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Dimensions 2 Buckby Lane Good

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 3 July 2014
Date of Publication: 19 August 2014
Inspection Report published 19 August 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 3 July 2014, observed how people were being cared for and spoke with one or more advocates for people who use services. We talked with people who use the service, 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.

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

People who use the service were protected against the risk of inappropriate or unsafe care because the provider effectively assessed and monitored the quality of the service provided. The manager operated auditing systems which ensured they identified and managed risks relating to the health, welfare and safety of people being supported.

People and staff had been asked for their views about their care and treatment and they were acted upon. The provider completed an annual survey of people who use the service, which was in a format appropriate to their needs. We saw that the results had been collated and analysed to identify areas which required improvement.

Staff had been encouraged to share their views on the service and staff meetings were held regularly where ideas could be discussed. Staff members told us that they were able to raise concerns and discuss ideas at these meetings.

The provider’s quality assurance auditor provider completed a compliance audit every three months. Where improvements had been required these were clearly recorded in an action plan with the action required. We looked at the most recent audit completed on 7 May 2014.

The registered manager told us that since their appointment in April 2014 they had identified that people required to have their support plans and needs assessments reviewed. They told us that they had arranged meetings with the assistant locality manager, lead support workers and dedicated key workers to complete reviews with people, their family and care managers.

We reviewed the registered manager’s annual service improvement plan, which they had completed on 26 June 2014. The registered manager told us that they had considered the findings of the compliance audit on 7 May 2014 whilst compiling the service improvement plan. We saw that they had identified that support plans, risk assessments and person centred reviews required to be updating. They had created actions for these to be completed by 30 September 2014. The manager had also created action plans to ensure that lone working risk assessments, staff one to one supervisions and mandatory training had been completed by 30 June 2014. We found these action plans had been completed.

There was evidence that learning from incidents and investigations took place and appropriate changes had been implemented. Records were kept of incidents and investigations. Each incident was looked at individually and details recorded of what had been done and by whom. For example, staff had recorded an incident which identified a health and safety risk regarding the storage of sensory equipment in the bathroom. We saw that the incident had been reviewed and guidance issued regarding future storage of this equipment. We noted that implementation of the guidance had been monitored.

The provider had completed detailed health and safety checks as required on a weekly, monthly and six monthly basis and we found that all care workers had completed mandatory health and safety training.

The provider had a complaints system, although there had been no complaints made since our last inspection. The last complaint had been appropriately recorded, acknowledged investigated and resolved to the complainant’s satisfaction. People had been made aware of the complaints system and this was provided to them in a format that met their needs. We saw that there was a copy of the complaints policy in each person’s care and support plan. This showed that the service had a clear system for receiving, handling and responding to comments.

Staff explained the communication methods people used and how they recognised if they were unhappy. Relatives of people told us that staff were very caring and responsive, which meant the service addressed minor concerns before they became a problem. This meant that people had their comments and complaints listened to and acted on, without the fear that they would be discriminated against for making a complaint.

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