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Archived: Sharnbrook Lodge

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Inspection report

Date of Inspection: 11 March 2011
Date of Publication: 18 May 2011
Inspection Report published 18 May 2011 PDF | 69.77 KB


Inspection carried out on 11 March 2011

During an inspection in response to concerns

We met with nine of the 23 people who live in the home at our visit. Eight of the people we met, had limited verbal communication or reduced cognitive ability, so were unable to tell us about their experiences, so we observed the care they received.

Information of concern had been received by the CQC in March 2011; one area of concern was that people who use the service were being woken by staff in the morning. Sometimes people were being woken and dressed as early as 05:45, this was not their choice.

We commenced our visit at 06:45, we noted that nine people were up and dressed when we arrived, most of whom were sitting in the lounges. On speaking with staff and looking at the staff rota two night staff were on duty, the people who were up had been assisted by them. On questioning staff as to what time people had been woken, they confirmed that they needed to start by 05:45 so that they would have enough time to get everyone up that they needed to.

Through looking at care records and speaking with both staff and people who use the service, it was only the personal choice of one out of the nine people to be up at this time.

The other areas of concern received by CQC were in relation to wound care and falls.

We found one person who was assessed as being at high risk of falling, that they had fallen a number of times within the past two months. No accident form had been completed for any of these falls, neither had any safeguarding referral been made relating to any of these falls as required.

None of the information about the falls had been entered onto the falls risk assessment or care plan for this person. The times and locations of these falls showed a clear pattern, in that they occurred at a similar time and place. Despite this the manager still did not introduce any additional measures to reduce risk in this area, or make a referral for specialist help. The person then fell again and sustained injuries.