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Princess Lodge Limited Requires improvement

All reports

Inspection report

Date of Inspection: 6 February 2014
Date of Publication: 12 March 2014
Inspection Report published 12 March 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 February 2014, 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 given to us by the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

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

We assessed this outcome area in our last inspection in October 2013 and we found non-compliance and judged it to have a major impact on people at that time and issued a warning notice. We followed this warning notice with another inspection in December 2013 and we found that some improvements had been made but the provider had not met all of the requirements of the warning notice. We issued another warning notice in December 2013. At this inspection we looked for evidence to see if the provider had met all of the requirements of the warning notice. We saw that the provider had made the required improvements to monitor the quality of the service provided.

At this inspection we found that a new manager had been in post since January this year. All of the staff and people spoken with were positive about the manager and how things had improved since the manager had been at the home. Most of the staff spoken told us that the manager spent time in areas around the home so they knew what was going on and had taken action to make improvements. One member of staff said, "We can approach the manager anytime about our views on how the home is run and our views are valued." All people, relatives and staff spoken with told us that it was very easy to raise any concerns with the manager and would act immediately. This meant that people were able to comment on the service they received so that improvements could be made..

We found that people, their relatives and staff were asked for their views about their care and treatment and they were acted on. We saw that meetings with people and their relatives were being held. Minutes of these meetings showed that people talked about the food, activities and any suggestions they had to improve the home. Some people spoken with confirmed that they were given feedback on what actions were taken as a result of comments made during these meetings. One relative told us, "We get questionnaires and have meetings so we are asked what we think. When I visit, the manager and staff have asked me for my views too." This meant that the views of people who used the service and their relatives were listened to and acted on.

We saw that the provider had system to record and review complaints. We saw that there was a complaints logbook which showed the nature of the complaint, the outcome and action taken. We saw that complaints made had been investigated appropriately and the issues resolved accordingly. The manager told us that they used complaints to learn lessons and improve the service. We found that information was made available to people explaining how they could complain using their complaints process. The staff we spoke with were able to explain what they would do if someone had a complaint. People and their relatives spoken with told us they knew how to make a complaint if they were unhappy with the service provided at the home. This meant that people were able to complain about the service they receive and there were processes in place to act on people's complaints.

We saw at this inspection that a system was in place for recording incidents/accidents. We saw that there was evidence that learning from incidents and investigations took place and appropriate changes were implemented. Records we sampled showed that when people had accidents these were recorded and the person was regularly monitored to ensure their safety. We saw that the accidents were analysed and looked at to see if they could be prevented in the future. This meant that the provider had a process to ensure incidents were recorded and any themes and trends would be monitored.

We found that the provider had systems in place to monitor the quality of the service they provide. We saw that a wide range of audits were completed to ensure that where needed improvements could be made. The audits we saw identified areas where the home had done well and where improvement was needed. We saw that action was taken to make improvements as a resu