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Inspection report

Date of Inspection: 10 February 2014
Date of Publication: 7 March 2014
Inspection Report published 07 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 10 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 and talked with staff.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients using the service and others.

Reasons for our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients using the service and others.

There were policies and procedures for dealing with complaints, data protection, safeguarding, infection control and health and safety. We saw evidence that these polices were regularly updated and they had been signed by all members of staff to confirm they had read and understood them.

Regular audits were carried out for cleaning, infection control, clinical waste and patient and clinical records. This meant the provider monitored the service to ensure that they were continuing to comply with appropriate legislation and guidance.

We examined the most recent patient satisfaction survey and found that all people questioned were very happy with the service they received. 96% of patients questioned stated they were happy with the way that treatment was explained.

A complaints policy was displayed in each of the waiting areas. There were procedures in place to ensure that any complaints were dealt with appropriately and in a timely manner.

The provider had an effective system for the recording and investigation of accidents and incidents. Fire evacuation procedures were clearly displayed and weekly checks on the alarm were carried out.