You are here

All reports

Inspection report

Date of Inspection: 21 January 2011
Date of Publication: 25 May 2011
Inspection Report published 25 May 2011 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

Our judgement

People who use the service were being treated with respect but were not fully involved in planning their own care. Records showed that people were not at the centre of assessing their individual needs and preferences, and planning to meet these. The planning of their care demonstrated that risks to their health and welfare were not being identified or managed safely.

User experience

We spoke with a close friend of a person who uses the service. She confirmed she was involved in reviewing her friend’s care plan one day in 2010 but could not recall if she had signed it. She felt that this care plan was an accurate reflection of the person’s needs. She also told us that, “staff treat residents as human beings”.

Other evidence

We spoke with the service’s activities co-ordinator who explained she is one of three dignity champions at the location and that a staff resource pack is being developed. We saw reference on the ‘Dignity Board’, in the entrance hall, to a Dignity Action Day being held on 25 February 2011.

The acting manager told us that staff were currently attending person centred care planning training with Nottinghamshire County Council. She said that eight care plans (recent admissions) had been completed in a new person-centred format; the rest were to be completed within the following three to six months.

We examined two files of people who use the service. The first file was in the ‘old’ format and was holistic but not person-centred. Most of the information on the file ‘front sheet’ was from June 2008, including medication, and therefore considerably out of date. Risk assessments were all out of date, with many being unsigned and undated – therefore not providing an adequate audit trail. For example, in a Waterlow tissue viability risk assessment, there was only one entry dated 29 July 2010 and this gave a high risk ‘10+’ score. The regional manager told us that such a score indicates a need to review a person’s risk of developing pressure sores monthly. We noted that a requirement had been made following a key inspection, in May 2010, for care plans to reflect current issues. Therefore this had not been met.

The second file was in the ‘new’ format. The person had been recently admitted. There was little evidence of this file being any more person-centred than the ‘old’ format. There was some reference to the person’s preferences. However, the format did not prompt staff to write in a person-centred way. There was no signature by the person, or their representative, to show they had been involved in developing the care plan.

Our assessment of these two files supported the observations of Nottinghamshire County Council’s Quality Development Officer, on their visit to the service on 4 January 2011. They also found care plans were not person centred and monthly care plan reviews poorly worded.