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Inspection report

Date of Inspection: 13 August 2013
Date of Publication: 19 September 2013
Inspection Report published 19 September 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 13 August 2013, talked with people who use the service and 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

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Decisions about care and treatment were made by the appropriate staff at the appropriate level. The provider took account of complaints and comments to improve the service.

Our inspection of 12 February 2013 found there were inadequate systems in place for monitoring the quality of the service. There were no systems to audit compliance with the service's policies and procedures. Monitoring systems were not in place to assess the organisation's clinical performance in order to ensure services were safe. For example, there were no audits of clinical practice; infection control and decontamination standards; personnel records; or patient documentation. There was also no systematic process for identifying and minimising risks to people using or visiting the service. Staff told us risk assessments were not in place.

During our visit on 13 August 2013, we found significant improvements since our last inspection. Improvements included checks on the administration of medicines, cleaning and infection control arrangements, and patient records. Staff were able to describe some of the changes they made in response to these checks. For example, the provider identified some concerns about the administration of medicines and, in response, implemented new protocols for administering medication. These were monitored by the provider. There were also new procedures for monitoring cleaning and decontamination which were reviewed weekly.

As in our previous inspection, we found a complaints system was in place and it was monitored. People we spoke with told us they were not aware of a specific complaints policy but said that if they had a complaint, they would feel comfortable raising their concerns with the nurses or the consultants. None of the people who spoke with us had any complaints.