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Inspection report

Date of Inspection: 6 January 2014
Date of Publication: 5 February 2014
Inspection Report published 05 February 2014 PDF | 79.29 KB

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 6 January 2014, 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 and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

People who used the service told us they were happy living at the home. They told us all their needs were being met and staff were pleasant and kind to them. One person said, "If I need anything staff will get it for me. " Another person said, "I have everything around me which I need and staff are very pleasant."

We observed staff throughout the day assisting people with a variety of tasks; such as helping drink a cup of tea and assisting to the toilet. They spoke calmly and respected the person's wishes when they did not want to do something. They knocked on doors before entering and announced who they were. Staff ensured when walking aids or wheelchairs had to be used to assist a person's mobility, these were safe to use before handing them to the person concerned.

We looked at three care plans. Each person had an assessment prior to admission to the home of their needs. Staff told us the care plans had been developed over a period of time once they had reassessed them in the care home. The records confirmed this. The daily report sheets were easy to read and had been written at the end of each shift. They detailed the sort of day each person had experienced; such as the meals they had consumed, treatment given and visitors seen.

Each care plan had been evaluated on at least a monthly basis and contained the signatures of people who used the service or their advocate to say they had seen the care plans. An advocate is a person who came speak on someone's behalf if they can not do so for themselves or have communication problems. People told us they knew staff kept records about them.

The provider may wish to note we looked at one care plan which was incomplete, where a person had mobility problems due to a back injury. Staff had documented how often they assisted the person to be turned in bed and what prescribed pain relief medicine the person was taking; but the care plan for the person's mobility needs was not up to date. This could put them at risk of injury if staff were unaware of the safest way to move the person. This was fed back to the manager during the visit and she allocated a staff member to up date the plan.

The provider may wish to note we looked at a person's care plan who required dialysis to aid their kidney function but not all of the documentation was complete to instruct staff on how to use the machine. The person who required the treatment was able to verbally tell the staff, as they normally completed the treatment in their own home, but the instructions written for staff did not confirm the process required. This may put the person at risk if staff were unaware of how to correctly administer the treatment, if the person could not speak to them for any reason. All other sections of the care plan were up to date including the daily charts to record fluid intake and output. The manager was informed of this during our visit and allocated a member of staff to check the written regime of treatment and inform staff.

The provider may wish to note we looked at a person's care plan who required to be fed by a tube directly inserted into their stomach but the recording of the feeding treatment did not always follow the regime set out by the hospital dieticians. Staff were able to explain what they did each day, which did follow the regime but the recording differed depending on what staff were on duty. This may lead to confusion and may result in the person not having the correct amount of nutritional supplements each day. The rest of the care plan was complete and included plans of care for nutritional well being, personal care, mental health needs and end of life care. The manager was informed about this during our visit and allocated a member of staff to give clearer instructions to staff on how to record events.

Staff we spoke with had a good knowledge base of the needs of each individual who lived at the home. They were able to tell us a lot of previous history of the person, details about relati