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Archived: West Lodge Residential Care Home

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Inspection report

Date of Inspection: 4 October 2013
Date of Publication: 5 November 2013
Inspection Report published 05 November 2013 PDF | 90.07 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met this standard

We checked that people who use this service

  • Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
  • Other records required to be kept to protect their safety and well being are maintained and held securely where required.

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 4 October 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

People had not been protected from the risks of unsafe or inappropriate care and support because accurate and appropriate records had not been maintained.

Reasons for our judgement

During our inspection we looked at the care records relating to four people who lived at the home. Whilst care plans had been personalised and gave staff good guidance about people’s individual needs, some aspects of the records we saw were inaccurate and out of date. This meant that people who lived at the home may not always have been adequately protected against the risks of unsafe or inappropriate care and support.

In one of the records we looked at, charts used to record and monitor the personal care and support provided on a daily basis had 19 unexplained gaps between 1 January 2013 and the date of our inspection; 4 October 2013. We looked at other records and saw that one contained 13 unexplained gaps for the same period, while another had 26. It was therefore, unclear from these records whether or not personal care and support had been delivered to the people concerned for a total period of 58 days.

Although some aspects of the records we saw were incomplete and poorly maintained, people who lived at the home, staff and a health care professional told us that the levels of care and support provided on a daily basis had met people’s needs. However, staff told us they found the care plans difficult to work with and maintain because they were complicated and not very user friendly.

We saw that the provider's own policy recommended that people’s long term needs assessments should be reviewed and updated every six months or more frequently if necessary. However, one record we looked at showed that the long term physical needs of the person had not been reviewed since October 2012. In addition, their personal hygiene and medication needs had not been reviewed since January 2013.

The provider’s own policy also recommended that identified risks should be reviewed on a monthly basis or twice monthly in cases where risks had been assessed to be high. In one record we looked at the person had been assessed to be at a high risk of suffering falls. However, records showed that the risk in question had only been reviewed once a month since September 2012.

We looked at records relating to another person which showed that risk assessments in the areas of falls and personal hygiene had not been reviewed since August 2013. Other records showed that another person had been identified as being at risk of developing pressure sores on their skin. However, we saw that the risk assessments in question had not been reviewed since May 2013.

Although we saw evidence that people’s individual care and support needs had been met, the failure to maintain accurate records about the reviews carried out meant that staff may not have been provided with the most up to date information in all cases.

The provider’s own policy recommended that dependency profiles, used to assess and monitor people’s individual needs, should be reviewed on a monthly basis. None of the profiles we looked at had been reviewed during the two month period immediately prior to our inspection.

This meant that people’s care and support records were not accurate or up to date and may therefore not have been fit for purpose. We spoke with the provider who told us that they were aware of the problem and in the process of drawing up new care plans that would be more effective and improve record keeping.