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Turning Point - Avondale Good

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Inspection report

Date of Inspection: 31 July 2013
Date of Publication: 4 September 2013
Inspection Report published 04 September 2013 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 31 July 2013, 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 had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

There was a system to monitor the quality of the service people received. The manager showed us records of various monthly checks carried out such as health and safety, fire safety and water temperatures. In addition there were other annual checks such as ensuring testing of portable electrical appliances, checking the fire extinguishers and servicing of the boiler which she was responsible for organising.

We saw the quality assurance tool used by the service provider which involved an internal audit based on compliance with the majority of the Care Quality Commissions essential standards. Examples we saw included areas such as Infection control, record keeping and medication administration. This was spread over the year and was carried out by the manager. It was then reviewed by the providers own audit department each year and action plans had in the past been put in place. We noted these action plans were intended to enable greater involvement of people in choice of food, choice of day to day events and other important parts of their lives. The manager told us the quality assurance process helped her identify when there were problems and to put them right.

The service had developed a person centred risk assessment process. Risk assessments showed evidence of review, routinely and in response to identified changes in risk level. For example, when the people living in the home wanted to go on holiday a specific risk assessment had been undertaken to meet this need.

We were unable to talk in detail with the people who used the service about their views of the service because of their communication abilities. However we saw evidence that relatives and health professionals were given the opportunity to comment directly to the service provider through the person’s annual care reviews. The manager showed us the questionnaire she had created and was planning to use later this year, where she could formally ask families about their views on the home. She had created this as the provider only undertook a generic survey which could not be specific for the home.

Three relatives told us they attended annual reviews with staff and relevant healthcare professionals. They confirmed this enabled them all to discuss the care and treatment provided and how effective it had been. One relative told us they could speak to any of the staff anytime to give feedback, and offer suggestions about what could be done better.

The provider had a system to report and record accidents and incidents which occurred to the people or staff in the home. For example, we saw how concerns had been raised by staff over the need for one person’s wheelchair to be repaired by another provider.

Staff we spoke with understood the importance of making comments or expressing concerns on behalf of the people who lived in the house. They were also clear about the procedures for reporting incidents and changes in a person's needs. We saw that the monthly team meeting included an opportunity to feedback concerns and raise suggestions to improve the quality of the service.

There were systems to identify and manage risks to people's safety and welfare. We saw the team meeting records which showed that health and safety was discussed at team meetings. The manager told us that she did visual health and safety checks around the house and the staff also monitored health and safety on a daily basis. Any issues identified were recorded in the communication book and the manager made sure these issues were addressed.