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Inspection report

Date of Inspection: 6 December 2012
Date of Publication: 15 January 2013
Inspection Report published 15 January 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 6 December 2012, talked with people who use the service and talked with carers and / or family members. We talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that patients receive.

Reasons for our judgement

Patients told us that they were asked their views about the service. Some patients told us they had been asked to complete patient feedback forms about the service.

We saw that there was a record of identified risks and issues with action plans in place where needed. We were shown examples of audits about patient records and consent and treatment plans. We looked at minutes of staff meetings and feedback forms completed by patients using the service they showed positive feedback. These demonstrated that the quality of the service was monitored and concerns addressed appropriately.

Information about patient’s experiences had been gathered in such a way to allow for monitoring of risks and the quality of care delivery.

There was a written complaints procedure that explained how patients could raise concerns and complaints. There was a system to investigate and promptly resolve complaints. The provider was not dealing with any complaints at the time of our visit.

The management structure for decision making and accountability provided guidance for staff, to ensure that care and support needs were met consistently and safely. Staff were confident and aware of how to raise concerns.