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Inspection report

Date of Inspection: 22 May 2012
Date of Publication: 21 June 2012
Inspection Report published 21 June 2012 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

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

The provider was meeting this standard.

User experience

People who use the service, their representatives and staff were asked for their views about care and treatment and they were acted on.

We spoke to people who confirmed that they were consulted and involved in decisions about their care. We were told about a recent decision to restart residents meetings and how these meetings would be chaired by a person who lived at the home.

The home had a monthly newsletter with contributions from residents and staff which contained a wealth of information about social activities, entertainment, church services, cookery and information about future plans.

The deputy manager described how the provider sent a questionnaire to residents and relatives to seek feedback on their satisfaction with the service but there were no recent survey results available at the time of our visit.

Staff and unit managers we spoke to told us about the range of ways in which they sought feedback from people who live at the home in their day to day work and addressed any issues raised.

Other evidence

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

The deputy manager described how they regularly monitored people’s care records and gave feedback to each unit about areas for improvement. We saw some of this feedback on the assessment documentation for a person recently admitted which included constructive feedback and additional suggestions.

A monitoring visit was carried out monthly by representatives of the provider and a report written and shared with CQC. These visits included speaking to staff and residents about the home. The reports received detailed findings and actions taken as a result which demonstrated robust internal monitoring by the provider. We were told about other occasional visits to the home on behalf of the provider by nurse specialists.

We looked at a database which showed a range of audits undertaken to monitor quality across all areas of the home. These included monthly audits of pressure area care, monitoring of accidents/incident including falls and a range of other regular audits such as medicines management and infection control. This showed that the home had systems in place to monitor quality to highlight and take action on any concerns.

The home had cleaning schedules and regular spot checks of cleanliness were carried out. We heard how the manager did a regular walkabout throughout all areas of home to monitor that quality standards were being maintained. We met with the support services manager who showed us their system for maintenance of all areas of the home. This included servicing schedules for equipment, fire safety arrangements, environmental risks assessments and water testing. We saw that contingency arrangement were in place to manage any disruptions to major services such as electricity and gas supplies.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented.

We looked at some completed accident/incident forms. We saw how each incident was analysed and any learning identified to reduce the risk of recurrence. Any trends in relation to individuals or areas of the home were quickly identified and preventative action taken. We were told by the registered manager how all accidents/incidents were reported within the company to ensure any wider training, safety or policy issues were addressed.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

The service showed us the systems in place to manage risks in relation to the premises. We saw written environmental risk assessments were completed for each area of the building, which were regularly updated. We saw records which showed regular fire equipment safety checks, daily and weekly checks and regular fire drills were undertaken. We saw records which showed regular maintenance and servicing of equipment was carried out.

The home used well known tools to identify, prevent manage and monitor risks related to pressure area care, nutrition and falls. Each person had individual risk assessments completed to identify any risks associated with their care and treatment which identified measures to reduce those risks to a minimum.