We reviewed seven people’s care plans and associated documents. Six people’s medicines records. Four staff recruitment records, staff supervision and appraisal records and staff training. We looked at audits used to monitor and improve the home and documents pertaining to the health and safety of the home.

Learning lessons when things go wrong:
Accidents and incidents occurring at the home were clearly recorded and analysed to look for patterns and themes to help prevent further occurrences.

Assessing people’s needs and choices; delivering care in line with standards, guidance and the law:
Staff completed a thorough assessment of people’s needs prior to them moving into the service. Assessments captured a holistic picture of the persons needs and followed best practice guidance from the National Institute of Clinical Excellence (NICE).

Mental Capacity:
We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met.

People had as much control over their lives as possible. Capacity assessment were carried out where required. Where people lacked capacity, decisions were made in people’s best interests.

Care plans contained detailed information about support people needed to weigh up information and how best to provide this information to aid understanding. For example; in pictorial format or, using closed sentences or other forms of communication aids.

Where required applications had been made to seek authorisation to deprive people of their liberty to safeguard them.

Life stories:
Life stories had been developed to enable staff to understand people’s background and relate to the person. People and families and friends had contributed to the life stories and they were used to develop conversations and reminiscence.  People’s life history was recorded and used to develop conversations. Life stories had been developed from people’s and family’s experiences and enhanced people’s sense of identity and understand people’s needs and wishes.

Planning personalised care to ensure people have choice and control and to meet their needs and preferences:
People received person centred care based on their likes and preferences. Care plans were personalised, and captured people’s needs accurately. They were continually updated to reflect the changing needs of people.

Staff had a good understanding of people’s needs which enabled them to provide consistent support. Care plans were stored electronically, and staff had access to electronic devices. They told us; “The care plans are much better, we can now document everything in real time and it’s very easy for me to come on shift and review what’s happened overnight” and “We can set up well-being checks for people in their rooms which confirms we have checked on people and they are okay.”

End of life care and support:
Care plans captured people’s personal preferences for end-of-life care and staff had good knowledge of people’s religious or cultural requirements.

Meeting people’s communication needs:
Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. The standard applies to all people with a disability, impairment or sensory loss and in some circumstances to their carers.

People’ communication needs were considered as part of their initial assessment, such as the use of a translator or visual or hearing aids.

Information of how to meet each person’s needs was captured in the care plan to give directions for staff to follow to enable them to effectively communicate with others which included being sat in a particular position or using closed sentences.

External Link: See Care Quality Commission website

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