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Inspection report

Date of Inspection: 14 January and 14 June 2011
Date of Publication: 23 August 2011
Inspection Report published 23 August 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

The care planning process did not fully reflect all aspects of the service user’s individual circumstances, and their immediate and longer term needs. Risk assessments were not fully identified, and did not state how these should be managed.

User experience

We did not talk to people about this outcome.

Other evidence

We looked at each service users support plans and the plans about how staff would support each person. The support plans were generally person centred and described each person’s likes dislikes, family, friends, hobbies and interests. Information included diet, health, medication, morning, afternoon and evening routines. There were sections on communication, choices and decisions, how money is managed and support networks.

Overall the support plans were well written and informative. However, we found that there was reference in the staff support plans that highlighted individual risks, for example: one person was at risk of choking, but there was no specific risk assessment in place about how this should be managed.

In another support plan it clearly stated that one person was at risk of malnutrition, and should be weighed weekly however, there was no evidence of a special diet or a specific risk assessment in place for this person. This person’s weight had not been recorded on their weight chart since 23 May 2011.

In another support plan for another service user, there was a risk assessment on file which indicated the need to implement the behavioural management guidelines and plan, but there was nothing available for staff to follow. This related to someone who had a behaviour which involved harming them self. There was no clear management plan in place regarding this behaviour.

We found that the social activities plan’s/diary for each person were out of date, or not being followed. For example: one person no longer attended a social gathering, but their support plan stated that they attended this venue several times each week.

We found that staff were taking several services users out every day to local shops, pubs, and local places of interest. However, there was no social structure or formal planning for these outings. These ad hoc arrangements were exacerbated by 2 service users who displayed very challenging behaviour, and staff told us that service users were taken out to avoid them becoming stressed by this. We saw very little constructive or meaningful activity with service users in the home. This was because the staff team were spending a great deal of their time trying to manage/cope with 2 service users with challenging behaviour.

During the visit on 14 June 2011 one service user was displaying very challenging behaviour, they had a ‘when required’ medication plan in place and this was exhausted during our visit, there was no other plan in place to tell staff what to do when these medicines were exhausted. We found that the daily records gave little information about the individual’s health and social wellbeing, and did not relate to the individuals support plans.

The acting manager told us that she had made arrangements to audit each service users support plans, because she had already identified lots of gaps and out of date information since she commenced employment. She was particularly concerned about the lack of risk assessments, management guidelines, the lack of menu planning and how meals were being prepared.