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Inspection report

Date of Inspection: 18 October 2013
Date of Publication: 3 December 2013
Inspection Report published 03 December 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 18 October 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 staff and reviewed information given to us by the provider.

Our judgement

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

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.

Reasons for our judgement

Due to their needs, the people using this service did not have the capacity to share their views regarding their care. We gathered evidence of people’s experiences of the service by reviewing care records, surveys, audit reports for the home and speaking to members of staff.

We saw that people using the service, their relatives, the staff and other professionals were given satisfaction surveys once a year. The most recent questionnaires were completed in June 2013 and people who responded gave positive feedback. We saw that dialogue with parents and representatives was actively encouraged and they were asked for their views about Hylton House. People’s families were involved in social events such as parties and birthday celebrations. The provider had sent out a newsletter in July 2013 which gave relatives and representatives information about activities people had taken part in, individual achievements, staff updates and plans for the future.

There were a range of quality checks in place to ensure that people were safe and appropriate care was being provided. Staff had designated responsibilities to help audit and monitor service provision. These routine checks were undertaken weekly or monthly and looked at areas such as the environment, food safety, care plans, medication and fire safety.

The provider took account of complaints and comments to improve the service. Following our last inspection in February 2013, we made some suggested improvements for the provider to consider. We saw that the manager had implemented an action plan to address these recommendations. Examples included arranging for refresher training for staff on infection control, issuing staff with surveys and reviewing people’s person centred care plans.

We saw that monthly unannounced visits were being undertaken by the registered provider. These reports always considered the experiences and outcomes for people using the service as well as any actions taken to improve where needed.

This demonstrated that the service was taking steps to monitor the quality of care and make improvements where required.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. The service kept appropriate records of all accidents and incidents and these were regularly audited by the manager. As required by law, our records showed that the service had kept us promptly informed of any reportable events.