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Inspection report

Date of Inspection: 15 May 2014
Date of Publication: 11 June 2014
Inspection Report published 11 June 2014 PDF

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 15 May 2014, 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. Where people did not have the capacity to consent, the provider acted in accordance with legal requirements.

Reasons for our judgement

During our inspection, we saw that staff gained verbal consent from people who used the service for their day to day care. People were asked where they wished to sit and what they wanted to do. People confirmed that the staff asked their permission before supporting them to do something. This meant that the provider acted in accordance with people’s wishes and people were asked for their consent prior to any care, support or treatment.

We looked at five people’s care records and saw they included information about how the people who used the service made decisions and gave consent to their care and treatment. We saw that a capacity assessment had been completed to identify whether people had capacity to understand and agreed with their care records. Having mental capacity means being able to make decisions about everyday things like what to wear or more important decisions like making a will and deciding where to live. People can lack mental capacity because of an injury or condition for example, a stroke or dementia. Some people may have capacity to make decisions about some things but not others, or their capacity to make decisions may change from day to day. A capacity assessment determines whether people are judged to have the capacity to make a specific decision. We saw the capacity assessment included information about how a decision relating to capacity had been gained and how a decision about the support plan had been reached in people’s best interests.

One care record included arrangements demonstrating a Lasting Power of Attorney (LPA) had been made, so others could consent on their behalf. Whilst people have capacity they can choose to set up a LPA. This gives someone the authority to make decisions on the person’s behalf. For other people to make decisions about health and personal welfare, the registered person must be able to evidence a Personal Welfare LPA is in place. This meant the registered person had ensured that decisions were being made by people had the authority to do this in the person’s best interests.

We spoke with three people who had the mental capacity to make decisions, who told us they were consulted about how they wanted care and support to be provided. They told us that they had reviews of their care and their families could be involved. People we spoke with said their care and support was being delivered as agreed. One person told us, “They never just do things; they always ask me what I want.” Another person told us, “The staff are very kind hearted and are always interested in what we want. They don’t just assume.” This meant the provider ensured that people who used the service were at the heart of decision making.