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Archived: Lammas Lodge

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Inspection report

Date of Inspection: 21 June 2011
Date of Publication: 8 August 2011
Inspection Report published 8 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

People have been put at risk of not always receiving safe and appropriate care and support that met their assessed needs and protected their rights.

User experience

We met one person in the flat he had recently moved into from another part of the home. The wet room shower was more suitable for him and he also now had a larger bedroom. He looked well presented and was calmly engaging in an activity at his table whilst listening to music. He was going out later in the day to a local yoga class he enjoyed. He had one to one support from a worker who he seemed very relaxed and confident with. Staff said they hoped to get garden furniture for the person as this flat has a small patio area outside. This person prefers not to mix with other people in the home, although he occasionally joins the main house for a specific activity. Staff explained how they were meeting his health needs. He had been successful in losing weight which was helping his mobility. A referral had been made regarding his changing posture and he was attending regular sessions with an occupational therapist. The staff had purchased soft shoes to help heal the sores that had been developing quite often on his feet. A chiropodist was involved but the GP had not yet been asked to refer the person to a podiatrist.

We met another person who showed us his bedroom in the main house. His room was nicely personalised and he had family photographs on display. Following a request from relatives the room had recently been sound proofed to reduce the disturbance another person’s music sometimes caused. Staff helped the person explain that he goes horse riding twice a month, enjoys walking the pet dog and caring for the two ducks.

One person’s records showed that since moving into the home several preventative health appointments had been arranged such as the dentist and an overall health check.

Other records and feedback from staff showed that people’s daily personal care needs were being met and any physical health concerns were acted upon.

In recent months staffing levels had often not been at the required level, which the manager and staff told us should be seven during the waking day. Staff told us this had meant that some people had not taken part in as many activities as they would have previously done. One person’s parents told us they had become aware of this and had raised it as a concern with the manager but things had not improved. Staff told us this had led to an increase in some people’s negative behaviours as there was a lack of positive stimulation and structure to their day.

On some occasions when people living in the home had become physically challenging to others there had not been enough staff available to respond in the best and safest way. Following our visit further enquiries were carried out by other agencies and the company. This was to see if this had led to methods being used to manage incidents that were not approved and breached people’s rights

Other evidence

We looked at the care records for one person in the home. We found that there were some important gaps in the information that was needed to guide staff in how to meet this person’s complex needs. For example, the guidance about how staff should respond to behaviours that were challenging and aggressive did not include the action to take if staff or another person living in the home were actually physically assaulted.

There was no clear plan about how the person’s mental health needs would be met if they became unwell. The staff had not received any training on working with people with mental health illnesses. As a result of this staff felt they were not fully equipped to support this person. The manager had arranged training sessions for July 2011.

The way the care records were organised made it difficult to assess the information. For example there were two folders of records for each person. After an incident where staff had to intervene they completed a report about this, if there was an injury a body chart for the person in the home was completed, when the incident was serious a critical event form was also completed. All three forms were then filed separately and so it was difficult to get a view of the whole situation.

Further concerns that link to people’s care and welfare are covered in other parts of this report but have been considered in our judgement.

When our findings were shared with the company after our visit they took prompt action and started the process of improving the arrangements in the home.