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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 31 December 2013
Inspection Report published 31 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 10 December 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 people who use the service, talked with carers and / or family members, talked with staff and reviewed information sent to us by other authorities.

Our judgement

The provider had an effective system in place to monitor the quality of the service.

Reasons for our judgement

We found that arrangements were in place to ensure complaints could be made and that these were addressed. People and relatives we spoke with told us they knew how to complain. Minutes for meetings held with people and relatives showed that they were encouraged to complain and complaints that had been received were shared with all relatives. One person said, “The owners are always here so we can always tell them.” One relative explained that they once made a suggestion for some equipment to be labelled. They told us, “Two days later, everyone’s equipment was labelled.” We saw a complaints log which showed that complaints were dealt with promptly. Records showed that a number of compliments had been given to the home by people, relatives and professionals.

People, relatives and staff were asked for their views on the service. We looked at the results of recent questionnaires completed by people, relatives and staff, which were mostly positive. Some of the comments written were, ‘We had a positive experience’ and ‘After visiting many care homes in the area this was the best one, I felt, for dementia’. One staff member had raised some issues with the management team and we saw that this was addressed appropriately. We read minutes of meetings held with people and relatives, which showed various aspects of the home being discussed. One relative said, “We attend the meetings, they tell us about the changes they plan to make and then we have some time to raise any concerns.”

We found that regular checks and audits were carried out for different aspects of the home. The systems used identified shortfalls and areas where improvements could be made. We saw a book which was in place to show shortfalls that had been identified and the proposed action that should be taken. Staff had lead roles and certain designated time to work on this to make improvements, such as care plans. We saw that care plans were audited to highlight areas which needed changing or updating. One staff member said, “I would not improve anything here.” We saw that the home had taken a proactive approach in preparing for inspections in the way that they demonstrated whether they were compliant or not.

We saw that a summary was maintained for all incidents, which was also recorded in the staff communication book so that all staff were aware of this information. One staff member said, “We do it to find trends, which lets us see if it is out of the ordinary so we can take action.” Records showed that following incidents, all follow up action was recorded in detail. In some instances, support from other professionals was sought. We found that most incidents took place during the night, which staff were aware of. We looked at an electronic system that was used to record the number of times staff supported people. This showed that people had received support from staff throughout the night. We saw different equipment being used for people at risk of falling, which was linked to the call system. This meant that staff would be alerted if people tried to get out of bed, so they could support them in a timely manner.