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Inspection report

Date of Inspection: 7 January 2013
Date of Publication: 9 February 2013
Inspection Report published 9 February 2013 PDF

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 7 January 2013, 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.

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. Care planning did not incorporate issues around medicines management.

Reasons for our judgement

People were at risk of receiving inappropriate care or treatment. We spoke with four people who used the service and a relative. People told us that the care and treatment they received met their needs. One person told us that staff “help us every way they can.”

People told us that call bells were responded to promptly. However, one person told us that occasionally, at night, there was a delay. We observed call bells being responded to in a timely manner. People had access to the call bell system when they were in their room so were able to summon assistance if required. When in communal areas, we observed staff interacting with people and there were members of staff in the lounge with people most of the time.

Care plans did not always reflect the needs of people. We reviewed three people’s records. One example was a person had a care plan for Methicillin-Resistant Staphylococcus Aureus (MRSA). The care plan had been last reviewed in September 2012. In the doctor’s notes it stated in December 2012 that the person was clear of MRSA. The care plan had not been updated to reflect this. However, we also saw evidence that some care plans were reviewed and reflected people’s needs. For example, one care plan covered a person's personal care needs and included the detail of what the person could do to assist themselves. The registered manager told us that the home were undergoing a complete review of people’s care plans and risk assessments and showed us a plan of when people’s records were going to be reviewed.

Staff understood people's needs and were delivering care according to their needs. For example we observed a member of staff support a person with an activity. The member of staff understood the person’s needs and tailored the information they gave the person to assist them.

Risk assessments were not always reviewed. One example was a person who had risk assessments for the risk of falls and diabetes. These risks were last reviewed in September 2011. We also saw a risk assessment for another person regarding falls and in October 2012, they had been deemed at a medium risk. The risk assessment stated that the risk needed to be reviewed monthly. Since the assessment in October 2012, the person had two recorded falls, however the risk assessment had not been updated following these falls.

The provider told us that there was one person living in the home who required medicines administered covertly at times. We reviewed the person’s records. There were no care plans regarding covert administration. There was evidence of discussion with the person’s GP, Community Psychiatric Nurse and the person’s relative, but there was no evidence of a formal assessment or care planning. Covert administration of medicines should only take place within the context of existing legal and best practice frameworks.

People did not always receive safe and appropriate care. For example, one member of staff administered eye drops to a person. The member of staff was able to explain why the person received the medicine for one of their eyes. The member of staff administered the drops to both eyes. We reviewed the person’s Medication Administration Record (MAR). The MAR sheet stated that the drops were to be administered “to dry eye”. However it did not detail which eye this referred to. When we asked the member of staff why they had administered the drops to both eyes, they told us that they “presumed it was both eyes”. We reviewed the person’s records. The eye drops were not included on the medicine form. There was mention of an eye condition in the doctor’s notes on 14 September 2012 and 11 December 2012, however it did not detail to which eye any drops were required to be administered to. There was also no care plan regarding the dry eye or medicine to be administered.

There was not a clear process in place for the monitoring of air mattress settings. The provider told us that visiting healthcare professi