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Inspection report

Date of Inspection: 25 November 2013
Date of Publication: 11 December 2013
Inspection Report published 11 December 2013 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Meeting 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 25 November 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.

Our judgement

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

We looked at three care plans that were personalised and detailed people's individual needs and preferences. There were 'My Care Plan' sheets that detailed how each person liked to be supported, what was important to them and actions to be taken to improve their lives. This meant staff members understood how people expressed their needs and wishes about how they wanted to be supported with their care. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care plans included up to date risk assessments.

During the inspection staff explained how they assessed the needs of people in the service. Staff confirmed that they developed the care plan by talking to the person using the service and also gained information from family, friends and professionals. The care plans showed that family and health professionals were involved in writing the care plans to ensure routines were maintained and support was person centred.

Daily records were completed during each shift and included any observations throughout the day and any actions taken. These evidenced people received support and care that was specific to their needs and wishes. Records we looked at, discussion with staff and observations showed that people's wishes were respected and acted upon. People took part in varied activities that were meaningful to them.

Each person had a section in their care plan which evidenced regular contact with medical professionals. This helped to ensure health care professionals knew about the needs of the individual. There were also sections at the back of each care plan that evidenced visits to health professionals including opticians and dentists. However, the provider may wish to note that the two recording sheets used to record health appointments did not match and there were discrepancies. Significant event records were completed for all incidents around behaviour and there were completed incident records. This showed that the care and treatment of people using the service was planned and delivered in a way that was intended to ensure people's safety and welfare.

Discussion with staff evidenced that they were aware of the home's incidents and accidents process and confirmed that it was reviewed by the provider following an incident. All reports were cross referenced with people's care plans.

The incident and accident reporting procedure was reviewed in 2013 and the forms used to report any incidents were detailed. During the inspection we were unable to view copies of completed forms as the manager advised that they were stored at another office.