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Archived: Victoria Lodge Residential Care Home

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Inspection report

Date of Inspection: 26 February and 8 March 2013
Date of Publication: 28 January 2014
Inspection Report published 28 January 2014 PDF

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

Enforcement action taken

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 26 February 2013 and 8 March 2013, 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 and talked with commissioners of services.

Our judgement

People did not experience care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

A ‘daily log’ recorded the essential elements of care that people received such as food intake, bowel movement, oral care and bathing/washing. This ensured people received support with personal care. People told us that they felt cared for and supported. One person told us that they liked it here and saw the district nurse and GP when they needed to. Another person told us “if there’s anything that needs changing I ask and it’s done”. We spoke to relatives who told us that staff were caring and met people’s support needs. We were told, “he is clean and always looked after. He likes it there”.

Information was gathered on people at the point of referral. This was demonstrated through an example of someone who had recently been admitted and included separate assessments on nutrition, moving and handling, skin integrity and risk of falls. Care plans identified aspects of people’s support needs and how to meet them. This included washing, nutrition, day centre involvement and night time care.

Assessments were fragmented and not comprehensive. Assessments were contained on individual sheets that addressed individual aspects of need such as moving and handling and skin integrity. Information contained on care plans was not informed by documented assessments. There was no single assessment that drew together a holistic view of the person and no space on assessments for people to state their view or opinion on how they wished to be treated or cared for. People’s health needs were not stated on assessments and care plans did not address how health needs should be met. This meant that people were not protected against the risks of receiving care or treatment that was inappropriate or unsafe because proper assessments of need had not been carried out and the planning and delivery of care was not meeting people’s individual needs

Individual care files contained lists of medical/health professionals who had visited people such as GP, psychiatrist, pharmacist and optician, whose names had been recorded alongside a very brief description of what had been carried out. For instance, next to the psychiatrist’s involvement it stated that medication had been changed and next to the optician’s name it stated ‘eye test’. There were examples where doctors had only stated what medication people were on such as heart medication or mood stabilisers, suggesting serious physical and psychiatric health issues. These health issues had not been included in individual assessments of need and there was no information in care plans about how to meet these identified health needs.

We were given an example by the manager where one person was being treated for a serious medical issue. We were told how their needs were being met from a practical perspective although this had not been documented in assessments or care plans. This meant that it was unclear how the service understood what the person’s health needs were or how they understood whether they were meeting them or not. It was difficult to ascertain from the assessment and care planning documentation how the service met people’s health needs or how staff understood how they were to meet these needs.

The local authority’s safeguarding and quality monitoring teams visited on 13 March 2013. They checked people’s individual care records and found that one person’s challenging behaviour did not feature in their care plan and that a risk assessment was not in place. They found that another person’s medication for a serious health complaint ran out in two days time and they had not been registered with a GP and did not have a prescription to continue this medication. Another person’s challenging behaviour did not feature in their care plan and a risk assessment had not been completed. This meant that people’s health and care needs were not being met and their safety and welfare was not ensured.