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Inspection report

Date of Inspection: 11 April 2013
Date of Publication: 11 May 2013
Inspection Report published 11 May 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 11 April 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.

Reasons for our judgement

Regular monitoring had taken place to protect the people against the risks of inappropriate or unsafe care and treatment. The decontamination processes were recorded and these could be assessed as being effective or potential risks identified.

We saw records to show the emergency drugs and equipment were checked regularly by staff.

We saw evidence of a recent radiographic audit which was conducted annually. This showed evidence of discussion between professionals, recommendations for improved practice and plans for review.

The provider may wish to note that while we saw evidence that medical history checks were being conducted we were told by the manager that no audits were currently being undertaken to check this process.

We saw a comments book available in the reception area for patients to read and complete if they wished. We saw evidence of patients’ suggestions and the resulting response from the practice. For example, a recommendation had been made to provide children’s books in the waiting area. We could see that this suggestion had been noted and subsequently children’s books were provided.

We saw that patient satisfaction surveys was completed on an ongoing basis and results were collated monthly by the head office. The result of this survey was displayed in the reception area. The manager explained to us that information from these surveys was passed to staff during staff meetings and areas of learning were discussed. The manager also told us that on the next staff meeting agenda she plans to discuss the recent NHS website comments regarding the practice.

The manager also told us that she used examples of learning and good practice from the other practices that she managed and used these to improve the service at Kendal.