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Inspection report

Date of Inspection: 20 May 2014
Date of Publication: 24 June 2014
Inspection Report published 24 June 2014 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 20 May 2014, 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 given to us by the provider and reviewed information sent to us by other authorities.

Our judgement

Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

We saw an up to date care plan in place for every person who used the service. We looked at all fifteen care plans, and saw that people were assessed by care staff prior to admission to the home. The provider carried out risk assessments for each person, and identified measures to address areas of identified risk. All people had a documented falls risk assessment, a pressure ulcer risk assessment, nutritional assessment, and a call system safety assessment.

We saw there was a signing in book for visitors at the entrance hall but that this was not being used on a daily basis. Managers told us that they were aware that this process was not always followed.This left people who use the service at risk from unauthorised visitors.

Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare. Managers told us that each care plan was reviewed monthly by the deputy manager, and where applicable an annual review took place with the person's social worker. We looked at records which confirmed this. Managers told us all care staff were required to sign a form to say they had read and understood the changes in the care plan but that this was not happening in the majority of cases, and there was no formal mechanism in place to ensure this was happening. We looked at records which confirmed this. Only one care worker out of four we spoke with told us that they attended care plan reviews and contributed to their development. Other care staff we spoke with said they did not regularly read or contribute to care plans and relied on daily verbal handover reports from colleagues for information on the level and type of support people needed. This meant that people were at risk of receiving care, treatment and support that was inappropriate and unsafe and people's health and wellbeing were at risk of being compromised.

Care plans we looked at did not always contain up to date information about people's preferred daytime activities, all aspects of their individual circumstances, or their longer-term needs. People we spoke with, and those acting on their behalf, could not recall being asked to discuss any aspect of their care plan with staff other than during the admission period. One person acting on another's behalf said "a member of staff had told me they had not realised the person could mobilise with the help of one carer until I had demonstrated this to them. I would have expected them to know this." They told us this had been raised as a concern with the manager at the time. This was not reflected in the care plan review.

We saw call bell leads were not connected in some rooms, including the communal lounge. The managers told us: "The residents call out if they need us, we always hear. We are continually walking around the home." People told us that staff were accessible at all times. Staff told us that they carried out checks at least once every two hours on all people in the daytime and at night, and that these checks were documented. We saw that staff were regularly attending to people's needs during our visit and people's records confirmed this. One person told us " It is not a problem. I am settled at night and don't often need much."

There were arrangements in place to deal with foreseeable emergencies. All the staff we spoke with accurately described their responsibilities in managing medical emergencies and first aid situations, and we saw that a record was kept of accidents and incidents. Eight of the staff were trained first aiders and had recently completed a first aid training update. The provider had recently undergone an external audit. Emergency equipment was clearly labelled and had the appropriate safety and maintenance checks.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a