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Archived: Tonbridge Recovery Service

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Inspection report

Date of Inspection: 3 December 2013
Date of Publication: 4 January 2014
Inspection Report published 04 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 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

There was a range of audits and checks to monitor the quality and effectiveness of the service. There was a series of meetings called the Integrated Governance Team meetings (IGTM). These were held at the local level, i.e. the Tonbridge office and issues were fed

up to an area meeting, i.e. Kent and then to a regional level. We looked at the minutes of some of these meetings. We saw there was a standard agenda which included areas such as training, safeguarding and feedback from service users. Specific serious incidents were discussed. There was discussion about training, on understanding of domestic violence, and audits.

There was scheme of audits for the year. For example, a recent safeguarding audit had identified that only the recognised form should be used to present material at child care cases to avoid confusion. An infection control and hygiene audit in November 2013 had identified various areas for improvement. It was too soon for most of them to be actioned although one area, providing hand washing posters, had been done.

Incidents were recorded on a system called DATIX. This is a standard system used by many NHS bodies. We looked at two reports. Both had been well recorded and investigated. There was in-depth analysis of trends in incidents. Conclusions reached included that staff were unsure as to what was an incident and what a “near miss”. Reports showed what had happened but often not why and medication issues were often the reason for people becoming upset. We saw from meeting minutes that these issues were discussed at different levels across the provider’s services. There were several lessons for staff from the analysis and we saw that these were fed back through training, daily morning meeting and e-mails.

People who used the service were consulted about it. There were regular surveys of people who used the service, these indicated a high regard for the staff and for the service. There were questions to help identify what people wanted, for example, “would you like workshops in the … evening ,,, weekends?” The volunteers, who had themselves used the service, had regular meetings. The issues they raised were acted upon. In the November meeting the volunteers discussed holding a “Xmas buffet” and this had been costed and planned. They had asked for better communication of training opportunities and a noticeboard had been put up. They had asked to be allocated a supervisor and this had been done.