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Princess Lodge Limited Requires improvement

All reports

Inspection report

Date of Inspection: 24 October 2013
Date of Publication: 4 December 2013
Inspection Report published 04 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)

Enforcement action taken

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 24 October 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 given to us by the provider. We talked with other authorities.

Our judgement

The provider had no effective system to regularly assess and monitor the quality of service that people receive.

The provider had no 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

When we asked people about their general views of the service provided their responses included comments such as, "Good," and, "Alright". One relative said, "The home is quite nice compared to others".

We asked for specific information during the visit relating to how the service assessed and monitored the support and care it provided to people. There was a considerable delay before some information was provided. Both provider and deputy manager could not access the information on the computer or were unable to find the information from the paper files. They told us this was because the information would have been held by the previous manager. The deputy manager confirmed that they had been in post since March 2013 and the provider reported they did regular visits but neither of them were aware of where the information was held.

The provider showed us the complaints policy, however there was no complaints information available in an accessible format for people. The provider was unable to show the system used for recording and reviewing complaints. We were not provided with details to show how each complaint received was investigated or that themes and trends from complaints could be identified. One relative told us, “I have made a complaint about my mum three months ago and nothing has been resolved yet, it’s difficult to access management here.” One person said, “They don’t listen”.

We saw no evidence of staff’s meetings, residents’ meetings or relatives’ meetings. All the staff we spoke with told us meetings for staff do not take place. All residents and their relatives we spoke with confirmed that meetings did not happen. There was no system in place to demonstrate that peoples' views were taken into account to inform and comment on how the service should be run.

All of the people using the service and their relatives confirmed to us that they did not have any surveys or questionnaires provided to them to give a feedback on how they felt the service was managed. We saw no evidence that any surveys for people who use the service and their relatives had been undertaken. One relative said, “My mum had been here three years but I have never been asked for feedback”. The deputy manager confirmed that there was no system in place to seek people’s views.

We saw that there was a system for recording accidents and incidents. We looked at the accident book and saw that an incident we had been aware of was not recorded. This meant that the system did not fully reflect all accidents and incidents that had occurred in the home so that themes and trends could be identified and acted on.

Records we saw indicated that the last medication audit was done on 18 June 2013 and, the last infection control audit was done in April 2013. The deputy manager stated that these audits should be done every three months. This meant that standards in medicine management and infection control were not being monitored regularly to provide some assurance that people received safe care.

The provider and deputy manager confirmed that no audits of staff files had been undertaken but they advised that had recently started the process of going through each file. The deputy manager confirmed no record keeping audits had been completed.

Prior to our inspection we had been made aware of a concern relating to the care and welfare of one person which had been investigated under safeguarding procedures. This meant that some staff did not take action to report concerns about vulnerable people.

The provider had not forwarded a statutory notification for the fall or allegation of abuse to CQC as required by the regulation. We saw that there was no overall system to record and track safeguarding referrals.

The absence of effective audits and checks showed that the systems in place for monitoring the standard of care provided by staff were not effective.