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Inspection report

Date of Inspection: 18 September 2014
Date of Publication: 20 November 2014
Inspection Report published 20 November 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)

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 18 September 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 reviewed information given to us by the provider.

Our judgement

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

During our inspection we were not able to access any audit information as the staff were not aware of where the information was stored. We spoke with the manager the following day and they emailed us the most up to date audits. We saw that the last care plan audits had been carried out in February 2013. We were concerned as the care plans were very poor and the lack of monitoring had contributed to this as regular audits would have highlighted the issues.

The manager also sent us continence audits. These consisted of a monthly list of people who lived in the home and the continence products that they used. We could not see any purpose for these audits. We were not provided with any health and safety audits or infection control audits except for 'bare below the elbow' audits which had last been completed in June 2014.

There were no audits in place to monitor staff supervision or training. Regular monitoring of these would have identified the lack of both taking place for the staff.

We saw that no staff team meetings were taking place and the last meeting for people who lived in the home had been held in December 2013. The activities programme we saw said that a 'resident's forum' took place on a monthly basis but there were no records to evidence that these were taking place.