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Inspection report

Date of Inspection: 23 October 2012
Date of Publication: 27 November 2012
Inspection Report published 27 November 2012 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 reviewed all the information we have gathered about Trinity House Annexe, looked at the personal care or treatment records of people who use the service, carried out a visit on 23 October 2012 and observed how people were being cared for. We talked with people who use the service, talked with staff and talked with stakeholders.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

The service had formal systems in place to monitor the quality of the service, including a quality assurance policy. They are subject to a six monthly and yearly inspections from stakeholders. We spoke with some of the stakeholders and they confirmed that they had no concerns about the quality of the service.

There were opportunities for people using the service to give feedback. Regular residents’ meetings took place and a suggestion box was placed in the hallway for people to post comments. People were involved in how the service was planned and run. We saw from records the service was responsive to user feedback as was the case when they responded to changing visitation times to reflect specific user preferences.

The manager told us that they obtained feedback from people who use the service and key stakeholders using a yearly questionnaire. At the time of our inspection they were in the process of analysing the feedback of 2011/2012 survey. People who use the service, relatives and stakeholders confirmed that the service had sought their views. This meant that the service took account of feedback to improve the service.