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Archived: Rydan Lodge Residential Home

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Inspection report

Date of Inspection: 17, 18, 22 October 2013
Date of Publication: 15 March 2014
Inspection Report published 15 March 2014 PDF | 118.17 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 17 October 2013, 18 October 2013 and 22 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, talked with staff, reviewed information sent to us by commissioners of services and reviewed information sent to us by local groups of people in the community or voluntary sector. We talked with commissioners of services and talked with other authorities.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment. People’s personal records including medical records were not accurate or fit for purpose. Records could not be located promptly when needed. Records relevant to the management of the services were accurate and fit for purpose.

Reasons for our judgement

We found that care records at the Rydan Lodge and the domiciliary care service were not fit for purpose. People were at risk because there was a lack of proper information about them and some records were not accurate.

We looked at seven care plans for people who lived at the home and saw that there were significant information gaps. We saw that some people had been identified as being at high risk of developing pressure sores. Assessments had been completed but there were no records of actions needed to manage the risks. We asked the registered manager about this. They responded that "We have a good record on skin here. There are no problems". We saw comments in daily care records, staff memos and care plans about people at the home being "difficult". There were no records of strategies to meet individual’s needs, to assist and reassure them and to de-escalate situations.

Records at the domiciliary care agency were not accurate. We saw three entries by one care worker which showed the precise duration of their visits at people's homes. On the other records we saw when we visited people in their homes most visits were recorded as only AM or PM. We asked to see a specific record in the agency office. We had received information that a care worker had left a visit early. We asked the manager why the carer had left early. The manager's explanation did not reflect what was written in the record of the visit. This entry described the care delivered and the arrival and departure times. It was signed by the care worker. It recorded that the care worker had stayed for the full visit time. The manager said that the care worker "may have left 10 minutes early, but sometimes spent longer there". We found that there was a risk from false recording of visit times and a lack of accurate full recording of the care which had been delivered.

We found that files were not well organised. We looked at some archived files and files for people who had stopped using the service within the last 12 months. We saw that these were largely loose sheets, not in chronological order. We made the manager of the domiciliary care agency aware that some medication administration records (MARs) appeared to have been partially covered and overwritten. They could not provide an explanation for this.

Records could not be located promptly when required. During our inspection we asked the registered manager to show us a number of policies and records. They were unclear as to where some hard copy policies were and had difficulty finding them on a computer system. They were unable to locate the safeguarding policy. We found the policy when we looked in another file.

The provider had a records and records retention policy. It was dated 2011. We asked if it had been updated and the registered manager said that it had not been. The registered manager asked us about the legal requirements for document retention. They were not familiar with the Data Protection Act 1998. The retention policy contained conflicting information about record retention times. The office at the home was not well organised. Open boxes of archive records were stored on the floor of the office.