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Inspection report

Date of Inspection: 24 May 2011
Date of Publication: 12 July 2011

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 using the service did not experience safe and effective care and did not always have their personal care needs met. People were at risk of injury through a lack of procedures for dealing with falls.

Overall, therefore, we found that there are areas of non compliance with this outcome. We are taking further action to protect the safety and welfare of people who use services.

People were not regularly checked on by staff and those that had difficulty with their mobility were not always supported to maintain a comfortable seating position.

Overall, therefore, we found that there are areas of non compliance with this outcome.

User experience

We received information before we visited the service telling us that people were not helped to have baths and that they were often left in wet clothes after being incontinent.

People that regularly visit the service told us that they had seen people sitting in the lounge for long periods of time without any staff talking to them. One person said they had seen people slumping in armchairs without any staff checking if they were uncomfortable. We saw one person sitting slumped in a position that did not look comfortable on one of the sofas when we arrived at 10.05am. We returned to the lounge at 10.30am and they were still seated in the same position. We spent some time watching to see what life was like for people living in the home and saw that the person remained slumped in the seat until a staff member gently woke them at 11.35am. None of the other staff had stopped to check whether they were uncomfortable.

When we spoke with people who visit the service some people were not happy with how often people were helped to the toilet. One person told us “I am not always sure that people get toileted very often. X is continent but doesn’t know how to ask staff to take them to the toilet. Several times I have come in and X has been soaked up their back. Once I had to ask staff to take them to the toilet to and when they brought them back they went to sit them on the same chair. I had to stop them and clean it myself first”

Another person said “I have seen others being taken away [to get changed] and chairs not cleaned and then another person goes and sits in it.” They also said they had needed to point out to staff that someone had been incontinent. During our visit we noticed that two people we were sitting near to smelt of unpleasant body odours which did not promote their dignity.

However, this was not everyone’s experience and one person told us that they were completely satisfied that their relative was helped to the toilet when needed and as far as they were aware they were helped to have a bath regularly as they always appeared clean. They said “the level of care shown to X has transformed my family’s life” and that there was an “emphasis on normality of life”.

During the time we spent using our SOFI tool to see what people’s experiences were we found that four out of five people were not offered help to go to the toilet during the hour and a half period before lunch. People were then helped through to the dining room for their meal without any offers of help to the toilet.

The lounge area of the home was busy and visitors to the service told us that they liked the social atmosphere this provided for people. However, the time we spent watching the support given to people also showed that the staff did not provide support to everyone using the service in an equal way. People that were able to verbalise their requests or their discomfort received more support that those that sat quietly. We saw two people receive no interaction from staff during the hour and a half period.

One person told us that they were concerned about the number of falls people using the service had. They said their relative had twice fallen and been injured since being in the home. They felt that they had not been given a satisfactory explanation about how the falls had happened or what would be done to stop it happening again. Another person told us that their relative had fallen in the home, but they were satisfied that the service had told them what action they were going to take to help keep the person safe.

Other evidence

Staff told us that the manager would complete an assessment of people’s needs when they started using the service and that information about how to care for the person was shared with staff during the handover each day.

Everyone using the service had a plan for their care, which gave staff information about how to meet their needs, but as described under outcome 1 these plans did not always reflect people’s preferences about how they receive their care.

We looked at the records for 15 people that show when they had been helped to have a bath or a shower and we found that 11 people had not had a bath or shower between 1st and 24th May 2011. Staff told us that there was a bath rota for a weekly bath or shower for everyone, but that they did not always have time to follow this. One staff said that “sometimes people have said they have not had a bath in a long while” whilst another said

“People rarely get a bath as the staff do not have time”.

Staff told us that there was also a schedule for helping people to the toilet. They told us that they would help people when they got up, before lunch (between 11.00 and 12.30), after lunch, before supper, after supper and when they went to bed. Staff told us that people had not been helped to the toilet between getting up and lunchtime that day as they had still been helping some people to get up at 11.20am. Staff said that sometimes this meant that people only got to go to the toilet two or three times a day.

There were three people using the service who had a pressure wound or pressure area when we visited. We looked at the risk assessment for one person that said they needed to be helped to the toilet regularly. We did not see this person being helped to the toilet during the morning we visited. We also found that this person had not been helped to have a bath or shower between 1st and 24th May 2011. The records for this person show that they developed the pressure area since they had moved into the home. The district nursing team confirmed that there was no reason why they should not have been bathed or showered.

Staff told us that they did not always have the time to wash people after they had been incontinent, and that sometimes they just changed the person’s clothes. Staff also said people were often only washed in the morning and they were not washed before they went to bed.

Staff told us that they would like to have more time to spend with people during personal care as they felt it was currently “A Conveyor belt system”. Staff and visitors also said they would like there to be more time available to sit and talk with people. One person said “residents will call out and want staff to sit and talk to them, but we have no time”. Another said that the staff were rushed and could not give people the time they needed.

The service employs an activities worker who is in the home Monday to Friday. A programme of activities was displayed on the notice board in the hallway and this included colouring, music, ball games, reminiscence, cards, exercise, crosswords, films, arts and dog visits. We saw the activities worker spending time with people on a 1-1 basis singing and dancing to music with them. People seemed to enjoy this time, but due to the need for this to be done on a 1-1 basis not everyone received any attention during this time.

We saw records that showed that there had been 16 occasions where people had fallen and injured themselves within a six week period. Where action had been agreed to prevent a fall happening again this had not been added to the care plan and therefore staff would not know what help they needed to provide. There were no assessments of the risks of people falling completed as part of the plans.

We asked staff what the procedure was if a person had a fall. They told us that they were not aware of a written procedure and they gave varied responses about what action they would take. The manager of the home told us that there w