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Inspection report

Date of Inspection: 4 June 2013
Date of Publication: 14 June 2013
Inspection Report published 14 June 2013 PDF | 82.81 KB

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 4 June 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Reasons for our judgement

We looked at this outcome to see what arrangements were in place for obtaining the consent of people who were living at home in relation to their care and support needs.

As part of our inspection we spent time with six people who were living at the home and two relatives who were visiting the home while we were undertaking the inspection. Relatives told us the manager and staff communicated well regarding any changes to treatment and care. Some people were able to tell us about the care and support they needed. They said staff discussed their care with them and explained things to them.

We looked at four care record files for people who were living at the home. With the exception of one person who had very recently moved into the home, the person or their relative/representative had signed the care plan.

One of the care record files we looked at included an agreement about the medical attention a person should receive if they became very ill. We could see that the person’s relative and GP had been involved in the discussion, and had signed a form to confirm they supported the decision and agreed plan. This agreement had recently been completed and we asked the manager how frequently it would be reviewed. The manager informed us that it was discussed each time the GP visited the person. The provider may wish to note that we did not see a formal record of these discussions with the GP.

The provider (owner) had commissioned an external organisation to carry out an annual quality audit (check) of the home. The purpose of the audit was to assess the standards of care and facilities. The last audit was completed in March 2013. We observed the audit report made a recommendation that Mental Capacity Act assessments should be completed for each person who was living at the home. The Mental Capacity Act (MCA) 2005 is legislation to protect people’s rights regarding decision making should the person lack mental capacity.

We observed from the care records we looked at that an MCA assessment had been completed for each person. The forms were incomplete as they did not outline what decisions needed to be made in the person’s best interest. We discussed this with the manager at the time of our inspection.