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Archived: Cartmel Old Grammar

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Inspection report

Date of Inspection: 5 December 2012
Date of Publication: 9 January 2013
Inspection Report published 9 January 2013 PDF

People should get safe and coordinated care when they move between different services (outcome 6)

Not met this standard

We checked that people who use this service

  • Receive safe and coordinated care, treatment and support where more than one provider is involved, or they are moved between services.

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 5 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

People’s health, safety and welfare were not protected because advice from the health care services which supported them was not taken into account when planning their care.

Reasons for our judgement

The records held about people showed they were supported by health care services including doctors, district nurses and chiropody services. Individuals’ records had a separate sheet where visits from health services were recorded. People we spoke with told us they had been supported to see their doctors as they needed.

We looked at the care records for a person who had complex health care needs. The records did not show how they had been supported by health care services when their care needs had changed and increased. This person’s records showed that they could have been at increased risk due to the complex aspects of their care needs. Their care records did not include information for staff about the health care services they needed to contact in the event of this person requiring support with this aspect of their care. This meant they may not have received the support they needed from health care services in a timely way.

The manager of the home told us the local district nursing team had been contacted to provide advice about the care of a person who was at risk of developing pressure sores. We looked at the care records for this person but found no information about the advice the district nurse had given about their care. Their care plan had not been updated to include the advice from the district nurse so care staff did not have the information they required to ensure the person received safe and appropriate care.

We looked at the care records of another person who had complex care needs. The home manager told us the local district nursing team visited this person each week to support them with a particular aspect of their care. The person’s care plan did not include information about how this care was to be provided. We saw that the care plan did not state that the district nurses were responsible for this area of their care. Some of the records made by care staff showed they had carried out this care themselves. The care staff did not have information about how to deliver this care safely because it was not in the person’s care plan. This placed the person at risk, as care which we were told should have been provided by the district nurse had been provided by care staff who had no information about how to deliver the care.