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Archived: Cartmel Old Grammar

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 3 December 2013
Date of Publication: 7 January 2014
Inspection Report published 07 January 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 December 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and talked with commissioners of services.

Our judgement

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

Reasons for our judgement

We spoke with people who used the service but they made no specific comments relating to this outcome. When we visited the home we found there was a system being used to assess and monitor the quality of the services and records about the care and support people living at the home received. We saw that information about the safety and quality of the service was being gathered from different and relevant sources and that this was being recorded and stored securely. The service had procedural guidance for staff to follow on maintaining confidentiality and data protection.

We asked the manager how falls and adverse events in the home were analysed and used to inform practice. We looked at how the service had managed falls in the home and looked at the falls reports and analysis for the last two months. This analysis had looked at the times and places where people had fallen to help identify themes. For one person who had experienced a high number of falls a diary had been kept and analysed. The high risks times had been identified as periods following the administration of medications that had sedating side effects. A medication review was undertaken with the person’s GP and changes made to the medication regime. The person had not fallen since the new plan had been implemented and this had helped improve their wellbeing.

We found that there had been recent improvements in the control measures in place for assessing the risk of falls and their monitoring. This included check lists for equipment being used to make sure it was working correctly and had been switched on. We saw additional monitoring being done through handover checks from each shift to make sure anything staff needed to know about changes during a shift was handed over.

The manager had been doing some regular checks or ‘audits. This was being carried out with care plans to help make sure they were accurate and up to date. The sample of care plans being audited each month was a small one and may not be fully representative of all those in use. The provider may want to note that.

Infection control and environmental audits had also taken place. We saw recommendations from these were being carried out in the home with redecoration and refurbishment. A recent health and safety audit had highlighted that people needed personal evacuation planes in case of fire or emergency. This was being done for all the people living there. It also highlighted the need for some staff to have moving and handling training. Staff had either received this or were booked onto training for this.

The care staff told us they had regular meetings with the manager and senior staff and where they were able to discuss their practice and raise any concerns. They said they felt well supported by the manager of the home and said their views about the service were listened to. We also saw records of the regular monitoring visits made to the home by the provider.

We spent time attending a ‘resident’s meeting’ that was taking place. There were 11 people attending the meeting and one relative and all had been given agendas. The meeting was lively and people gave their views openly and made comments for management to consider. We heard people discuss the food. Some people had asked at the last meeting if they could have cheese and biscuits after meals and a cold meat platter at tea to make the sandwiches how they liked. These things had been tried and one person told us “It has worked out well”. A suggestion was made to hold a whist drive and the activities coordinator was going to arrange for that.

We saw the summaries of the surveys carried out at the start of the year with the people living there and the comments were largely positive. A survey had been carried out with outside agencies coming into contact with the home and the results had been positive. The next survey was due in January 2014 and would be sent out by the provider from their head office.

We looked at a sample of the care plans