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Kings Lodge Nursing Home Good

All reports

Inspection report

Date of Inspection: 10 September 2014
Date of Publication: 31 October 2014
Inspection Report published 31 October 2014 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 10 September 2014, 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.

We spoke to health professionals.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Reasons for our judgement

We looked at six care plans in detail and the associated documentation. We found the care plans included information about people's health and social care needs. There was evidence that mental capacity assessments had been completed and that they reflected the needs of the people concerned. We saw that overall the care plans had been reviewed and updated; with information about people’s diet, and records were kept of people’s weight.

However, in some care plans we saw that people’s life story had not been completed, which meant that staff may not be aware of how people spent their time before moving into the home or people’s interest and hobbies, when planning support. Some body charts had not been completed following falls, which meant that staff may not know if there were any injuries, and there was no evidence to show that appropriate treatment had been provided. In addition, the care plans did not reflect people’s changing needs. For example, one care plan stated in February 2014 that the person was ‘independently mobile and finds staff if they need assistance’, and in July 2014 the care plan stated that the person ‘can be independently mobile’; although the care plan also stated the person was at risk of falls and had experienced a number of falls since admission to the home. The assessments may not reflect the needs of the person, which meant that the information staff referred to for guidance, may not be appropriate. This showed that staff may not be able to provide safe and consistent care, which may put people at risk.

We found that daily records varied. We saw that for one person there was clear information about how they spent their day, their mood and their meals. In the another daily record we found staff had written how the person had been supported during the morning, but there was no record for the afternoon or during the night. These records did not show how people had spent their day, and if they were enable to make choices and be independent, which meant that staff were unable to evidence if they had provided the support and care people needed and wanted. The manager said the systems were new and some staff required more support than others with regard to record keeping.

Food and fluid charts were in place to record how much people who had lost weight, were eating and drinking. We looked at a number of records and found that on 8 September 2014 one person had not been offered or eaten dinner or supper. On the 9 September 2014 one person had no food and fluids that day, and another had only biscuits and three drinks. On five of the records viewed we saw that fluids were not recorded after 5pm. We observed during the inspection that people were offered drinks and meals throughout the day and staff said they supported people to have an appropriate diet, but the records viewed did not reflect this. This meant that the records did not reflect the support provided by staff, and may have put people’s health at risk due to poor nutrition.

We saw that topical creams were not recorded accurately. For example, one care plan stated that cream was applied three times a day, but the records stated that they were applied twice one day and only once on some days. This meant that people may not have received the treatment they required.

We looked at the information available about the home and their policies and procedures. We found they had been developed by the provider and were generic. This meant that the policies and procedures had not been reviewed and updated to provide staff with guidance to refer to, and meet people’s individual needs. For example, we looked at the policies and procedures for the administration of medication and found that it was not clear who was responsible for administering medication to people admitted for personal care and support and nursing care. We were told that a senior care worker administered medication to people in receipt of personal care and nurses took responsibility for people