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Archived: Oakwood Grange

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Inspection report

Date of Inspection: 4 June 2014
Date of Publication: 27 June 2014
Inspection Report published 27 June 2014 PDF | 89.56 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 4 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information sent to us by commissioners of services.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

The provider had an effective system in place to regularly assess and monitor the quality of service that people received and had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service.

Reasons for our judgement

The manager of the home was registered with CQC. She understood her responsibility in regard to the management of the regulated activity and was supported by the registered providers. The submission of notifications confirmed the service were complying with their registration requirements and that the service encouraged an open and transparent culture, promoting communication with people, staff and other stakeholders. This meant that in the main, the service reported incidents to stakeholders of the service and took appropriate action, including action to minimise the risk of the similar incidents recurring.

We spoke with the manager about the quality assurance policy/procedure that was in place. She explained the systems in place to ensure a quality service and to identify, assess and manage risks. This included various quality audits, complaints and surveying stakeholders of the service. From these, she explained an action plan would be implemented if necessary to make improvements to the service. The manager also explained that the outcomes from audits and improvements were discussed in team meetings and within staff supervisions if needed.

The manager told us that resident meetings were held which provided people with an opportunity to say what they thought about things like meals. This was confirmed when we looked at records. A notice board in the entrance hall provided people with information about what they had said and what the service had done in response to this. This demonstrated systems were in place to listen and act upon people’s comments about the quality of the service provided.

Family members also confirmed they had completed surveys about the quality of the service. One relative described how they had responded positively to this and had never complained because they had never had any issues. Representatives told us they would go to the manager if they had any concerns, as she responded to requests immediately.

When we spoke to family members they said, “it’s very well led by the managers and deputies, in fact everybody, they all play their part” and “[the manager] sets the culture, so it must be well led”.

Staff told us team meetings were held and this included feedback on incidents/accidents. Comments by staff included, “I love working here, it’s amazing”, “I think it’s a well led service. The manager’s strict but fair because she wants the home running to the highest standard. It’s a good staff team. If staff don’t feel they can raise concerns with the manager they can complete the staff survey anonymously” and “senior care staff and managers listen to us”. Staff also explained each shift there is a staff handover where incidents/accidents get identified and discussed.

We saw evidence of the handover documentation that staff spoke about and the manager provided a staff meeting from the previous month as evidence of meetings.

There was a system of audits in place to ensure the quality of the service provided and to identify any improvements. This included a summary and analysis of accidents, near misses and incidents, complaints/compliments, floor management folder, medication, catering, infection control, pressure sores, weight loss, bed rails, maintenance, fire, care profiles, dependency, surveys, minutes of resident’s meetings, staff meetings, health and safety and safeguarding. We looked at a sample of the audits that had taken place. The provider may wish to note not all of the full range of audits had taken place in April and May and ‘signed off’ by the area manager. We saw that, where necessary, action plans had been implemented to improve the service with completed dates for action and that these actions had been carried out.

Oakwood Grange had a complaints policy/procedure in place. The manager said that people, relatives, other stakeholders and staff were encouraged to make complaints and share comments they had so that poor practice and service improvements could be made. This was