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Inspection report

Date of Inspection: 22 August 2013
Date of Publication: 24 September 2013
Inspection Report published 24 September 2013 PDF | 77.27 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 22 August 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

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

When we made checks to ensure the provider was meeting this standard we spoke to people receiving care and support. We reviewed how people had consented to care and any planned treatment. We also made checks to see how people's relatives were involved when appropriate. Where any person had been identified as unable to make decisions themselves, we checked the provider had followed best practice to ensure that decisions made were in a person's best interest.

At the time of our inspection there were four people living at York Road. We found that care plans were signed by the person they related to. This indicated that people's daily care had been discussed with them and they had consented to the care planned.

We looked at one person's care plan in detail. From this we could see that visits to other clinicians had been organised. In the case of visits to a dentist, the person had been involved in discussion on the importance of the treatment required, how any dental treatment would be carried out, where it would be performed, and whether the person may prefer to be sedated for that treatment. Records of these discussions were held in the care plan. Letters relating to appointments for treatment were addressed to the person concerned, indicating their involvement in any planned treatment. Notes added to those letters confirmed a support worker had explained options available for receiving the treatment.

We reviewed notes in respect of a person who had been assessed as being unable to make decisions on a variety of things, for example, administration of their daily medicines. We noted this person's care file did not hold a copy of the original mental capacity assessment regarding this. We could see from care records held that a review of this person's care had taken place recently, that relatives had been involved in the review and that the person concerned had signed the updated care plan. However, there did not appear to be any formal review of the mental capacity assessment. We discussed this with the temporary manager of the home and with the Operations Director. Both agreed that a formal review of the mental capacity assessment was something that should have been done as part of the care plan review. We were assured that the review would be organised immediately and that a copy of the original assessment would be located and held with the care plan for future reference. At the time of our inspection, the provider's quality development lead was also working at the home. They had recently conducted an audit of people's care records and were aware of the missing paperwork and evidence of review of this person's mental capacity. As a result, training on the Mental Capacity Act 2005 and associated guidance on best interest decisions and supporting paperwork was being delivered to staff at the time of our visit.

We spoke to one person at York Road about their care and support. They confirmed they were happy with their care. In our observations of care and support of people at the home, we found that consent was sought by staff, for example, when offering support to complete a task. This meant that people received the support they needed and it was delivered in a way that protected their welfare and supported their independence.