You are here

Riverview Nursing Home Requires improvement

All reports

Inspection report

Date of Inspection: 8 May 2012
Date of Publication: 30 July 2012
Inspection Report published 30 July 2012 PDF | 49.89 KB

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

Enforcement action taken

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 reviewed all the information we hold about this provider, carried out a visit on 08/05/2012, looked at records of people who use services and talked to staff.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment as the documentation we saw was uncoordinated, inconsistent and contradictory.

The registered care provider was not meeting this standard.We judged that this had a major impact on people who used the service and action was needed for this essential standard.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

User experience

We used different methods to help us understand the experiences of people using the service based on the records being fit for purpose because the people using the service had complex needs which meant that they were not able to tell us their experiences.

We found that contradictory information within a care plan for one person using the service had resulted in another person using the service being harmed.

Other evidence

Peoples' personal records were inaccurate and not fit for purpose. The individuals' records were kept securely but could not be located promptly as they were stored in a number of different places.

We looked at the records of four people using the service in order to check that the compliance action, set following the review of compliance in February 2012, had been addressed. Each person’s records had been put into separate sections within a large folder using numbered divider sheets, however there was no indexing system in place and therefore information was difficult to find.

We saw that some of the assessments and care plans were blank. The daily records were not in the individuals files we saw. We asked the nurse in charge and she told us that the nurses kept their daily records in a separate file and there was a separate file where the care assistants kept their daily records. Having information about people’s care and treatment in three separate folders, kept in three different places in the home made it difficult to get a clear and accurate picture of people’s care and treatment needs and the actions being taken to meet those needs.

We looked at the care records of one person using the service as we had observed extensive bruising to the person’s face and we wanted to see if the person had received appropriate care. The daily records were non specific about the bruising therefore we had to look at the accident book to find information. This showed that the chaotic nature of the records and the lack of a documented system to convey information between staff shifts had resulted in a number of actions not being communicated or acted upon.

This prompted us to review other care records. These records were also found to be incomplete with daily records kept separately from the individuals care record. We reviewed the content of the care record for another person using the service and found evidence of contradictory information regarding the care to be delivered.

The absence of clearly documented information about the persons' needs and the actions that should be taken to meet those needs meant that the person was at risk of not receiving appropriate care and treatment and other people using the service were at risk from their behaviour not being managed correctly.

We saw a separate overarching list of peoples' weights which revealed that one person using the service had lost a significant amount of weight in a three month period. When we looked further we saw that the documentation for monitoring nutritional intake for that individual was incomplete and that although the staff had noted the refusal of meals no action was planned or taken to address this.

The lack of ongoing review and care planning seen during the visit demonstrated risk of people using the service not receiving safe and appropriate care.