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Archived: Avonwood Manor Home Care Angels

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Inspection report

Date of Inspection: 20, 28 January and 3 February 2014
Date of Publication: 5 March 2014
Inspection Report published 05 March 2014 PDF | 79.62 KB

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 20 January 2014, 28 January 2014 and 3 February 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.

Our judgement

Care and treatment was not assessed, planned and delivered in a way that was intended to ensure people's safety and welfare. This was because there were shortfalls in the assessment of care needs, planning and delivery of care.

Reasons for our judgement

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

During the inspection we pathway tracked the care of three people. This involved looking at people's care plans and speaking with them, their relatives or other representatives, and care workers. Everyone we spoke with confirmed that the agency had spoken with them; carried out an assessment of their care needs and developed a care plan to meet these needs.

We spoke with three of the people who were receiving care from the agency. All of them spoke positively about the way care workers supported their relatives. They told us "they (the care workers) are so helpful to me", "I really like this agency", "all the staff are good but XXX is unbelievable. She listens and is compassionate and will do anything for you". Every one we spoke with was happy with the care they received and told us that their care workers always met their needs.

During our visits and analysis of records we found that people had needs that had not been fully assessed and planned for. Care workers had documented these tasks in daily visit records but these had not been noted and followed up in any reviews. We also saw that care workers were using equipment such as special beds and wheelchairs but records did not include information on the safe use of these items. We found that care records did not make clear the areas of responsibility for care workers when family members or carers from other services were also involved. The lack of assessment and care planning in these areas meant that people were at risk of inappropriate or unsafe care.

All of the people we pathway tracked had skin conditions and needed prescribed creams to treat this. We found that there was no assessment of needs or plan of care relating to the skin condition for any of the people. There was no guidance in place for care workers to follow to ensure creams were applied correctly. Daily visit records showed that care workers had administered creams without any instructions to do so. This meant that, potentially, people were not receiving the creams as prescribed and as directed by a health professional.

One of the people who received support from the agency, had pressure sores. There was no assessment or care plan to instruct care workers how care should be provided or what pressure relieving equipment should be used. Records showed that pressure relieving equipment had been provided and special creams prescribed. The lack of assessment and care planning in relation to this person's skin care needs meant they may not be receiving the care they required to promote the healing of the sore.

We found that one person suffered from diabetes and other people had Parkinson's disease, Multiple Sclerosis and other long term health conditions. There was no information in the care plans about the implications of these diseases and the implications they may have upon the person's care needs. We also found that there was no information about how the person's diabetes was managed, what care workers should do if they suspected hypo or hyper glycaemic attacks. (Low or high blood sugar levels). We also found that one person had had special medical equipment fitted to them to manage a specific health problem. There was no information about this in the care plan although daily care records showed that care workers were using this equipment to assist the person. This meant that care workers were meeting needs that had not been assessed or planned for and there were no arrangements in place to deal with foreseeable emergencies.

People's wishes for end of life care had not been obtained or documented. Some people who were supported by the agency were frail and may be at risk of suffering life threatening events. There was no information about their wishes for end of life care should their health deteriorate. This meant that foreseeable emergencies had not been asse