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Inspection report

Date of Inspection: 12 August 2013
Date of Publication: 18 July 2014
Inspection Report published 18 July 2014 PDF | 93.66 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 12 August 2013, 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 staff and talked with commissioners of services.

Our judgement

People did not always experience care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

When we visited Brandon House Nursing Home we spoke with the Acting Home Manager who had been in position for three weeks. They explained they were going to undertake an audit of all care plans for people living in the home as they had identified that care plans were not up to date. Care plans should provide staff with information about how to meet people’s needs effectively and safely in a way people prefer. During our visit we looked at six people’s care plans.

We saw people had an assessment of their needs and abilities prior to moving to Brandon House. The information obtained in these assessments informed the plan of care. For one person we saw the pre-admission assessment form detailed that they were allergic to eight different types of medication. The care plan stated that they had “no known allergies”. This meant there was conflicting evidence which could result in that person being given medicines to which they were allergic.

We saw the evidence of risk assessment tools to identify any risks in areas such as falls, nutrition, mobility and pressure sores. We saw that where a risk had been identified the actions put in place to manage the risk were not up to date. One person’s care plan stated they were able to walk small distances independently from their bed to their chair. A member of care staff told us, “X does not walk on their own – they would fall over. They need two staff to stand them and two staff to get them walking and stay with them.”

Many people living at Brandon House had been identified as having poor skin integrity. They were at risk of developing pressure ulcers. Pressure ulcers are graded from one to four depending on the level of skin loss. Grade four pressure ulcers can be life threatening. At the time of our visit nursing and care staff we spoke with informed us there were eight people living in the home with pressure ulcers. The information provided by staff about the number of people with pressure ulcers did not tally with that held by managers. We asked both nurses on duty about one person's pressure ulcer. Neither were aware of the condition of that person's pressure ulcer and whether it had deteriorated or improved. There was a lack of clarity around pressure area management within the home.

We saw the wound management plan for one person with a pressure ulcer stated that their dressing was to be changed every three days and documented. There were no records of any dressing changes to confirm they had been carried out in accordance with the plan. There were no records of the ulcer being assessed or monitored. The wound management plan said that staff were to ensure the person was sitting on a pro-pad high profile cushion. During our visit the person spent the majority of their time sitting in a chair in the lounge. There was no pro-pad cushion in place.

The risk assessment tool had identified another person as being at very high risk of developing pressure ulcers. We saw they slept on an alternating mattress at night to reduce the risk. On the day of our visit we observed this person was seated in a chair in their room for over five hours. There was no pressure relieving cushion in place.

We identified eight people who had lost between 2kg and 6 kg in weight within the last two months. There was minimal information in care plans to support what actions had been put in place when people had been identified as losing weight. For example there was no information about fortified drinks, food supplements or increasing calorie intake. There was no audit tool in place to monitor or analyse people's weights in the home. People's health and wellbeing can be compromised if weight loss is not swiftly identified and acted upon.

Topical medicines are those that are applied directly to the skin. We looked at the topical medication records for people to ensure they were being applied by care staff as directed. There were gaps in the records so we could not be sure topical medications were