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Inspection report

Date of Inspection: 3 January 2013
Date of Publication: 24 January 2013
Inspection Report published 24 January 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 3 January 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members 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

We saw evidence that the views of the people who used the service and their relatives were sought. This involved the provider sending all tenants and their relatives a questionnaire to enable them to comment on their care. The results for 2012 were being analysed at the time of this inspection. Tenants meetings were held every 6 to 8 weeks and we saw minutes from these meetings. One relative told us “I regularly get invited to meetings and asked for comments on care.”

Incidents were reported and then stored within people’s individual care plans. There was evidence that learning from incidents / investigations took place. For example, the manager told us that they had recently changed their process for ordering and monitoring the supply of medication in response to a recent incident.

We asked the manager if reported incidents were analysed for any patterns. We were told that this used to occur but had recently been stopped and that the staff now used their own judgement. The provider may like to note that it is good practice to conduct an analysis of reported incidents on a regular basis, to assist in the identification of risks to the care and welfare of people using the service.

Monthly work based supervision took place where staff were monitored and observed giving personal care and medication. Findings were reported back to staff in monthly appraisals.

We saw evidence that monthly medication audits took place which detailed actions taken where short falls had been identified. The manager told us that they conducted monthly audits of the care plans. They were however unable to provide evidence of this. The provider may like to note that it is important that all audits and relevant findings are documented so that the appropriate actions taken can be evidenced.

Monthly team meetings were held. We saw from the minutes that any issues regarding care were discussed. Staff also told us they gave feedback to the rest of the team on any training they had received. This showed that the staff were able to discuss care needs of the people using the service and that they could share their learning.