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Inspection report

Date of Inspection: 13 December 2013
Date of Publication: 25 December 2013
Inspection Report published 25 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)

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 13 December 2013, observed how people were being cared for and talked with people who use the service. We 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. Staff and people who used the service were integral to the provider's quality monitoring and improvement processes. Staff prioritised meeting the needs of people who used the service when delivering care.

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. A satisfaction survey had been undertaken in June 2013 and included responses from all groups. Feedback had been collated, responses had been provided to staff and service users and an action plan had been developed. Regular staff meetings were held and the staff we spoke with told us they were able to approach their manager with any concerns. Staff felt that the service was well led and told us that any issues were addressed quickly. A staff member said, “I absolutely love working here. It’s a privilege and a pleasure. It’s about the whole ethos and environment.”

We spoke to one person who used the service who told us that the service was well run. They told us that they had not had to raise any concerns or complaints. The service user, ‘Butty Advisory Group’, had been running since April 2012. The group were consulted by the provider whenever a service user perspective was needed. For example, the registered manager told us about a new Saturday drop-in service that the group had been consulted on and would be involved in evaluating. This service was to be trialled with the aim of broadening accessibility of the service to people.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. The service had grown significantly over the past year and we saw that a proactive approach had been taken to make sure that the service could meet the increased volume of referrals. The registered manager told us about changes the provider had made to the staffing structure following additional recruitment. This included bringing in a ‘middle management’ level to ensure that care provision and staff support remained “robust and underpinned”. All of the staff we spoke with were clear about their role within the service and who they reported to. We found that without exception, all staff we spoke with were committed to ensuring the quality of the service and to putting people who used the service first. This was evidenced by the following comments: “The service can always be improved, none of us are complacent”… It’s a fantastic place to be and it’s lovely to see our patients benefitting”… “It’s very person orientated, it’s about the whole person… it’s their day”.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We saw that a clear governance structure was in place and any incidents were reviewed by the registered manager. Any issues or questions arising from the review of incidents were taken to the appropriate groups or meetings. These included the Health and Safety Group, Clinical Governance Group and Heads of Department meetings. Where indicated any issues were escalated to the Board of Directors, who met quarterly. An annual report to the Board was produced by the registered manager and an external financial audit had been undertaken in 2013.