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Archived: Belgravia Nursing and Care

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Inspection report

Date of Inspection: 27 January 2014
Date of Publication: 12 February 2014
Inspection Report published 12 February 2014 PDF | 80.21 KB

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 27 January 2014, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We 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.

Reasons for our judgement

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

All of the people we spoke with said they were happy with the service and had never felt the need to make a formal complaint. One person said “I only have good things to say about them.” Another person said “I have no complaints; they are very good and do their best for me.”

We saw that the manager regularly assessed the service provided in a number of ways. For example we saw the minutes of a quality assurance and safeguarding meeting held in December 2013. The manager explained that this was the first meeting, and future ones were scheduled to take place each month. The meeting was attended by the registered manager and senior staff from the provider. The effectiveness of the service was discussed by reviewing the results of quality audits; feedback from people who used the service; accidents and incidents and safeguarding issues.

The manager showed us that an annual quality audit had been completed in January 2014. This audit looked at different aspects of the service to check that they were meeting the needs of people who used the service. For example a review of care records had been completed to check documentation was complete and correct. A random selection of daily support log books had also been checked to ensure records were complete. Other areas covered in the audit included a review of notifications that were made to outside agencies; a review of risk assessments; and a review of medication administration records. This meant that the manager had a system in place to monitor and review the service provided.

The manager sought the views of people who used the service. This was done by the use of an annual feedback questionnaire. We saw the results from the last survey that had been carried out in 2013. The manager explained that the one for this year was in the process of being developed and sent out. We saw that the results from the last survey had been analysed and a report written. The report highlighted the areas that the service was doing well, and those that required improvement. We saw that where improvements had been identified appropriate action had been taken.

At the time of our visit we saw there had been one complaint recorded since our last visit. We saw that appropriate action had been taken and the family that had raised the complaint had been kept updated with the action taken. People we spoke with told us they had never felt the need to make a formal complaint. They said that if they did raise any minor issues the manager had quickly put things right. For example one person said “I had a conversation with the manager about an issue. They responded to me and have been very reactive to put things right. I am very impressed.”

The staff that we spoke with told us that during staff meetings they were told about issues that may have been raised by people who used the service. This showed that the service reviewed feedback from people and passed the information on to the staff to reduce the risk of someone else experiencing the same issue.

We saw that the service had a system to record accidents and incidents. At the time of our visit there had been none recorded since our previous inspection.