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Temple Grove Care Home Outstanding

All reports

Inspection report

Date of Inspection: 13 January 2014
Date of Publication: 11 April 2014
Inspection Report published 11 April 2014 PDF

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 looked at the personal care or treatment records of people who use the service, carried out a visit on 13 January 2014, 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, were accompanied by a pharmacist and were accompanied by a specialist advisor.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. Regulation 20(1)(a).

Reasons for our judgement

We saw that records that related to people at the home, staff and the management of the service were stored in lockable cabinets and were accessible when needed.

Care plans were sometimes found to be confusing and poorly organised. One person who received end of life care had many care plans and some of the information seemed to overlap. The "Medical condition" section included information on personal care needs, however there was also a "Washing and dressing" care plan. Breathing was included in the "Tracheostomy- maintaining airway" and also in a "Difficulty in breathing" section. There was no end of life care plan. We asked a member of staff about this who was unable to locate it.

One person's documentation to record weight, blood pressure, pulse and blood sugar were all seen to be blank. Another person at risk of falls had a bodymap and wound chart to record falls and injuries. This was confusing and showed a number of wounds but not all of these were dated. It was difficult to assess which were current and which wounds were historical. This meant that some people's personal records including medical records were not accurate and fit for purpose.

We looked at one person's record of syringe driver checks at 1.20pm which showed no entries after 10am on the day of the inspection. When we checked this chart later we saw that entries had been completed for 11am, 12pm and 1pm, including a syringe driver change at 1pm. A member of staff admitted that these records had been filled in retrospectively. It was unclear if these checks had actually taken place which meant that the records could not be relied upon to be accurate and fit for purpose.

We were shown a training matrix for staff. However this was not up to date and did not reflect all the training undertaken. This record, which was relevant to the management of the service, was not accurate.

Some of the records we asked to look at were not available at the time of inspection. These included the complaints record for 2013, minutes from team meetings and quality assurance questionnaires completed by people at the home in November 2013. The manager explained that these had been sent to storage in error. This meant that not all records relating to the management of the service could be located promptly when needed.