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Inspection report

Date of Inspection: 19 February 2014
Date of Publication: 29 March 2014
Inspection Report published 29 March 2014 PDF | 79.26 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 19 February 2014, observed how people were being cared for and talked with carers and / or family members. 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 who use the service and others.

Reasons for our judgement

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We reviewed the results from the most recent families and service user questionnaires and saw that people's families had rated the majority of care given as "excellent" and "good", comments written had included "well looked after" and "there are lots of activities to keep her occupied". The service user questionnaire was available in an easy read format and people had been helped to complete these using facial expressions as the indicators for how they felt about the service, the majority of the responses were indicated with a smiley face which meant they were happy with the care they received.

We spoke with one relative who told us the staff communicated with them regularly and discussed the care provided, they told us they felt the care reflected in the care plans was what was given and they felt involved with reviewing and planning future care within the home.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. We spoke with the deputy manager who told us they were in the process of updating the care plans for people after a quality audit performed by the provider in October 2013. They told us the care plans were reviewed by a senior carer or the manager and deputy manager and that all decisions regarding the management of the home were discussed and communicated through the provider's operations manager.

We saw the results of the quality assessment that the provider had performed in October 2013, the provider had high-lighted some issues that required resolving including gaps in the care plans with monitoring of weight and records of other professionals visits and updating of available policies for safeguarding. We saw that the manager had taken steps to resolve these by acquiring updated policies and they had added new documents to the care plans to record people's weights and other professionals visits. We saw that the provider performed monthly audits of the service and the manager had actioned the areas identified.

There was some evidence that learning from incidents / investigations took place and appropriate changes were implemented. We reviewed the policy for the provider for managing incidents and accidents and saw that it detailed the responsibilities of the manager with investigating incidents, reporting forms were available for medication errors, accidents/incidents and witness statement and body maps were also available in support of this. The policy did not give any timescales for completing an incident investigation however the report form included a format for conducting an investigation and a severity rating for harm.

We saw that there was one incident recorded for 2013 and the provider might like to note that there was no investigation present with this incident, two report forms were also completed which gave differing outcomes with the severity scoring. We reviewed the care plan for this person and found that an ambulance had been called for this incident however this was not documented in the incident report.

We reviewed the training policy for the provider which stated regular appraisals and supervision should be completed however there were no timescales for how often this should be performed with staff. We reviewed the staff files for three people and reviewed the supervision and appraisal records, two of the files we reviewed had supervisions recorded every three months and had appraisal recorded for March and May 2013. One person's file showed they had last had supervision in August 2013 and there was no record of an appraisal. One record of supervision we reviewed had focused on a medication incident however we were unable to find any documentation to support this error in the incident file as is detailed in the provider's policy documents.

The provider took account of complaints and comments to impro