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Inspection report

Date of Inspection: 2 May 2013
Date of Publication: 30 May 2013
Inspection Report published 30 May 2013 PDF

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 2 May 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

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

The people that we spoke with told us they were consulted about the care they received. One person said, “The staff always ask and explain what they are going to do when they support me”. We observed staff talking to people throughout the day and gaining people’s permission before providing care and support.

We looked at two people’s care records. We saw that consent had been obtained in relation to specific areas such as medication. However there was no written evidence to support that people had consented to all aspects of care and treatment. There was also limited evidence in the files to support that people and their relatives had been involved in their care plan. The provider may find it useful to note that people's care files did not fully reflect their involvement and consent to the care and support they recieved.

When we spoke with staff they told us how they obtained consent from people who used the service before they provided care. One staff member said, “I always ask people if it is ok for me to provide care to them”. Another staff member told us, “I always explain and ask people before I provide any care or support”. This meant that staff recognised the importance of ensuring people agreed to any provision of care before they attempted to carry it out.

The care records we looked at showed that people's mental capacity was now being assessed and we were told the care plans were being updated to include this information. This should ensure that where a person lacked the mental capacity to make decisions about their health and welfare, the appropriate decisions could be made in their best interests.

We found that staff had not yet received training in the Mental Capacity Act and the Deprivation of Liberty Safeguards that accompany this legislation. We saw evidence that staff had been provided with information leaflets. The provider may find it useful to note that access to this training should enable staff to have a better understanding of mental health and what to do if a person lacked capacity to give consent for care or treatment.