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Stoneacre Lodge Residential Home Requires improvement

All reports

Inspection report

Date of Inspection: 28 September 2011
Date of Publication: 15 November 2011
Inspection Report published 15 November 2011 PDF

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

Our judgement

Records about people who use the service were used to plan appropriate care, treatment and support. Some of the information needed for this was not systematically recorded.

User experience

People who spoke with us did not comment on this outcome area.

Other evidence

As part of our visit we looked at three care plans for individuals who had dementia and other conditions associated with old age. We had some concerns that staff were not always recording the care being given to individuals by visiting health professionals. For example one person’s care plan indicated that the district nurse visited in May, June and July 2011 (professional visitor’s sheet). However there was nothing recorded about the reason for the visits in the care plan.

We were concerned that staff were not always recording and updating the care being given to people. For example we saw that one person’s care plan recorded that the individual ate on her own due to problems with aggressive behaviour. However in the professional visitor notes it said this person saw their GP in August 2011 for weight loss. The GP recommended that this person start having meals again in the dining room. We discussed this with the staff on duty who said the person was eating with others. They told us they must have forgotten to update the care plan. We found that this person’s care plan had not been updated since they were initially segregated for meals in May 2011.

We looked at a care plan for an individual whose mental wellbeing form said they were not able to make their own decisions about care due to memory loss. This assessment was last updated in 2008. The care plan did not say who was responsible for supporting this individual in making these decisions on their behalf. Discussion with the staff and manager indicated that they knew who to contact in the family for this support.

We expressed our concerns to the manager about the fact that staff had knowledge of the care being given to people who used the service, but were not recording this into the care plans. This had the potential to affect the continuity of a person’s care. For example one care plan that we looked documented that the GP was going to refer the individual to the tissue viability nurse with regard to a pressure sore (August 2011). No more information was recorded about this in the plan. When we spoke with the staff they told us the GP then spoke to the district nurse who came out to attend to the pressure sore. The staff had full knowledge of the care being given to the person using the service, but nothing had been written down about it.