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Inspection report

Date of Inspection: 21 January 2011
Date of Publication: 25 May 2011
Inspection Report published 25 May 2011 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

Our judgement

People who use the service benefited from some quality monitoring systems but risks to their health, welfare and safety were not being consistently managed. The service was not making full use of satisfaction questionnaires. There was no annual development plan or business plan that set out the service’s objectives.

User experience

The close friend of a person who uses the service told us that the acting manager responds well to any concerns raised with her and will communicate any concerns the service has about the person to this friend.

Other evidence

There was evidence on one person’s file, as shown in Outcome 7 of this report, of a lack of explicit guidance for staff managing risks. There were fire risk assessments on some people’s files but not on one file we examined. There was evidence of monthly recorded water temperatures, fire safety and health & safety checks on people’s files.

There was no Annual Development Plan or Business Plan in place. Satisfaction questionnaires were last sent to the people using the service and their relatives in August 2010 but records to support this were unavailable at this visit. Other stakeholder groups had not been sent a satisfaction questionnaire.

Approximately five residents meetings were held in 2010. Minutes of these were seen but showed poor recording practices: not all were dated with the year; not all had a record of the people present; it was not always clear who was staff and who were the people living in the home; and there was no record of any action taken to address concerns expressed - for example one person referred to “bland meals”.