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Beverley Grange Nursing Home Good

All reports

Inspection report

Date of Inspection: 19 November 2013
Date of Publication: 24 December 2013
Inspection Report published 24 December 2013 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 19 November 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, talked with commissioners of services and talked with local groups of people in the community or voluntary sector.

Our judgement

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

Reasons for our judgement

People’s personal records including medical records were not accurate and fit for purpose. Staff records and other records relevant to the management of the services were not always accurate

We undertook this inspection to follow up on previous concerns. A the last visit we found that both records for staff and people who lived in the home were not adequately completed and kept up to date, with some records being stored in a communal area.

At this visit the manager confirmed that a large amount of work had been undertaken in response to the previous concerns raised. This included that the access to the storage areas for records was now lockable and that care plans and staff training documents had been reviewed and updated.

We looked at peoples care plans and saw that the majority were in a new format with plans in place to ensure that all care plans were transferred to this. All of these included up to date information in relation to the individual person and their needs. Although comprehensive the new care plans did not always cover all of the areas of need for the person. For example although recorded as a need there was not an individual care plan to support someone in managing their diabetes. The provider informed us that this was addressed in the persons other care plans. Additional work was required to ensure that these were comprehensive and personalised. For example, people’s likes and dislikes were recorded but this was not detailed.

We saw that some care plans included the details of the moving and handling equipment to be used. However this was not the case for all of the care plans reviewed, for example, one file recorded the use of the hoist but not the colour of the sling to be used. The provider informed us this information was in the persons' room. However this information should be clearly recorded in the persons care plan.

Additionally we saw monitoring forms for people's health needs, again these required more detail. We saw where one person had been supported after a fall; information regarding this was recorded in thier care plan but the details had not been transferred into their risk assessments.

Daily diary notes had been completed. However the style of these records had changed and was now less person centred.

The staff training matrix recorded some of the courses people had attended. However, it did not record all of the courses attended or the expiry/renewal date of the courses completed.

We looked at peoples’ individual training records and saw that their individual training matrix recorded additional training to that recorded on the overall training matrix.

Details of training dates did not always match individual staff training records and no actions plans for future staff development were held in staff files; records were not detailed.

Although there was a new induction package there was no evidence that this met the skills for care guidance, which is a nationally recognised standard.

We also saw that no training had taken place with staff regarding information governance.