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Coundon Manor Care Home Good

All reports

Inspection report

Date of Inspection: 10 December 2012
Date of Publication: 5 January 2013
Inspection Report published 5 January 2013 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 10 December 2012, 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 and talked with staff.

Our judgement

Care and treatment was not being planned and delivered in a way that ensured people’s safety and welfare.

Reasons for our judgement

On the day of our visit we spoke with eight people living in the home, three relatives and a visiting GP. We also spent a period of time observing those people in the home that were not able to speak with us. This was so we could determine what it was like for them living there.

All the people we spoke with were positive about the home including the GP. People told us: “All very good.” “It’s smashing they are all friendly people.” “They are very helpful and do what they can for me.”

During the morning we saw staff instigating a dancing session in the lounge. Care staff danced with people and some people danced independently. There was laughter and smiles all round and some people hummed or tapped their feet to the music. We also saw staff talking to people who could communicate on a one to one basis about their past lives.

We observed those people with limited abilities to effectively communicate received less staff interaction than those who were able to communicate well. This could lead to some people feeling isolated and less valued.

We asked people about the food. They told us: “Very good. It’s nice to get up and get breakfast, dinner and tea all prepared.” “I have my meals in the dining room except for tea and sandwiches. It’s as good as you can expect for a place catering for a lot of people.”

We found care and treatment was not always planned and delivered in a way that protected people's safety and welfare. For example we saw that one person had leg ulcers. There was a leg ulcer care plan in place but this was not up-to-date. It did not state the current condition of the ulcers. It was also not clear about how these should be managed. Staff told us this person’s legs should be elevated for at least two hours a day. This was not detailed in a care plan. We observed the person throughout the day and did not see their legs elevated. We saw a record stating they were sleeping in a chair at night as opposed to their bed. We did not see a risk assessment to show whether any risks associated with this had been assessed and were being managed.

During our visit we saw some people in the dementia unit with behaviours that challenged staff. We saw one person needed to be supported with personal care as they had soiled themselves. They were refusing to be assisted by staff despite their repeated attempts. This resulted in the person walking around in stained clothing and soiling chairs. We looked at the care records for this person as well as a second person who had behaviours that challenged staff. This was to see how staff were managing these behaviours.

Records stated that both people were reluctant to receive personal care. There were no indications of people’s normal patterns of behaviour. There was limited information about any difficulties this presented to the person or staff. This meant we could not determine what people’s behaviours were like over a period of time. We also could not see how staff should have delivered support to ensure a consistent approach to these behaviours.

There were risk assessments in place to manage individual risks such as the risk of falls and nutritional deficiency. We found information in the risk assessments was not always being acted upon. For example, one person required a soft diet. We saw they were given food that had not been specifically prepared for them and they could not eat it. The person told us they were hungry. We alerted staff to this.

We saw records showing some people had been assessed as requiring bedrails to manage their risk of falling out of bed. We did not see completed bedrail risk assessments showing how the risks related to bedrail use were being managed to keep people safe.

We saw monitoring sheets on care plans for staff to record when people had fallen. We found these did not contain accurate information. This meant we could not be confident the risks associated with falls were being managed to keep people safe.