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Inspection report

Date of Inspection: 8 September 2014
Date of Publication: 11 October 2014
Inspection Report published 11 October 2014 PDF | 80.62 KB

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 8 September 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and talked with commissioners of services.

We reviewed all the information we have gathered about Voyage 1 Limited - 3 Edith Road (Tregona) and spoke with the registered manager and the provider's local operations manager.

Our judgement

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

Reasons for our judgement

People who use the service, their representatives and staff were asked for their views about their care and support and they were acted on. The provider had recently carried out an annual survey of people living at the home, their relatives, care managers and staff. The provider had produced a report of the responses in August 2014 and an action plan had been developed to address any areas identified for improvement. We saw the improvements identified on the action plan were underway. The manager expected the actions to be completed by the target date of November 2014.

All people living at the home met with their key worker each month. We saw records of those meetings and details of the topics covered. They showed that people were being included in discussions on how things were going and were involved in planning for the following month.

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. We looked at a selection of audits and monitoring records. For example, health and safety risk assessments of the premises and the home's fire risk assessment. All records were up to date and any issues identified were being addressed.

There was evidence that learning from incidents or investigations took place and appropriate changes were implemented. For example, following an incident, the home had obtained a specialised piece of equipment that would enable staff to assist someone up from the floor if needed.

The manager was required to complete a quarterly audit form. The audit form was designed to cover each of the government's essential standards. Once the audit form was completed the manager identified actions needed for areas which were not fully compliant. The manager then had to ensure the actions were taken and the areas were re-assessed in the following quarter. We saw the actions for the current quarter had been identified and were underway. As part of the system the area operations director visited monthly to carry out their own audit and talk with the people living at the home. This meant the home had an effective system to regularly assess and monitor the quality of service that people received against the requirements of the essential standards.

The relative we spoke with confirmed they were asked their opinion on the service provided by the home. They were aware of how to complain although they commented they felt there was nothing to complain about. They were complimentary regarding the care provided to their family member and commented that their relative always seemed happy.