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Archived: Victoria Lodge Residential Care Home

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Inspection report

Date of Inspection: 1, 8 May 2013
Date of Publication: 29 January 2014
Inspection Report published 29 January 2014 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Enforcement action taken

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

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 1 May 2013 and 8 May 2013, observed how people were being cared for and talked with staff. We reviewed information given to us by the provider, reviewed information sent to us by commissioners of services and talked with commissioners of services.

Our judgement

The service had developed their assessment and care planning methodology but this had not been implemented and the service could not demonstrate that care and treatment was planned and delivered in a way that met people’s needs and ensured people’s safety and welfare.

Reasons for our judgement

We looked at the individual care files for all three residents. The registered manager told us they had begun implementing a new system of care planning and assessment which involved replacing previous documentation which was not fit for purpose. They had started to replace the paperwork with a new system which had been subsequently abandoned in favour of a further set of paperwork covering care planning and assessment. As a result, the files contained documents from three different systems, none of which were complete. There were blank documents from the favoured care planning system in each file which we were told they planned to complete. There was also a ‘daily report’ folder which recorded: intake of food and fluid, bowel charts, oral care and bath and showers.

We found that personal details had been completed for people on the new care planning forms while some assessments had been started using the assessment and care planning forms that had been recently introduced but subsequently abandoned. There were also blank forms in the file that the manager said were to be completed. This meant that it remained unclear what system was in use and how the staff would assess people’s ongoing needs in order to ensure that people’s needs were met.

We asked what care plan the service was currently working to for the people living there. We were shown care plans that were dated 7 March 2013 for two of the three residents which were from the old system due to be replaced. The registered manager told us that this care plan was her preferred care plan and that she had updated the care plans for all three people following our last, inspection visit. Two of the three updated care plans were held on the registered manager’s laptop they were not in the files and had not been shared with staff. We were told they were being prepared ready for the next Care Quality Commission visit. This meant that two of the three care plans were not active and were not being used up to the time of our visit, when they were placed in to people’s individual care files. We were also told by the registered manager that this care planning system was soon going to be replaced.