You are here

All reports

Inspection report

Date of Inspection: 11, 13 April 2011
Date of Publication: 17 June 2011
Inspection Report published 17 June 2011 PDF

Contents menu

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

Our judgement

Information did not accurately reflect the care, treatment and support people require. Records were not completed in sufficient detail providing clear direction for staff about how people were to be supported so that their needs were met and risks minimised.

User experience

Whilst looking around the home we saw one person relaxing in their own room. This person did not want to talk with us however said they were fine. Other people were seen relaxing in the communal areas chatting with staff. We did note however that there was no structured activities taking place.

Feedback was also received from local authority commissioners and health care professionals about the service provided for people funded by them to live at the home. Whist people felt that the general care was good, arrangement with regards to ‘therapeutic’ support from nursing and care staff, who understood the mental health needs of people, was not being provided.

Other evidence

Prior to us visiting the home on the11th April 2011 we were made aware by visiting health and social care professionals of their concerns about poor care records and the lack of monitoring in relation to peoples health care needs.

Care records were examined during our visit. We found that files lacked information with regards to the specific needs of people.

Care plans did included personal information, general risk assessments (such as moving and handling, nutrition and falls), a psychiatric profile, observational charts, care plans and information about routines. However there was little information about the persons mental health needs, behavioural plans and intervention strategies for staff to follow so that areas of risk were minimised and people kept safe. Plans were not person centred nor did they evidence people were involved in the planning of their care, treatment and support.

Observational charts recorded where necessary people’s blood pressure, blood sugar and temperature. However there were no structured observational charts with regards to people’s mental health needs, identified risks and behaviours. There was also no evidence of monthly reviews of the plans or risk assessments and records where people had lost weight did not show what action had been taken to address this.

Records also provided no detail about the 1-2-1 support hours some people were in receipt of, the purpose for additional support hours and what was to be provided by staff. Some of the people living at Church Walk also had ‘restrictions’ in place such as requiring supervision away from the home. This was said to be due to potential risks however this too was not recorded within the care records detailing what support was required as well as intervention strategies and guidance for staff.

Information was received from the provider prior to our visit. They identified that improvements were needed. They also noted that ‘a copy of the refocusing the care programme approach was in place and that care planning was focused around this’. There was no evidence to support this.

We spent some time talking with the managers about our findings. We also discussed the role of the service, suitability of placements and the service provided at the home. The managers acknowledged that documentation needed revising. They were also reviewing the purpose of the service as they felt this was not being delivered to its full potential. ‘Therapeutic’ support required to promote and enable personal growth and encourage people in becoming more independent was not being provided. However plans were being made to address this.