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Archived: Cartmel Old Grammar

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All reports

Inspection report

Date of Inspection: 5 December 2012
Date of Publication: 9 January 2013
Inspection Report published 9 January 2013 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

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 5 December 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

People were placed at risk because the provider did not have an effective system to regularly assess and monitor the quality of service that people received and robust systems were not used to manage risks to the health, safety and welfare of people who used the service.

Reasons for our judgement

People we spoke with told us they were given opportunities to express their views about the services provided at Cartmel Old Grammar. One person told us, “The staff always ask if everything is OK, and it is.” Another person we spoke with told us they found the manager to be “approachable” and said they would speak to her if they had any concerns about the care provided in the home.

We saw that the manager had held a meeting with people who lived in the home to obtain their views about proposed changes to the use of communal areas in the building. We saw copies of letters which had been sent to people’s families to keep them informed about important events in the home. This ensured people were given information about the home and the opportunity to be involved in decisions about how the service was carried on.

We looked at some of the records held in the home. We saw that risk assessments had been carried out including to identify if people were at risk from falls, inadequate nutrition and from developing pressure areas. We found that where people had been assessed as being at high risk their care records did not include information about the actions which needed to be taken to minimise and control the risk. We saw that one person had been assessed as being at high risk of developing pressure areas. Their care records did not include detailed information for care staff about how they were to support the person to reduce the risk of them developing a pressure sore. This meant they were not protected from the risk of harm.

During our inspection we found a number of issues with the accuracy of the records held in the home. These issues showed that the manager had not carried out robust checks to monitor the quality of the records or to ensure that care staff had the information they needed to protect people from the risk of unsafe or inappropriate care.