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Inspection report

Date of Inspection: 15 August 2013
Date of Publication: 13 September 2013
Inspection Report published 13 September 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 15 August 2013, observed how people were being cared for and talked with people who use the service. We 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

We viewed the systems that the provider had in place to monitor their own service. We saw that the risks associated with the building had been assessed and equipment maintained. For example we saw that there was a fire procedure policy in place and a fire risk assessment had been conducted. Information was made available to show that checks were regularly made on equipment. This meant that the provider ensured that the equipment at the practice operated safely and efficiently.

We found that there was a system in place to address patient complaints and a policy was available to guide staff in how to manage complaints. The complaints policy was well publicised in the practice. We found that the practice had not received any recent complaints. People we spoke with told us they had no complaints about the treatment they had received.

There were arrangements in place for staff to record details of any adverse incidents that can occur at the practice. An adverse incident is something that can happen, which impacts on a member of staff, a patient or on the practice itself. We found that three had occurred in the past year and that the provider had a satisfactorily robust system in place to identify these risks and took action to minimise any future risks.

We found that people who used the service were offered a regular opportunity to provide feedback regarding their experience of the service. The last annual patient survey was reviewed in January 2013. The results were analysed and identified factors which patients deemed of most importance and where they thought improvements could be made. This meant that the provider regularly sought the views of the people who used the service to enable them to come to an informed view in relation to the standard of care and treatment provided.

The provider carried out an audit of infection control twice a year. This meant that the provider had a robust quality assurance process which reviewed the suitability of the decontamination and infection control measures of the practice.