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Saltmarsh House Residential Care Home Requires improvement

All reports

Inspection report

Date of Inspection: 21 February 2014
Date of Publication: 19 March 2014
Inspection Report published 19 March 2014 PDF

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

Meeting 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 21 February 2014, talked with people who use the service and talked with staff. We reviewed information given to us by the provider.

Our judgement

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

At an inspection in November 2013 it was judged that the provider was not meeting this essential standard.

At that time the registered person had not taken proper steps to ensure that each person using the service was protected against the risks of receiving care or treatment that was inappropriate or unsafe, by means of an up to date risk assessment, plan and delivery of care to ensure their welfare and safety. This concern was judged to have had a minor impact on people who used the service.

The provider was required to submit a plan detailing the action they were taking to ensure compliance with this standard and the date at which they would be compliant. The provider told us in their plan that they would be compliant with this standard by 23 January 2014.

At this inspection we spoke with two members of staff, the deputy manager and registered manager who each told us they had a system of reporting and monitoring accidents, falls, slips and trips. The deputy manager showed us the forms they used which included an accident/incident report and a falls register form.

A member of staff we spoke with demonstrated their understanding of the reporting procedure and told us they were not at the staff meeting, held earlier in the month of our inspection, but the manager had spoken with them separately. They also told us that there was a poster for staff which described the actions to take following an accident/incident. We saw this in place on the staff notice board.

Another member of staff told us they were told about the new reporting procedure at a staff meeting and went on to described the procedure to follow after an accident/incident. This matched the actions listed on the poster the previous member of staff spoke about. This member of staff said, "You've got it covered. This way there is less chance of it (accident/incident) not being communicated as there a number of copies made".

The manager told us, "Following any accident risk assessments are completed and care plans are updated".

During our inspection the registered manager told us, “A resident had a fall last night and the paperwork is still on my desk ready to be completed”. They went on to tell us that this was the only accident that had happened since the date of their action plan and the new process had been put into place. Records we looked at confirmed this.

We looked at the falls register, which we were told was completed for all falls, and found that a record had been completed for the person who had fallen the night before our visit. The registered manager told us that they were in the process of completing an accident/incident form for this person at the time of our inspection.

We asked the registered manager to tell us what their next steps would be and they said, “I would speak to the resident and double check for injuries”. We observed them checking the person who had fallen for injuries. We also observed them checking the person’s wellbeing with a member of staff who had given them personal care earlier that day.

The registered manager also said they would, “Observe and record anything in the daily care diary”. We looked at the daily care diary for this person and saw that the fall had been documented; which included, how the fall happened, action taken and that, “No injuries had been sustained”.

We looked at this person’s manual handling risk assessment which was completed in August 2013 and found that the assessment had documented the person was at risk of falling and had been assessed by a physiotherapist.

We spoke to the registered manager and asked if falls were audited and they told us, “A member of staff looks at falls incidents regularly and if they notice anything concerning they will liaise with appropriate professionals”. We asked for documented evidence of this and was told, “No central audits are kept. The information is written in the care plan files”.

We looked at the care plan file of one person who had fallen and foun