12 December 2016
During an inspection looking at part of the service
When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.
We conducted this unannounced focused inspection to review two requirement notices given at our last focused inspection in August 2016. The requirement notices related to the effective key question which we rated as requiring improvement due to breaches of regulation 12 – Safe care and treatment and regulation 17 - Good governance. Following the inspection in August 2016, the provider submitted action plans telling us how they would make improvements. This also covered areas where we had made recommendations.
We inspected Abbey Court on 12 December 2016 to check whether these improvements had been made. We found areas of good practice:
- We found staff were taking and recording physical health observations in line with their provider’s policy. Staff were using the modified early warning score tool to identify and action any concerns with a patient’s physical observations.
- Staff had completed training in modified early warning scores which enabled them to use the tool correctly.
- A risk assessment protocol had been put in place for the use of the posture support chair. This ensured that staff had an understanding of how to use this safely.
- There was a procedure in place for recording clinical room temperatures. Staff understood what to do if the temperatures rose above a certain point.
- Line management supervision was taking place regularly, in line with the service policy.
However,
- One patient who had an increase modified early warning score did not have this followed up as per the escalation procedure.
- The clinical room temperatures were not recorded on 11 occasions.
- Staff told us that they did not feel that they received enough clinical supervision
As we did not review the ratings for the other four domains the ratings for those remain as previously rated in August 2016.