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Inspection report

Date of Inspection: 6 May 2014
Date of Publication: 26 June 2014
Inspection Report published 26 June 2014 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 6 May 2014, observed how people were being cared for and talked with carers and / or family members. We talked with staff, reviewed information sent to us by other authorities and talked with other authorities.

Our judgement

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

Reasons for our judgement

Relatives of people who used the service had been asked to complete an annual survey about the service provided which the provider analysed. We saw the results of a survey from autumn 2013 which was presented to relatives attending a meeting in February 2014. Analysis included both the important improvements from the previous survey and ‘things we could do better’. An action plan was available to address concerns and manage improvements. Some of these had already been implemented when we visited and others had target dates for implementation.

We saw that a quality and safety assessment commissioned by the local authority commissioning group had recently taken place. It had focussed on clinical effectiveness and people’s experiences and we saw that the report was a positive one. We saw another report from the commissioning group dated April 2014. It showed that the home had a significant decrease in NHS accident and emergency attendance in a five month period ending in March 2014, compared to the same period in the previous year. The manager told us that this had followed an 18 month period working closely with a specialist nurse, making changes to improve the quality of care.

During our visit we met with an independent quality assessor who had visited the home each month to help staff improve mealtimes for people. They told us that staff at the service had implemented suggestions for improvement.

Within each unit, there was a registered nurse manager. We met with one who told us of the regular audits and checks that they carried out within their own unit in order to assess the quality and safety of care for people. These included medication and nutrition audits, infection control, pressure ulcer and hospital admission incidence and overall documentation. They told us that the results were reviewed by and discussed with the general manager of the service periodically. We saw an action plan that had been implemented following an error in record keeping. All of this evidenced that the quality and safety of the service was regularly monitored and assessed.

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