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Inspection report

Date of Inspection: 20 February 2014
Date of Publication: 20 March 2014
Inspection Report published 20 March 2014 PDF

Before people are given any examination, care, treatment or support, they should be asked if they agree to it (outcome 2)

Meeting this standard

We checked that people who use this service

  • Where they are able, give valid consent to the examination, care, treatment and support they receive.
  • Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.
  • Can be confident that their human rights are respected and taken into account.

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 February 2014, talked with people who use the service and talked with carers and / or family members. We talked with staff and reviewed information given to us by the provider.

Our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Reasons for our judgement

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Most people that we spoke with told us they were given enough information about the benefits, side-effects and costs of their treatment before they had agreed to the recommended vaccinations. This was reflected in six out of eight treatment records that we looked at where people had signed and dated forms to declare; “I have received information on risks and benefits of the vaccines and medications administered and have had opportunity to ask questions. I consent to the vaccines listed being administered”. The other two records we looked at had not been signed as the individual’s had only received information. Clinical staff we spoke with showed an awareness of informed consent, and people told us that both verbal and written consent were obtained by the doctor prior to any vaccinations being administered. We also saw that parental consent had been obtained from a person with parental responsibility before a child received an immunisation.

Staff that we spoke with demonstrated an awareness of the Mental Capacity Act 2005, and implications for this before the delivery of a person's treatment. The registered manager told us that no concerns had been raised to date with regard to the mental capacity of individuals they had provided care and treatment to within the clinic. However, staff records that we looked at did not contain certificates to confirm that all staff had received related training and / or a provider policy was in place to provide staff with guidance. The registered manager explained that clinical staff responsible for seeking people’s consent were all qualified doctors and had received training in relation to the Mental Capacity Act 2005 in other courses such as safeguarding vulnerable adults. However, the manager acknowledged that specific Mental Capacity Act training would be considered as part of staff future professional development . As this had not been planned and taken place, we were unable to assess the impact on informing staff practice.