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Inspection report

Date of Inspection: 10 October 2013
Date of Publication: 8 November 2013
Inspection Report published 08 November 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 10 October 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.

Our judgement

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

Reasons for our judgement

We saw that a range of risk assessments in relation to health and safety and the environment had been undertaken, monitored and reviewed to ensure necessary measures were put in place to reduce any potential risk to the safety of people using the service.

There was an annual plan for maintenance, redecoration and renewal and servicing of equipment and installations in the home and the manager told us this was up to date.

Records showed that checks and audits were regularly undertaken to ensure that systems and processes in place were being carried out properly by staff, such as medication management, care planning, weight monitoring and fire safety.

We saw that accident and incident records were analysed each month to identify trends and themes. These mostly focused on the individual to identify any change in needs. The provider may find it useful to note that times of accidents/incidents/falls, which may be significant, were not analysed.

There had been only one complaint about the service in the last 12 months and we saw evidence to demonstrate that the provider had taken account of this to improve the service.

Residents meetings were held. The records of the minutes showed that people who used the service, where able, were supported to, express their views, choices and preferences in relation to entertainment, activities, outings and menus. We saw that a new wide and varied menu had been introduced based on people’s feedback.

The provider may like to note that the systems in place did not include an overview of the information gathered to identify the weaknesses and strengths of the service delivered. This would enable the provider to make the necessary improvements or enhance the quality of the service and effectively complete the quality monitoring cycle.