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Inspection report

Date of Inspection: 25 June 2013
Date of Publication: 20 July 2013
Inspection Report published 20 July 2013 PDF | 81.8 KB

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 25 June 2013, 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.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

People who use the service, their representatives and staff were asked for their views about care and treatment and they were acted on. There were monthly residents and relatives meetings where people were encouraged to share ideas and raise concerns. There was a newsletter created to keep people up to date with everything that was going on in the home.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. We looked at the care plans for four people who had medium to high risk skin integrity issues. We saw that there was clear guidance to staff on what to look for, what to do and who to report to if concerns were noted. In two of the care plans we saw that care staff had noted deterioration in people’s skin. This had been reported to the nurse in charge who in turn had assessed the person and requested the tissue viability nurse to attend for advice. We saw that this had been done in a timely manner and was clearly recorded.

The provider took account of complaints and comments to improve the service. We saw that the provider recorded all complaints made and kept a log of their actions. Any actions taken were recorded and the complainant responded to in a timely manner. There were numerous compliments cards of which a selection was displayed in the entrance area for everyone to look at.

The deputy manager completed a monthly audit of tissue viability concerns, people’s weights, incidents and investigations and any infections. We saw that these were collated and analysed to determine if any action was required. The manager also audited the ‘resident of the day’s’ care plan. We saw that a form was completed with actions for the nurse to complete. This meant that there was evidence that learning from incidents and investigations took place.

The manager and deputy manager conducted unannounced night time visits every few months. These were recorded and any concerns addressed with the staff appropriately. The provider conducted monthly visits. Each aspect of the service was inspected over the course of the year. Staff and people who lived in the home were spoken with as part of the audit. Compliments, concerns and required changes were recorded and discussed with the manager. The manager also completed a Quality Assurance Tool twice a year which covered every aspect of the service. The result of this formed an action plan of changes with clearly identified deadlines and who was responsible for completing the action.