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Mildenhall Lodge Outstanding

All reports

Inspection report

Date of Inspection: 26 September 2014
Date of Publication: 4 November 2014
Inspection Report published 04 November 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 26 September 2014, 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, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider. We were accompanied by a pharmacist.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

During our last inspection on 31 July 2014 we were concerned that the service was not meeting the needs of people with a diagnosis of diabetes. During this inspection we looked at the care plans for two people with diabetes and saw that there was clear information about how their diabetes should be managed. We saw that people had their blood glucose levels tested appropriately and that this was recorded. We found that staff showed an increased understanding of diabetes and were working in partnership with the local GP service to support one person with a change to their medication in order to manage their condition.

We observed some care practice that concerned us on the dementia unit. When we arrived we noted that one person remained in bed and had their drink and call bell out of reach. We raised the matter with a member of staff and these were immediately placed within reach. We saw that one person’s care plan stated that their food should be cut up and, if possible, sauces added to meals to moisten them. We saw that this person was eating fish, chips and peas which had not been cut up and noticed that they were pulling the food apart with their fingers. This meant that staff had not followed this person’s care plan and which resulted in them eating in a way which could compromise their dignity.

We also saw that the agency member of staff who was on duty was giving a person their lunch in bed. We saw that the person was lying almost horizontal on the bed and was at risk of choking. Again we alerted a member of staff. We established that the agency staff member had not read the eating and drinking care plan for the person they were supporting and noted that staff were busy supporting other people at the time. This incident placed this person at risk of unsafe care.

At our last inspection we were concerned that low staffing numbers meant that people’s care needs were not met in a timely way. At this inspection we found staff numbers reduced at times to a level that meant people did not always receive support promptly. On the nursing unit two people were still in bed at 11.00. Staff told us that they were sometimes pushed to get people up in time for lunch. We noted that relatives came in to assist their family members with their meals. They told us they did this because they were concerned that their family member would not receive their food on time. Staff confirmed to us that without this support they would struggle to meet the needs on this unit. Relatives also had concerns about how long their family members had to wait to receive support to go to the toilet or have their incontinence pad changed.

We saw that the service used the CAPE dependency assessment. However we found that staffing levels were not always assessed in line with people's everyday needs. We saw that on the nursing unit the impact of this was that people’s basic care needs were not always met in a timely way. We asked how often people had baths or showers on this unit and established that one person was able to communicate verbally and asked for a daily shower which they were given. The other people were less able and staff told us that baths and showers were not offered frequently. For some people there was no evidence in records that they were given regular baths or showers.

We noted during our inspection that at 14.10 the team leader was on duty on the dementia unit and supporting someone in their room. The only other member of staff on duty was on a shadow shift as they were new to the service and they told us their shift should have finished at 14.00 but they had stayed on as no other staff were around. We asked the support manager how they could ensure people were kept safe with these staffing levels. They told us they were unaware that the unit’s staffing for the afternoon was for only two people, one of whom was on their break. They arranged for additional staffing but we were concerned that this error in staff allocation placed people at p