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Archived: White Lodge Rest Home

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Inspection report

Date of Inspection: 2 November 2012
Date of Publication: 27 November 2012
Inspection Report published 27 November 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 2 November 2012, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

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

At the previous inspection in November 2011 we found that there was no culture of monitoring the quality of service provision established within the home. There were insufficient systems in place to enable the quality of service provided to be regularly assessed and monitored. A compliance action was sent and the home sent us an action plan as to how there would become compliant.

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. At this inspection we found there was a system established to consult people about the quality of service received from the service. Questionnaires were completed by people annually. The manager told us of action taken regarding one person's comments but had found that other feedback had been positive. We saw that this was reflected in the returned questionnaires. People told us they felt able to talk to the staff and say what they wanted. Staff were encouraged to give feedback to the manager and they confirmed that they were able to do this in regular staff meetings, informal discussions and individual supervision sessions. We looked at outcomes from the resident’s meetings where items were discussed, one such item being the request for more outings in the home’s Mini Bus. One person informed us that they would like to go out in the Minibus more often which we had been informed by the manager was currently being investigated. There were some essential repairs that had been completed and the manager was looking at appointing a driver to the staff team. This meant that that the manager and head of care were developing a culture of reviewing and revising the service through feedback from people.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We were shown by the manager a recent falls’ survey that had been completed and was being shared with the community falls’ team to look for trends and patterns. This was an ongoing piece of work with additional health professionals. This meant that the manager took account of accidents in the home and would take appropriate action to inform any improvements that might be needed. Two improvements had been made in relation to adequate and appropriate floor covering to two people’s rooms to ensure that they could be cleaned properly and reduce the risk of some one falling. Also bath mats and toilet mats had been removed from all bathrooms and toilets to ensure people did not slip on them.

The provider took account of complaints and comments to improve the service. People told us they felt comfortable to talk to the Manager or other staff if they felt concerned about anything within the home. A complaints’ procedure was available in the entrance hall although no forms were available for people to use without asking for them. We were shown the complaints’ book and there was a copy of the most recent complaint which was from January 2012. We saw that there was a clear trail of correspondence concerning this complaint and how it was resolved. It was also documented if the person making the complaint was happy with the outcome.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. At the previous inspection we found that there were no formal systems in place to regularly review or audit the service provided. The manager had a system in place to audit and assess the quality of the service provided. One example was a recent audit of medication that had been conducted the previous day. The outcome of the audit showed that the MARs sheets did not record the person’s room number or consistently record people’s known allergies. When we viewed the MARs sheets we found that the staff had already taken action on these points and we found that records contained this information. They were able to demonstrate that action was taken to amend records or systems