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Archived: Rushall Care Centre

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Inspection report

Date of Inspection: 5 June 2014
Date of Publication: 19 July 2014
Inspection Report published 19 July 2014 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 5 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information sent to us by other authorities and talked with other authorities.

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 there were systems in place to assess and monitor the quality of care, support and treatment provided to people. We found that some of these systems were informal. We found that the manager was aware of areas where improvements were needed and had started to make necessary changes.

We were told that people’s care plans were reviewed every month. In the care plans we looked at we saw that people’s care needs had not been reviewed every month. The manager told us that care plans were not at the standard that they wanted. They told us that some of the monthly reviews had not been consistently completed. They told us they had identified a key worker and named nurse for each person who used the service. They told us they would ensure that each staff member was accountable for specific care plan reviews. We will check this at our next inspection.

We saw that managers attended regular clinical governance meetings. We looked at the minutes of a meeting held on 28 January 2014 which identified the need for care plan improvements to be made. The provider may find it useful to note that we could not find evidence of an action plan to advise us when this issue would be addressed.

We saw that the provider had completed an infection control audit in March 2014. The provider may find it useful to note that most of the outstanding actions had not been signed off as completed in the action plan we looked at.

We saw that an annual survey was completed by the provider to get feedback from people who used the service. One person had written: “The carers and nursing staff are very good and patient. Cleanliness is especially good”.

The manager told us that they had introduced resident and relative meetings and staff meetings, every three months, to ensure that information was shared with everybody about the plans for the service and to ensure that people’s views were obtained. This was confirmed in the meeting minutes that we looked at. The manager told us they were going to display a ‘you said, we did’ board in the foyer to highlight when they were responsive to people’s requests. We will check this at our next inspection.

One member of staff told us: “[The new manager] had a meeting with us. This was a special staff meeting so they could let us know what is expected from us [staff]. It made things clearer for us”.

One relative who attended a relative’s meeting told us: “It was brilliant. The manager really put the effort in and gave people notice. I felt listened to”. One relative told us they made a request on behalf of someone who used the service and the next day it was dealt with.

We saw evidence of a complaints policy to enable positive outcomes for people who used the service. We saw that complaints were logged and responded to appropriately. We saw that complaints were acknowledged in writing and that the provider acted in accordance with their policy to resolve them. The provider took account of complaints to improve the service.

We found there was a system for recording when accidents and incidents occurred. We saw there was a system in place to monitor and analyse incidents to ensure that appropriate actions were taken.

We saw that the provider had training records in place which identified when staff needed to complete or refresh training in mandatory subjects such as safeguarding, medication management and first aid. The manager told us they checked training records on a weekly basis to ensure staff had completed the necessary training. We saw from the records that some staff were overdue for refresher training in manual handling. We saw that training for those staff had been arranged in June and July 2014.

We saw that the provider had been assessed by the Environmental Health Agency in December 2013 and had received the highest rating of 5. This meant that the provider ensured that the food was of a sufficient quality and the environment was safe and hygienic for people who used the service.