You are here

The provider of this service changed - see old profile

All reports

Inspection report

Date of Inspection: 28 February 2014
Date of Publication: 22 March 2014
Inspection Report published 22 March 2014 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

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 28 February 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

People did not experience care, treatment and support that met their needs and protected their rights.

We looked at the care plans for two people who were receiving nursing care. In the first care plan we saw the individual had been assessed at being at high risk of falling. The care plan stated the person needed constant supervision when they were sat up in the chair. We saw this person sitting in the lounge. They were sitting in a recliner chair that had been reclined. This meant they could not try and move out of the chair. We also noted the care plan instructed staff to make sure the lap belt was used when this person was using the wheelchair. We saw the lap belt was not used during our visit. This meant the care plan to reduce the risk of the person falling had not been followed.

In another care plan we saw the individual was at risk of developing pressure sores. When we looked in their bedroom we saw there was a specialist mattress in place. On top of the mattress there was an incontinence sheet in place, which would have reduced the effectiveness of the mattress. We asked the registered manager about this and they told us they didn’t know. We also noted the air mattress was on a high setting, but the person was very slight in stature. There were no instructions in the care plan as to what the correct setting was. We asked the nurse on duty who agreed the mattress was on the wrong setting. If specialist equipment was not being used correctly it could increase the risk of damage to the skin.

We saw care plans contained information about people’s personal preferences for example in one plan it stated the individual liked to get up between 8:30am and 9:00am. However, when we arrived at 9:30am this person was still in bed.

We also witnessed staff not responding to people during our visit. These were some examples: one care worker asked an individual if they were OK. The person responded stating they were cold. The care worker did not respond. Another care worker asked the same person how they were. The individual said they had ‘a bit of a headache.’ The care worker responded saying “Oh! I’ll shut up then.” Another person was complaining that they felt dizzy they reported this to more than one member of staff but no action or reassurance was given.

We did see some good interaction between care workers and people living in the home, however, staff were very busy and had no time to spend with people unless they were delivering personal care.