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Coundon Manor Care Home Good

All reports

Inspection report

Date of Inspection: 9 September 2014
Date of Publication: 25 October 2014
Inspection Report published 25 October 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 9 September 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, were accompanied by a pharmacist and talked with commissioners of services.

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 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

At our last visit in June 2104 we did not see systems in place to monitor and assess the quality of service provided at the home.

In June 2014 the registered manager had left and a new management team had been put in place. We found they had worked hard in the last three months to improve the quality of service provided in a short space of time.

Previously we identified gaps in staff training. We saw staff had either received training or were booked to undertake training to ensure they were knowledgeable in all areas considered essential to provide safe and effective care. For example, staff had undertaken moving and handling training, and tissue viability training.

At our last visit we were not sure how much involvement people had in their care planning. We found on this visit a ‘resident of the day’ initiative had commenced. This meant one day each month a person and their relative or advocate were invited to review their care and check they were satisfied with the care provided. This started in July 2014 and was still in its infancy. However the expectation was that this would ensure each person or their advocate would have the opportunity for regular contact with staff and be fully involved in care reviews and care planning.

Previously we were concerned that complaints were not being recorded, and when they were recorded, action was not taken in a timely way. This time we found good records had been kept of complaints raised. Since our visit in June 2014 the service had received six complaints. We saw these had been investigated appropriately and within the timescales of the provider’s complaint investigation policy.

We had previously been concerned about the high number of agency staff being used. Recruitment has since then reduced significantly the need for agency staff. We found there continued to be some practice issues and staff issues which needed to be addressed but the management were aware of these had had plans in place to deal with them.

We saw the manager had systems in place to monitor and check the safety of the home (audits). These included checks on medication, infection control, environment, safety and tissue viability. The provider might like to note our concerns that the medication audit did not identify the issues found by our pharmacy inspector.