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Inspection report

Date of Inspection: 9, 15 January 2014
Date of Publication: 11 February 2014
Inspection Report published 11 February 2014 PDF | 85.59 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 9 January 2014 and 15 January 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and 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. The systems in processes in place were robust and effective at all organisational levels.

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. Feedback was routinely sought from people who used the service and / or their close family members. This was reviewed by the service before being submitted to the provider’s quality team. Results for each of the provider’s services were published in the provider’s annual quality account which we reviewed. The registered manager told us about their plans to form a user group. We saw that this had been discussed at the service’s quality improvement group which met monthly.

We spoke with six people who used the service and some of their family members who all told us that the service was well run. They had no suggestions for improvements but told us about the ways the staff team worked which had made a “big difference” to them. Comments included: “It’s been wonderful, I feel like I’ve been one of the lucky ones.” and “They are very very special people who work here. The respect even in terms of the most menial tasks is lovely”.

The provider took account of complaints and comments to improve the service. A comments box had recently been located in the reception area. This meant that anyone who visited the service was able to give immediate feedback. The provider’s quality agenda for 2013/14 included revision of their complaints policy and improving information and accessibility to enable people to complain or express their concerns more readily. The management of complaints and concerns had been identified as a priority area by the provider for 2013/14 for all its services. This was in response to recommendations made in the Francis report 2013.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We viewed some examples of how incidents had been managed and the processes staff followed were explained to us. We found that these were robust and included use of decision-making tools and analysis tools when indicated. We saw that trends had been identified and appropriate action had been taken by managers in response to these. Staff told us that when they had been involved with a clinical incident they had been given the opportunity to reflect on what had happened and to identify where improvements could be made. Learning was shared within the service and with the provider’s other services, through the provider’s quality team.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. Staff told us that team meetings were held regularly and they were able to raise any issues or suggestions for improvement. They told us that they felt able to approach all members of the senior management team. Staff were confident that any issues they raised would be dealt with in confidence and would be resolved. They told us they felt supported and listened to. The organisational structure was clear and people’s areas of responsibility were understood by staff.

We saw that outcomes of the provider’s audit programme were reported to the provider's Board of Directors. Where audits had identified that improvements were needed, these were included in the service’s quality improvement plan. We found that the systems in place at Sue Ryder - Leckhampton were effective. When we identified areas for improvement and discussed these with senior staff they showed us evidence of the actions they had already planned to address these areas.

The Trustees’ Report and Accounts 2013/14 included progress against priority areas for the previous year and set out current priority areas. Analysis and breakdown of incidents, including incidence of acquired infections, falls, pressure sores and complaints, for each of the provider's services, were published in the provider’s quality account. This meant that the provider had good oversight of how well each service was performing and openly published these outcomes.