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Inspection report

Date of Inspection: 10 April 2014
Date of Publication: 9 May 2014

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 April 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 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.

Reasons for our judgement

People who use the service were asked for their views about their care and treatment and they were acted on. We spoke with one of the people using the service during our inspection. They told us their keyworker regularly met with them to talk about things they wanted to do. We were able to see minutes of monthly meetings between people using the service and their keyworkers on people’s individual records. From these we could see people were asked for their views and these were documented.

The deputy manager told us a designated staff member was responsible for contacting relatives for their feedback about the service. However they were not able to show us any recent evidence of discussions that had taken place with relatives. We spoke with a visiting relative of one of the people using the service who said, “I used to get asked for feedback but not lately.” However they also told us they felt comfortable raising any issues or concerns with managers if they had these and were confident managers would respond appropriately.

The provider had systems in place to regularly assess and monitor the quality of service provided. We were shown evidence of monthly quality assurance visits carried out by the provider to the service. The service was reviewed and rated by the provider and where issues or concerns were identified these were documented and reported back to the registered manager to act on.

The deputy manager told us staff meetings took place at the home and staff were encouraged to discuss improvements or changes they felt would improve the quality of service provided. They said the provider took account of these suggestions and acted on them. They told us staff had raised their concerns about the time spent cleaning carpets in the home which could have been better spent supporting people to undertake activities outside the home. In response the provider had replaced the carpet with new flooring that needed less maintenance and as a result staff were freed up to spend more time with people using the service.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. From people’s care records we noted accident and incident reports and body maps were completed in a timely manner by staff. These had been reviewed by the registered manager and any learning for the service and staff was noted following this review. For example one person received an injury following an accident. The registered manager had reviewed the incident and as a result gave staff guidance and instructions on how to minimise the risk of a similar incident reoccurring.

We saw evidence checks were carried out by staff in the home to minimise risks to people’s health, safety and welfare. Regular checks of hot water temperatures, food temperatures and fridge and freezer temperatures had been carried out and recorded. We also saw fire safety checks were carried out and documented daily.