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Inspection report

Date of Inspection: 10 July 2013
Date of Publication: 13 August 2013
Inspection Report published 13 August 2013 PDF | 91.05 KB

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 10 July 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and talked with commissioners of services.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

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

During the inspection visit we spoke with the manager and checked the quality assurance systems in place. We found that people who used the service, their representatives and staff were asked for their views about their care and treatment and these were acted upon.

We saw evidence that people were supported and encouraged to comment on the service and were involved in decision making. One individual had been supported to choose their own keyworker through discussion and showing them pictures of each staff member.

Records of residents meetings showed that people who used the service had the opportunity to discuss areas of the service such as meals, activities and outings. We saw records that showed the manager also held meetings with staff from all departments.

The service carried out a range of audits as part of their quality monitoring programme, with representatives from the provider carrying out an audit of the service. When shortfalls were identified action plans were agreed and put in place to address these.

Additional audits were also completed by the manager and house managers, including cleanliness and presentation of the building, care planning and medication.

We reviewed a selection of audit files and spoke with staff about how the provider carried out quality assurance. An audit was undertaken by the organisation and the result of this was published. A record of any actions undertaken to address any shortfalls or concerns was also available.

Details of accidents and incidents were audited and reported to the provider organisation. The provider organisation took account of complaints and comments to improve the service. We saw a record of informal complaints in the care record.

We saw records which showed that the manager closely monitored all incidents and use of physical interventions

in the service. All incidents were reviewed on a monthly basis, to support staff to identify any potential triggers and amend care plans, risk assessments and behavioural support plans accordingly.

Staff were asked for their views about care and treatment and they were acted on. We reviewed the minutes of three previous staff meetings and saw that, issues were fed back to staff, discussed, actions identified and acted upon. Staff told us they felt staff meetings were useful and that management arrangements were supportive.