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Inspection report

Date of Inspection: 4 September 2013
Date of Publication: 18 October 2013
Inspection Report published 18 October 2013 PDF | 88.74 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 4 September 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

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Reasons for our judgement

We looked at records, observed staff practice, spoke with eight people who used the service and three people’s relatives about agreeing with decisions about their care and treatment. People told us they were asked for their consent before they received any care or treatment. People we spoke with told us they made daily decisions for themselves. One person told us, “I can have a lie in if I want one, I am offered choices. I choose the clothes I want to wear and there is a choice of food offered”. Another person told us, “I am offered the choice to sit in my room or to join others in the lounge”. People were satisfied the staff acted in accordance with their wishes.

The discussions we had with some people were limited due to their individual communication abilities but people who could express their views said they were “generally happy with life at the home”.

We observed the care and support provided to people who used the service. We saw staff asked people about the care they planned to provide before they supported them. Examples included: staff asked people if they wanted to walk or be assisted to have lunch in the dining room and a person was asked if they wanted to go to their room for a rest.

We spoke with three members of staff and the manager. Staff could explain how people could consent to decisions. One staff member told us they would leave a person to lie in bed if they did not feel like getting up in the morning or if someone wanted support with a shave later in the day, they would respect the person’s decision.

People who used the service, or their representative had been asked to sign a service user agreement to the care plan, this was their consent in relation to care and treatment and a separate form to consent to photographs being taken.

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We spoke with the manager who knew what to do when important decisions needed to be taken on behalf of people who lacked capacity to make decisions. We saw where a ‘Best Interest’ decision had been documented. This ensured actions were taken in the best interest of people who used the service. We saw some files had copies of forms about action to be taken if the person became seriously ill. These forms showed that people, and/or their representatives, had been involved in discussions with a doctor about their wishes towards their end of life care. This showed that people and their representatives had been given opportunities to share their views.

We looked at four people’s care plans; these included a capacity assessment form to assess people’s capacity to make their own decisions around the proposed plan of care and medication. The provider may find it useful to note that capacity assessments should be time specific and decision specific. We saw two peoples care plans which showed that the staff had met with their families or a representative and where appropriate, had encouraged them to read and sign a consent form. This showed the person or their representatives’ were involved in their care.

People who used the service had access to information. This included the statement of purpose, service user guide and some patient information leaflets. The manager told us that access to information on local advocacy services was made available and we saw one person had used this.