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Scarsdale Grange Nursing Home Good

All reports

Inspection report

Date of Inspection: 31 July and 1 August 2013
Date of Publication: 2 October 2013
Inspection Report published 02 October 2013 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 31 July 2013 and 1 August 2013, talked with people who use the service and talked with carers and / or family members. We talked with staff and talked with other authorities.

Our judgement

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

Reasons for our judgement

We looked at a number of audits undertaken by members of the management team. Our review of these records evidenced that there was an effective quality monitoring system to analyse, identify and reduce risk. We saw that clear and comprehensive audits were undertaken for a range of areas, such as care planning, medication and nutrition. The audit documents in place clearly recorded the actions required to meet any identified shortfalls together with timescales.

The provider may find it useful to note that there was no satisfaction survey in place for people or their relatives to complete. We spoke to the manager about this who informed us that this would be implemented. A suggestions box had been purchased by the manager which we saw, but this had not yet been installed.

Staff spoken with during our inspection told us that staff meetings took place. Our check of records evidenced that staff meetings had taken place as scheduled throughout the previous year. On the day of our inspection staff meetings for care staff and qualified nurses were also taking place. Staff told us and our check of meeting minutes confirmed that relatives were provided with the opportunity to express their views and experience of the service through relatives meetings. We checked the minutes of these meetings and saw that meetings took place as planned. Our review of the minutes however identified that there were not clear records of how issues discussed within the meeting were being actioned.

There was evidence that learning from incidents/investigations took place and appropriate changes were implemented. There was a folder that contained the incident reporting policy and a copy of incidents that had taken place and what actions had been put in place as a result. We looked at an incident that had been reported about a person having a fall and saw that this was reflected in their care plan and an increased level of care around falls had been implemented.

There was also a complaints policy in place and a nominated complaints lead. We reviewed the complaints form 2013 and saw that all complaints had been responded to in a timely manner. The provider may find it useful to note that there was no summary of the outcome of any of the complaints and whether they had been resolved or accepted by the complainants.

The provider also informed us that they have achieved 'Investors in People Gold Standard'.