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Inspection report

Date of Inspection: 27 April 2011
Date of Publication: 28 June 2011
Inspection Report published 28 June 2011 PDF | 110.55 KB

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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

We reviewed all the information we hold about this provider, carried out a visit on 27/04/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

People had not benefited from safe quality care, treatment and support, due to effective decision making and people and staff had not benefited from the management of risks to their health, welfare and safety, because although there was a quality assurance system, which gathered information, it had not been used effectively to monitor the service provision or to analyse the information to identify non-compliance.

User experience

We had not spoken directly to people who used services in assessing this outcome.

Other evidence

In April the provider submitted a PCA document to the CQC which described how the home was compliant with the outcome and all of the elements that formed the outcome. The PCA was in the provider's own format and it stated that the home had been compliant. It said that audits and surveys had been carried out and that the system annually collated information to determine shortfalls. It was also annually appraised.

We viewed the information held on quality assurance and saw some of the surveys and audits completed. We did not see a recent appraisal or collation of information as we were told these still needed writing up.

We decided the quality assurance system had not been used entirely effectively or that it did not cover management issues as it had not highlighted the outcomes that had not been complied with such as recruitment, staffing levels and staff training. The quality assurance system had not been developed to include or assess all areas of the service performance.

In discussion with staff they said they had not been part of the auditing or quality assessing process and did not know what it entailed, though they said they had been asked to improve in areas where it identified shortfalls, but they could not be specific about this.