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Archived: SSA Quality Care

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All reports

Inspection report

Date of Inspection: 12 July 2013
Date of Publication: 5 September 2013
Inspection Report published 05 September 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 12 July 2013, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

Although people supported by the service received the care and support they needed, records held in the office did not always reflect this.This practice did not protect against the risk of inappropriate care because records about them were not always accurate.

Reasons for our judgement

Although people received the care and support they needed, records held in the office did not always reflect this. This practice did not protect against the risk of inappropriate care because records about them were not always accurate. We looked at two people's files and saw that one of these assessment forms were incomplete and did not provide a clear picture of the person's assessed needs. The assessment documented the person's personal care needs as 'wet room, shower care'. It did not inform as to whether the person was able to undertake their own personal care needs or what help they required assistance with and how. The section entitled mobility was left blank, although the care plan clearly showed the person had mobility problems and used a wheelchair. These omissions did not ensure a thorough assessment of their needs had been undertaken prior to the acceptance of a package of care. This had the potential to place people at risk of inappropriate care arising from a lack of detailed information gained at the outset.

Whilst we saw some risk assessments in relation to the working environment and moving and handling we did see some inconsistencies in relation to other areas of care. This had the potential of placing people's welfare and safety at risk. One individual’s file informed us they had the ability to move their upper body and not their lower body and were cared for in bed. A carer, employed by the agency, informed us the person had a hospital bed and a pressure relieving mattress and staff checked the person's skin for any sign of pressure area damage. However, there was no documentation within the care plan to show that a skin viability assessment had been undertaken or guidelines in place in relation to pressure area care.

At each visit staff recorded a brief summary of the care and support they had provided to people in the daily notes. We noted these were very brief and were not personalised. The documentation in use contained a tick box with headings such as bath/strip wash, assist to bed, food and drink, medication and a box entitled other. Staff were expected to tick the relevant boxes and provide a report of the visit. The tick boxes were not always completed and the visit report very brief and did not detail the care provided in a personalised manner. Instead they contained short statements such as 'wet bath given', 'dressings applied'. The provider told us this had been raised with staff and actions taken to address this. We saw minutes of a recent staff meeting to remind staff to ensure people's daily notes were more detailed and person centred.

There was an electronic monitoring system in place which recorded when staff arrived to provide the care and support and when they left. We noted inconsistencies in the dates recorded in the daily notes to those on the electronic monitoring system which suggested poor recording by staff. We also noted some visits had not been recorded in the daily notes and had not been logged on the electronic monitoring system to show they had been undertaken. However, most of the people we spoke with told us they had received their visits as agreed.

People’s records and staff personnel files were stored securely to comply with the Data Protection Act 1998. Staff were aware of confidentiality and data protection since this had been covered during their induction.