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Archived: Chaseley Bungalows

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Inspection report

Date of Inspection: 13, 21 August 2014
Date of Publication: 18 September 2014
Inspection Report published 18 September 2014 PDF | 107.7 KB

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 13 August 2014 and 21 August 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 staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services. We reviewed information sent to us by other authorities, talked with commissioners of services and talked with other authorities.

Our judgement

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

Accommodation was provided for people in individual bungalows with a call bell/bleep system to allow people to call for the assistance of staff when required. This ensured that people’s independence was maintained as much as possible.

People we spoke with told us, “I much prefer it here its much less restrictive, I like to spend time on my own. I do not like people around me all the time. Staff are always available if you need them.” And, “I have control over my care I say what I want and when I want it. No one tells me what to do. I have control over my life here in the bungalows.”

At the time of the inspection there were nine people living at the Bungalows. We looked at two care files in full and a further one to look at specific areas of care documentation.

The deputy manager told us that they were in the process of implementing a new style of care documentation. We saw that the service had started to review and rewrite one person’s care file. However, this had not been fully completed at the time of the inspection. Other care plans and documentation had not yet been updated.

Pen pictures were included in people’s files. These were a precis of people’s care and treatment needs. We saw that these were in the process of being reviewed. This was being done by the senior nurse and people’s keyworkers. Old style pen pictures were not seen to be up to date or person centred. We looked at the new pen picture in the file which was being reviewed and saw that the new format included person centred information and had been written with the involvement of the individual, including quotes and information provided by them about their lives, finances, preferences and care needs.

We looked at care plans. We saw that people who had indwelling catheters did not have clear documentation in place. We saw that catheter changes had been documented in different areas of the care plan. One person’s catheter change date had been missed. We saw in their daily records that their catheter had been changed on the 1 August 2014. However documentation stated this should have been changed on the 5 July 2014, but was still in place until 1 August 2014. This person was now on an anti-biotic for a urinary tract infection. We saw that when this catheter change had been completed by an agency nurse they had documented in the persons daily records that they had been unable to use the appropriate sized catheter as the correct stock had not been available. However, staff told us that this had not been the case, and the issue was that the agency nurse had not known how to use the type of catheter the individual had been prescribed. We saw from documentation that this individual had needed to have the procedure repeated a second time on the same day when staff found the correct equipment. This meant that the provider had not ensured that care and treatment had been delivered to meet people’s individual needs and ensure their welfare and safety was maintained. We discussed this with the deputy manager during the inspection. We were told that the newly appointed senior nurse had implemented a new logging system in the diary to ensure that future catheter changing dates are not missed.

We looked at people’s daily records. Staff had documented in one person’s daily records that this individual had been in pain throughout the day. However, no documentation was seen to evidence that this had been reported to nursing staff, or that actions had been taken appropriately to address this. This meant that people had not received effective care and support to ensure that their needs were met.

People were able to spend their time how they wished. We saw that one person went shopping assisted by a member of staff. Other people told us they chose how to spend their day.

We saw that people had personal emergency evacuation plans in their care files. And the service had systems in place to respond and evacuate in the event of an emergency situation occurring.