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Saltmarsh House Residential Care Home Requires improvement

All reports

Inspection report

Date of Inspection: 15 November 2013
Date of Publication: 18 December 2013
Inspection Report published 18 December 2013 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 15 November 2013, 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

Care plans included information relating to falls, and risk assessments which determined the risk of people suffering a fall within the service. However, there wasn't any evidence of the risks being monitored. Although all falls were recorded there were discrepancies and there was not any evidence that procedures were put in place to minimise the risk.

Reasons for our judgement

Staff confirmed that they developed the care plan by talking to the person and also gained information from family, friends and professionals. The care plans showed that family and health professionals were involved in writing the care plans to ensure routines were maintained and support was person centred.

We looked at three care plans that detailed people's individual needs and preferences. There was information about how each person liked to be addressed and how they wanted their support to be delivered. This helped staff understand how people wanted to be supported with their care.

During the inspection we viewed the accident file and falls register and looked at copies of completed forms. There were discrepancies between the two recording systems and the records did not match. There were 23 incidents of falls in 2013 that were recorded in the falls register but did not have corresponding completed accident forms. The manager told us that monthly reviews should be completed to look at the number of falls each month, how many people had fallen more than once and how many resulted in serious injury. The last monthly review of falls available at the time of the inspection had been completed in September 2012. During the inspection we were unable to evidence that risks were being regularly monitored as we were only able to view completed audits for January and September 2012. The care plans did not show evidence of reviews taking place following a fall to determine patterns or triggers in order to minimise the risk of falls in the future. The two members of staff we spoke to were not aware of any changes in people’s mobility needs following falls. This increased the risk to people of further falls.

The care records also showed that that care plans and risk assessments had not been reviewed following falls. The lack of regular updates, especially immediately following a fall, meant that people using the service were not protected from harm and the risks were not reduced. This evidenced that care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

Daily notes were completed at the end of each shift and included any observations throughout the day and any actions taken. These evidenced people received support and care that was specific to their needs and wishes. Records we looked at, discussion with staff and observations showed that people's wishes were respected and acted upon. People took part in varied activities that were meaningful to them.