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Two Cedars Residential Care Home Good

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Inspection report

Date of Inspection: 28 February 2013
Date of Publication: 1 May 2013
Inspection Report published 1 May 2013 PDF

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

Meeting 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 28 February 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

People experienced care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

We saw that care plans were in place in the six files we checked. They each detailed what support was needed and how it should be given. We saw that information gathered from the pre admission assessments had been included in the care plans. This ensured that people’s health needs were quickly identified as well as other safety and welfare needs. In addition to this people’s likes, dislikes, needs and wishes were gathered to ensure they were reflected in the care plans.

In the care plans we saw that they were split into sections, one part was based around people’s health needs, and the second part detailed their social needs and social history, as well as a social needs care plan. We saw detailed notes identifying people’s health needs and the treatment they required, for example we saw care plans for people who required creaming, body maps were included to indicate to staff where to apply creams. We saw that any action taken by staff was recorded in the daily notes. We saw evidence of close links with other services including district nurses and GPs regarding treatment plans. For example one care plan detailed numerous involvements with the GP service to monitor a person’s dietary intake. The staff had made detailed daily notes, and regularly recorded a Malnutrition Universal Screening Tool (MUST score). This is a tool that is used to identify people who are at risk of malnutrition. It also calculates the overall risk of malnutrition and offers management guidelines. We saw that the care plan had been regularly updated and medication reviews and changes were recorded appropriately.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We saw that information was recorded about how to support people appropriately. We saw that where risks had been identified there was a risk assessment in place to manage those risks. For example one person was at high risk of falls and the risk assessment detailed interventions to reduce the risk of falls which included the use of bed rails. It was equally recorded in their care plan. We also saw that the use of bed rails was reassessed monthly to ensure that they remained appropriate to meet the person's need.

During the inspection we looked at medication administration charts and we found that the medications were accurately recorded with no gaps. Any medication refusals were recorded in daily care records, and changes to medications were recorded in the medication review section of each persons file. PRN (as required) medication was also recorded in the care plan, and copies were also kept with Medicine Administration Record charts. The PRN plans detailed the name of the medication, dose, intervals, maximum dosage, whether it was ordered from the GP, route (whether oral administration or not), whether it was a special order and the reasons for administering the medication as PRN.