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Archived: Wansbeck Care Home Good

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All reports

Inspection report

Date of Inspection: 11 June 2014
Date of Publication: 22 July 2014
Inspection Report published 22 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 11 June 2014, 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, talked with staff and reviewed information given to us by the provider. We talked with other authorities and talked with local groups of people in the community or voluntary sector.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

People who were able to communicate verbally informed us that they were happy. One person said, “I wouldn’t go anywhere else. The manager is brilliant and the staff are brilliant. It couldn’t be any better” and “Out of 100, I’d give it 101. I’ve no complaints”.

A manager was in place who was not currently registered with the Care Quality Commission. The previous registered manager had left on the 4 November 2013. The manager submitted her application to register on the day of our inspection.

We received mixed opinions from relatives with whom we spoke. One relative told us, “There’s been positive changes since the new manager has come.” Another relative told us, “They just need to deal with the niggles and then we would be happy.” Relatives with whom we spoke informed us that relatives’ meetings were held. One commented, “They have relatives’ meetings, but I’m at work so I haven’t been able to attend, although they do have them in the evening too.” Another relative with whom we spoke informed us that she was not able to get to some of the meetings and was therefore not aware of what was discussed. We spoke with the manager about this comment; she informed us that she would display copies of the minutes of “Resident and Relatives’ meetings” on the home’s noticeboard.

We read the most recent minutes from these meetings which showed that changes to the home’s environment and garden were discussed with people and their relatives.

A range of quality documentation and audits were completed on a monthly, quarterly and annual basis. These included safeguarding; infection control; medication and specialist audits on end of life and care plan evaluations. The provider may find it useful to note that monthly evaluations of care plans were generally brief and repetitive and often did not record any changes or progress in needs. The manager informed us that she was aware of this issue and was in the process of addressing this to make sure that staff accurately documented people’s care needs.

The regional manager carried out monthly quality monitoring checks on all aspects of the home. We looked at the latest check which had resulted in two new slings being purchased and a focus on addressing environmental concerns highlighted in our last inspection.

Monthly Quality and Governance meetings were undertaken. We read the minutes from the last meeting on the 27 May 2014 when safeguarding, infection control, quality audits, care policies and procedures, complaints and departmental changes were discussed. We saw that changes were debated and agreed. We noted that a range of infection control changes were approved such as a new domestic rota and the purchase of new mattresses.

Staff told us and records confirmed that staff meetings were held. We looked at minutes from the last meeting which was held on 3 March 2014. Issues covered included staff sickness, documentation, the environment, infection control, information governance and manager expectations. We could see that key quality issues had been discussed such as how to keep the environment clean and how to report concerns to the manager.

We saw that complaints were examined and actions followed. The provider may find it useful to note that whilst while we could see that complaints had been investigated and dealt with, the complaints summary documentation which gave an overview of complaints received and actions taken was not up to date.

The home used a computerised software programme to document and assist staff to analyse incidents and accidents. The manager had a good understanding of the system and was able to demonstrate how notifications were entered, tracked and themes identified.

The manager and staff discussed their future objectives. They explained how they were going to undertake the PEARL Accreditation Scheme. PEARL stands for Positively Enriching And enhancing Residents Lives. The PEARL programme is an accreditation programme specifically designed by Four Season