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Archived: Albany Park

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Inspection report

Date of Inspection: 7 December 2010
Date of Publication: 18 April 2011
Inspection Report published 18 April 2011 PDF | 156.97 KB

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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 reviewed all the information we hold about this provider, carried out a visit on 07/12/2010, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

People told us that staff generally met their needs. People said that staff were generally caring and supportive. However, people felt that they had not been involved in reviews of their care. Care plans did not give guidance on how the needs regarding their pain relief, tissue viability and end of life care of people should be met. The registered person has not taken proper steps to ensure that each person is protected against the risks of receiving care or treatment that is inappropriate or unsafe as care plans are incomplete and do not match the care provided.

User experience

People spoken to generally felt that the home met their needs. We observed that staff generally responded to peoples’ needs. One person when asked about how the home had helped her said, “I couldn’t walk when I came but now I can”. We observed that staff responded to peoples needs. They showed us they understood how to meet peoples’ needs. People are given the support they need.

People told us that they could see their families when they wanted to. We observed that relatives were able to visit throughout the day. A person when asked about this said, “I see my daughter each week. She comes and we can go and talk in my bedroom.” The home encourages people to maintain contact with their families.

People spoken to said that they felt that the staff would respond to any changes in their needs. However, they were not aware of how they could be involved in making changes to their care. People said they had not been involved in reviews of their care. People were not consulted about how they would be supported.

Other evidence

We looked at a number of assessments and care plans of people living at the home. Some of the care plans did not have an initial assessment of the person's needs before coming to live at the home. Safeguarding investigation showed that a detailed assessment of peoples’ needs was not carried out in all cases. The operations manager explained that in future people would be assessed before they came to the home. She showed us an example of an assessment form. This format covered all the main areas of need. Its use had been agreed with professionals who make placements at the home. A detailed assessment of peoples’ needs should be made to ensure their safety and well-being.

Care plans that we looked at did not provide detailed information about how peoples’ needs would be met. For example, one person's care plan highlighted that they may at times be in pain. However, it did not give any indication as to what might show the person was in pain. There was no pain assessment detailing when pain relief should be given. Another person was identified as having a risk of seizures. The care plan did not provide guidance on when emergency medical assistance should be obtained. A relative had highlighted that staff did not appear to know how to respond when supporting a person's asthma care. Cares plans need to be detailed so that people’s individual needs are met.

A number of safeguarding alerts had highlighted issues with tissue viability treatments provided at the home. On a number of occasions visiting professionals found that care plans and assessments had not been carried out of people who had pressure sores. This had meant that on an occasion staff had not used the appropriate dressings. This had contributed making pressure sore of a person more severe.

We looked at the care plans and assessments relating to tissue viability care for a number of people. We found that assessments had not been completed in detail. A person had been identified as having a high risk of developing pressure sores. There assessment had not been reviewed regularly to make sure that they were receiving the appropriate treatment. Care plans for the prevention and treatment of pressure sores did not provide a detailed plan of care. There was no guidance as to what pressure relieving equipment could be used. Nor were the dressings to be used identified in the care plans. Assessments and care plans need to provide the necessary guidance to ensure that people receive the tissue viability care they need.

Safeguarding investigations have highlighted that peoples end of life needs had not been fully documented. The care plans we looked at did not have clear guidance as to support and wishes of people regarding their end of life needs. Staff spoken to could not explain fully how peoples end of life needs would be met. Staff told us they had not received training in how to meet people’s end of life needs. People may not get the care they need at the end of their lives. Peoples' end of life needs should be included in the assessment and planning of their care.