us, "I have an open-door policy here and people can just come in and talk about any problems they may have." We saw that any accidents or incidents were logged appropriately and were checked yearly and discussed with staff members which was aimed at learning from the incidents and improving the quality of service. We spoke with people who used services and a family member who told us, "If I have a problem I know I can talk to one of the staff when I come in to visit."

We asked the provider about surveys for people who used services and were told, "We have tried numerous times. The last one we sent out we included a stamped addressed envelope, and we got just one reply." We spoke with a staff member who told us they have meetings every six months. During these meetings, discussions had taken place relating to updating care plans, which we observed, and the introduction of a keyworker system which was being implemented over the coming months. We were told it was a work in progress because, "A few things were still to be sorted out."

Emergency procedures were in place at the rest home. We spoke to several staff members and they all were aware of their roles and responsibilities in the event of any emergency. Fire alarm checks were carried out on a weekly basis. We noted a whistle-blowing policy was in place and the provider told us, "All staff would report any form of abuse. I know they would not hesitate."