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Archived: Rydan Lodge Residential Home

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Inspection report

Date of Inspection: 17, 18, 22 October 2013
Date of Publication: 15 March 2014
Inspection Report published 15 March 2014 PDF | 118.17 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 17 October 2013, 18 October 2013 and 22 October 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information sent to us by commissioners of services and reviewed information sent to us by local groups of people in the community or voluntary sector. We talked with commissioners of services and talked with other authorities.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People did not experience care, treatment and support that met their needs and protected their rights. Care and treatment was not planned and delivered in a way that ensured people’s safety and welfare.

Reasons for our judgement

On the inspection we looked at the care planning and recording systems, spoke with staff, visiting relatives and people living at the home. We also observed care being delivered and spoke with management of the service. Many people were unable to tell us about their care. One person told us their care was "Fine, thank you." A relative of one person told us that they felt the care was "quite good".

We looked at the care plans for all the people who lived at the home. We found that they contained some assessments of needs but that these had not been fully completed. This meant that care workers would not have an up to date and full assessment of the person and their needs. We found strategies were not in place to reduce some identified risks. For example, where one person’s behaviours sometimes had a negative impact on other people who used the service, there was no recorded guidance for staff as to what might trigger those behaviours or how to manage them. Incident reports and daily care records showed that this was having an on-going negative impact on people who used the service.

There was very little information to help staff to deliver safe care. We saw a number of generic risk assessments, for example, risks assessments for going to the toilet and mobility. These recorded the control measure for the risk being “staff “and “at all times”. No other information was shown. One person’s risk assessment recorded “Prone to falls and pulling other clients”. Again the control measure to reduce risks was shown as “Staff” and “at all times”. This was not sufficient information to support care workers in protecting the person from harm.

We asked one care worker if they had used the care plans to inform their care. They told us they “used the daily care records more”. Entries in those records mainly related to people getting up, bathing and toileting. Some entries indicated that where people had fallen their condition had not been assessed or medical attention sought. They had just been given reassurance by care workers. We found that body maps showing bruises and bodily marks had been completed for some people, but there was no clear link recorded to an incident report or falls report. This meant that it was not possible to account for some bruising. This did not appear to have been investigated by the service’s management. A failure to assess potential or actual harm meant that the service were not able to protect people from future inappropriate or unsafe care.

When we visited during the night we asked staff about risk assessments in relation to the use of some equipment we saw in use. We asked about a mattress on the floor of one person’s room, about bed rails on a bed and the use of foam wedges. The staff did not know if any assessments had been done. We looked in the relevant care plans. There were no risk assessments just statements that that some equipment, such as the mattress was in use. This meant an informed decision about whether the use of such equipment was safely meeting people’s needs had not been undertaken. This meant the service management were not able to ensure the welfare and safety of the people living at the home.

We also received information from health professionals who had visited the home. They raised a number of issues about the standard of care delivered. They indicated that some care workers did not recognise the need to use equipment which met individual needs and showed disregard for professional advice. Equipment had been assessed by an occupational therapist as being necessary for one person. We were told that within minutes of the equipment being fitted care workers had removed it because they thought the person did not need it and it could be used elsewhere for another person. We also received information from an occupational therapist who had recently observed poor moving and handling and had advised that further training was necessary for care workers. Health professionals who had sp