2015

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

People are kept safe through a proactive response to accidents and incidents

• TITLE -FIRE RISK ASSESSMENT<br>

  Yes

  No

  N/A

• Accident Management<br><br>

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

People are kept safe through effective risk management.

• Risk Management

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

• The Livability Fire Risk Assessment has been<br><br>Reviewed in the last twelve months or following a significant change<br>Authorised by the service manager for use<br>Demonstrates that the monitoring section has been reviewed and all actions are noted with timescales for completion<br>Actions from the above are completed or a management plan is in place

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

• Desktop Review Findings

People are kept safe through the effective management of the individuals physical environment

• The Livability Fire Risk Assessment has been<br><br>Reviewed in the last twelve months or following a significant change<br>Authorised by the service manager for use<br>Demonstrates that the monitoring section has been reviewed and all actions are noted with timescales for completion<br>Actions from the above are completed or a management plan is in place

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

• The Livability Fire Risk Assessment has been<br><br>Reviewed in the last twelve months or following a significant change<br>Authorised by the service manager for use<br>Demonstrates that the monitoring section has been reviewed and all actions are noted with timescales for completion<br>Actions from the above are completed or a management plan is in place

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

Safe Transport

• The Livability Fire Risk Assessment has been<br><br>Reviewed in the last twelve months or following a significant change<br>Authorised by the service manager for use<br>Demonstrates that the monitoring section has been reviewed and all actions are noted with timescales for completion<br>Actions from the above are completed or a management plan is in place

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

• The Livability Fire Risk Assessment has been<br><br>Reviewed in the last twelve months or following a significant change<br>Authorised by the service manager for use<br>Demonstrates that the monitoring section has been reviewed and all actions are noted with timescales for completion<br>Actions from the above are completed or a management plan is in place

  Yes

  No

  N/A

• Action Required

• Date for Completion

  Date

• Person Responsible

Judgement - Safe

• Evidence Judgement - Safe Feedback about the safety of the service describes as consistently good and they feel safe. There is a culture of learning from mistakes and an open approach. The services manages incidents, accidents and safeguarding concerns promptly. There are policies and procedures for managing risks and staff understands them and follows at all times to protect people. Restrictions are minimised so they feel safe but also have freedom regardless of disability or other needs. Staff give information about other risks and support them in their choices so they have as much independence as possible. Risk assessments are proportionate and centred around the needs of the person. Are formal and informal methods used to share information on risks to people's care and support? Are there plans for responding to emergencies or untoward events, are these understood by all staff? How are the risks identified and managed? There are policies and procedures for managing risk and staff understand and follow them to protect people. The service does this consistently so that people feel safe whether they are within the service or out in the community.

• Judgement The service was safe/not safe Systems were in place for the management of... There were risk assessments in place supported by care plans which meant the risk was managed and people were kept safe. There was/was not a business continuity plan in place so that staff knew that/do not know what action to protect and keep people safe in an emergency.

  Select Outstanding Good Needs Improvement Inadequate

  • Outstanding
  • Good
  • Needs Improvement
  • Inadequate

judgement - Effective

• Evidence Peoples feedback about the effectiveness of the service describes it as consistently good. Peoples needs and preferences are taken into account when the premises are adapted or decorated. The environment is designed to promote independence.

• Judgement The service had a programme of training in place which meant that people were trained to care and support the people who used the service safely and to a good standard. Staff do not receive adequate training and supervision and therefore were not always equipped to meet peoples needs. Record keeping was good and up to date ensuring that staff had up to date accurate information when supporting and caring for people and ensuring they receive good quality care. Record were kept up securely and confidential records were... There manager had access to robust on line MIS system called.... Manager could use management information to... The manager used a paper based system and we saw this was... Records were updates in a timely way to ensure that...

  Select Outstanding Good Needs Improvement Inadequate

  • Outstanding
  • Good
  • Needs Improvement
  • Inadequate

Judgement - Well Lead

• Evidence Peoples feedback about the way the service is led describes it as good. How does the service make sure they have robust records and data management systems? How is innovation recognised, encouraged and implemented in order to drive a high quality service? How is information for investigations and compliments used to drive quality across the service? Legal obligations including conditions of registration from CQC, and other external organisations are understood and met.

• Judgement The service is/is not well led. Some improvements are required to ensure systems were formalised. The service was not considering best practice in regards to meeting the needs of people using the service. We saw that the quality of the service was effectively monitored by the manger to ensure ongoing improvements. The manager told us that they completed weekly audits including fire systems. Although quality check sheets for fire, medicines had been developed by the provider they had not been used by the service. There was no evidence/little evidence of any quality checks. Training records were in place, these had not been maintained last updated on X, therefore the manager could not confirm that trained staff were deployed in the service at time of inspection. Accident and incidents are monitored by the manager and the provider to ensure that trends are identified. People we spoke to said that they felt safe.

  Select Outstanding Good Needs Improvement Inadequate

  • Outstanding
  • Good
  • Needs Improvement
  • Inadequate

Judgement - Responsive

• Evidence Peoples feedback about responsiveness of the service describes it as consistently good.

• Judgement People received care and support which was personalised to their wishes and needs. Service users were excluded from the kitchen, therefore their independence was resricted.

  Select Outstanding Good Needs Improvement Inadequate

  • Outstanding
  • Good
  • Needs Improvement
  • Inadequate