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Archived: The Chestnuts Nursing and Dementia Care Home

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Inspection report

Date of Inspection: 18 July 2011
Date of Publication: 29 September 2011
Inspection Report published 29 September 2011 PDF | 81.68 KB

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 18/07/2011 and observed how people were being cared for.

Our judgement

Some systems were in place to prevent people from the risk of harm or abuse. The provider needs to demonstrate that appropriate action is taken to promote safe and effective pressure area care in the home at all times.

User experience

Most of the people we spoke to told us that they felt safe in the home. They told us that the staff were caring and treated them with dignity and respect. We spoke to peoples’ relatives and friends who told us that they felt that their relatives were safe in the home. They told us that the staff were caring and worked hard to meet peoples’ needs.

Other evidence

A safeguarding policy and procedure was available to staff in the home. We saw staff training records which confirmed that staff had completed safeguarding adults training. We spoke to various categories of staff who demonstrated an understanding of what was expected of them to safeguard people using services. We looked at some of the care practices and documentation around pressure area care and found that they were not adequate to prevent people from the risk of coming to harm. One example of this is where staff did not know how to operate pressure relieving equipment used in the home.

We found gaps in the records that staff were keeping in terms of turning charts, nutritional monitoring charts, fluid balance charts, ulcer monitoring charts and the care that was provided to people. This lead to people not always receiving safe and appropriate care in the home. The Commission was aware that action had since been taken by the manager, the tissue viability nurse and the community matron to improve the outcomes for people using the services. One such action has been the monitoring of pressure–relieving equipment twice per day, which commenced on the 8/7/2011 by the home manager. Up to twelve staff had training on the 1/07/2011 in using the pump for pressure relief mattresses, which should have happened sooner.

At the time of writing this report we were aware that an investigation had been launched by the local safeguarding adults’ coordinator into the pressure area care of three people who received services from the home. It was envisaged that the investigator would report the outcome to a meeting planned in September 2011. Although the safeguarding matter had not been concluded, we formed the view that improvements were needed to ensure that people receive safe and appropriate pressure area care at all times.