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Archived: Victoria Lodge Residential Care Home

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All reports

Inspection report

Date of Inspection: 18 December 2010 and 4 January 2011
Date of Publication: 21 April 2011
Inspection Report published 21 April 2011 PDF

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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

Our judgement

Records are not adequate to support and protect people who use services.

User experience

On this occasion we did not speak to people about this outcome area.

Other evidence

Staff were seen completing daily records which were detailed.

All other records seen were incomplete and/or out of date. There were gaps in records and where records were held it was unclear what the current needs and abilities of people were.

We looked at some people's care plans and found that where there was information, this was often out of date and difficult to access. Paperwork was not in date order and some documents seen dated back to 2004.

We found that some records were being kept for no clear reason and action was not being taken when a problem had been identified.

A nutritional risk assessment with a score of 9 indicating a cause for concern, had been completed each month since January 2010 but no action had been taken and when asked, staff did not know why the assessment was being completed.