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Inspection report

Date of Inspection: 27 September 2012
Date of Publication: 22 October 2012
Inspection Report published 22 October 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 was compliant with this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive.

User experience

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

Some people living at Chater Lodge had cognitive and communication difficulties. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We also spoke with two people who used the service and a visiting relative.

People told us that they had been asked for their feedback about the quality of the service provided.

Other evidence

We spoke with the acting manager and looked at quality assurance audits.

A senior manager visited the service on a monthly basis and looked at the quality of service provision. This included speaking with people who used the service and asking for their feedback.

The acting manager used quality audit tools to assess different aspects of service provision such as care plans, staff training and accidents and incidents. This information was then sent to senior manager for analyses.

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

We saw evidence that appropriate action had been taken in response to accidents/ incidents and information of concern.

Regular relatives meeting were held so that people who used the service could provide feedback about the quality of service provision.

During our visit we saw that the senior management team spent time with people who used the service. The acting manager and another manager form Barchester had their lunch in the dining room with people who used the service. Staff on duty also had lunch with people who used the service each day. This provided another forum for discussion and for obtaining feedback about the experiences of people who used the service.

The providers sent out satisfaction questionnaires to people who used the service and to staff.