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Inspection report

Date of Inspection: 9 April 2013
Date of Publication: 25 April 2013
Inspection Report published 25 April 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 9 April 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We sent a questionnaire to people who use the service, talked with people who use the service, talked with carers and / or family members and talked with staff. We reviewed information sent to us by other authorities and talked with other authorities.

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 in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Reasons for our judgement

We saw the summary results from feedback questionnaires completed by people who used the service and their relatives in July 2012. The feedback was positive.

The manager told us that she monitored the service on a daily basis by speaking with people who used the service, their relatives and visitors then addressing any issues straightaway. We saw evidence of this during our visit. The manager told us that residents and relatives meetings were held regularly which gave people an opportunity to raise any concerns or suggestions. We saw minutes of a meeting held in January. The manager told us they operated an ‘open door’ policy for everyone.

The provider had a complaints procedure in place, which included contact details for external agencies such as the Local Authority and CQC. We saw records of the complaints people had made, which included how they had been dealt with, the outcome and response. We saw that the provider kept a summary of complaints.

The manager told us that information obtained from satisfaction questionnaires, audits of complaints and accidents was discussed with staff through handovers and staff meetings so that lessons were learned and the service improved. We saw evidence of this in minutes from a recent staff meeting.

Staff we spoke with told us they felt the home was well managed, they had confidence in the management of the home and they attended regular team meetings.

One person who used the service said "The manager asks if everything is alright for me and we have residents’ meetings”.

We saw the internal audit system covered audits on the care plans; accidents, medication; infection control and pressure sores.