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Inspection report

Date of Inspection: 16 July 2013
Date of Publication: 2 October 2013
Inspection Report published 02 October 2013 PDF | 74.51 KB

Before people are given any examination, care, treatment or support, they should be asked if they agree to it (outcome 2)

Meeting this standard

We checked that people who use this service

  • Where they are able, give valid consent to the examination, care, treatment and support they receive.
  • Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.
  • Can be confident that their human rights are respected and taken into account.

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 16 July 2013, observed how people were being cared for and talked with staff. We reviewed information given to us by the provider and talked with other authorities.

Our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

Reasons for our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. During our inspection we observed a staff memeber ask the person "Are you happy to take your medication now" The person replied "yes" The staff member then administered the medication.

A staff member told us they always ask the person before providing care. They also explained that a best interest decision would be made and recorded in a person's care file if they were unable to make a decision. We looked at two care records and saw evidence of these consent procedures. For example one person who uses the service had become unsteady on their feet when mobilising and was now using a walking frame. We saw evidence in their care record that the decision to start using a walking frame had been discussed with the person, an occupational therapist and their family and consent had been obtained.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.A member of staff told us about someone who has capacity to make day to day decisions but not more complex decisions. They told us that they were able to gain consent from the person on day to day daily living decisions but that more complex decisions were discussed with the person's family and relevant professionals as required. We saw from the person's care records and saw evidence that recent dental treatment had been carried out through a best interest decision to enable treatment. We also saw that it was recorded in the person's care plans that the person had capacity to make decisions on their daily life.

The staff member told they always check the care plan before giving care to an individual. Staff told us they would involve health professionals, such as the person's GP and community learning disability nurses as appropriate to provide appropriate care.We looked at two care plan records. Capacity assessments had been completed and staff were aware of the information. There was evidence of family and health professional involvement in best interest decisions being made.

The staff member told they always check the care plan before giving care to an individual. Staff told us they would involve health professionals, such as the person's GP and community learning disability nurses as appropriate to provide appropriate care.

We when looked at two care plan records. We saw Capacity assessments had been completed and staff were aware of the information. There was evidence of family and health professional involvement in best interest decisions being made.