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Archived: Westleigh

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Inspection report

Date of Inspection: 16 January 2013
Date of Publication: 9 March 2013
Inspection Report published 9 March 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 reviewed information sent to us by other organisations, carried out a visit on 16 January 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, 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.

Our judgement

Lack of detailed records means that people are not always protected from unsafe or inappropriate care.

Reasons for our judgement

People personal records were not always detailed or fit for purpose. For example, one care plan stated that a person living at the service was subject to a community treatment order. However, we saw that the order had been removed several months previously. This inappropriate record may have resulted in a person’s lifestyle being restricted.

One care plan assessment that we looked at stated that the person was at risk from harming themselves, however, there was no further information recorded as to what support the person required. A further care plan assessment stated that the person had a tendency not to drink fluids, however, there was no further information recorded as to how staff should encourage and support the individual with this identified need.

We saw that several care planning documents contained limited records of the care and support people had been offered or received. For example, one care plan stated “does shower regularly with assistance” but no further information was recorded as to what assistance was actually required. Several records stated that people had been “counselled”, however there was no information recorded as to what was discussed.

We saw two people’s care plans stated that they were to be weighed monthly, however, records failed to demonstrate that this had taken place.

Records of care and support offered and delivered through the night were not being maintained. The manager told us that only incidents were recorded but not routine care. Failure to record all care and support offered and delivered to people may result in people not receiving safe and appropriate care.

We saw staff meeting minutes and staff notes that failed to promote people’s independence. For example, we saw information recorded by staff that was inappropriate and judgemental.