QUALITY ASSURANCE
Inspections:
Care Quality Review at Down Lodge was carried out by Wokingham Council on 22 April 2022: Down Lodge was awarded the highest, GREEN status with minor recommendations to be implemented (eg “remove equal opportunities forms from each staff file and hold centrally”, “consider adding diagnosis to the front of their care plan etc). All recommendations have now been implemented.
Service Users’ Surveys Analysis (2023): Topics in April 2023 service users’ survey included sets of questions which were defining if residents felt that the service was SAFE, EFFECTIVE, RESPONSIVE, CARING and WELL-LED. Questions making up the score ranged from "The environment and equipment that I use is safe and well maintained", "I am confident that any concerns I may have will be resolved quickly, and that they will not happen again", "the managers know what they need to do and are always honest, including when things go wrong" to "staff treat me with kindness and compassion"
SAFE - 64%
EFFECTIVE - 73%
RESPONSIVE - 64%
CARING -73%
WELL-LED - 91%
Internal Audits Analysis (May 2021- April 2022):
Our internal quality audits comprise 9 areas: medication management, staff spot-checks. We have carried out our 6- monthly reviews of all audits (Nov 2022 - April 2023): All processes shown improvements made.
Our internal falls audit compared data for past 2 years: March 2022 - Febr 2023 seen 24 falls, a reduction by 25% comparing with a previous year.
We noted that in former period one resident had 9 falls, attributing to nearly 40% of total home’s falls. Overall, current period, March 22- Febr 23 shown a substantial improvement.
STAFF SURVEYS ANALYSIS APRIL 2023
Yearly staff surveys conducted in Dec 2022 answered about below topics:
“IS THE SERVICE SAFE”:
· 100% of staff said OUTSTANDING
“IS THE SERVICE EFFECTIVE”:
· 100% of staff said OUTSTANDING
“IS THE SERVICE CARING” , “IS THE SERVICE RESPONSIVE” and “IS THE SERVICE WELL LED”:
· 100% of staff said OUTSTANDING
Further analysis from staff survey reveals that:
*** from those who overall feel that service is OUTSTANDING in terms of “SAFE”, 87.5 % point out that they would give “OUTSTANDING” rating, 12.5%-“GOOD” on topic “I feel that Down Lodge understands the need to safeguard people, and I am confident that they would act appropriately when concerns were raised”
*** from those who overall feel that the service is OUTSTANDING in terms of “EFFECTIVE”, 100% point out that they would give “OUTSTANDING” rating “In my role I am empowered to promote independence and health of the service users I support”
*** from those who overall feel that the service is OUTSTANDING in terms of “CARING”, 100% point out that they would give “OUTSTANDING” on “there are warm, positive relationships between service users and staff”
*** all staff unanimously agreed that service is RESPONSIVE as “OUTSTANDING”
*** from those who overall feel that the service is OUTSTANDING in terms of “WELL-LED”, 87.5% say that they would give an outstanding rating on “the managers know what they need to do and are always honest, including when things go wrong; 75% point out that they would give an “OUTSTANDING” on “I am clear on the vision and values of Down Lodge, and am supported to deliver them in my day-to day-work”
Actions taken: the above analysis of each response that deviated from “OUTSTANDING” was implemented:
· LEARNING FROM MISTAKES folder – completed
· To share in next Team Meetings
· To share in next Residents’ Newsletter
· To share in next Staff Newsletter
· To share on Website
· Addressed with Individual staff where responses were not anonymous