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Inspection report

Date of Inspection: 9 December 2013
Date of Publication: 16 January 2014
Inspection Report published 16 January 2014 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 9 December 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service and talked with staff.

Our judgement

Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

Reasons for our judgement

We spoke with three people who lived in the service. One person said, “The care I get is fantastic. If I need it they get a doctor straight away.” Another person said, “I’m happy, I’ve got jobs. I look after the chickens.” People told us they went out in the community whenever they wanted to. One person said, “I go out every day, I go on the tram, I go to meet my sister.” We observed a chair based exercise class taking place.

We saw that staff communicated with people according to their needs, giving time for the person to respond or using sign language. We found that people’s care and treatment was not always planned and delivered in line with their individual care plan.

We looked at the care plans of two people who lived in the service. Within one care plan we found that the person was at risk of developing a pressure ulcer. We saw from their care plan that they had a pressure ulcer which had been recorded on 15th November 2013 and that the district nurse (DN) had recommended two hourly turns while the person was on bed rest. Staff we spoke with told us they turned the person every two hours and made a note in the daily records that they had done this. We did not find any current turn charts in place which could detail the frequency of the person changing position. This meant that the provider could not be reassured that the person was having their needs met around pressure area care.

We saw that the person’s care plan stated that the Malnutritional Universal Screening Tool (MUST) should be completed and that the person’s weight should be recorded on a monthly basis. The MUST enables staff to monitor the risk of the person experiencing malnutrition. We saw that during 2013 the MUST had only been completed correctly on one occasion. This meant that staff were not fully aware of the person’s risk of malnutrition and any action they may need to take as a result of this.

We saw that this person was losing weight but there was no evidence that any action had been taken to consider the reasons for it. This meant that the provider was not providing or monitoring care according to the person’s identified needs. We informed the registered manager of our concerns and they told us they would refer this person to their GP.

We saw from the care plan that this person had a suprapubic catheter in place. It detailed what the DN would be responsible for and what the staff needed to be aware of. However the person’s care plan stated that staff should monitor the person’s urine output. We did not find any current records in place to monitor this. We spoke with staff who told us when they would need to report concerns about the catheter to the DN, but they did not tell us about the need to monitor the person's urine output. This meant that there was a risk that the person’s catheter could become blocked and the staff would not be able to respond to this in a timely manner.

We saw that care plans were not always regularly reviewed. This meant there was a risk that staff would not always have the most up to date information about a person’s needs. For example, we saw medication records that showed a person’s warfarin had been discontinued howeved the warfarin care plan in their care file had not been updated to reflect this. We saw there was a risk assessment November 2013 for the use of bed rails for one person. We observed that these were in place. However their care plan for going to bed had not been reviewed since June 2013 and did not include advice to staff on how and when to use the bed rails. This meant there was a risk that staff may not have the most up to date information about the person’s needs and how to meet them.

The manager told us that French doors had been fitted to people’s flats recently and this meant people would now be able to leave the service in the event of a fire in bed if they needed to. We looked at the Personal Emergency Evacuation Plans (PEEPs) of three people using the service. PEEPs are plans which