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Archived: SSA Quality Care

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Inspection report

Date of Inspection: 27 February 2014
Date of Publication: 2 April 2014
Inspection Report published 02 April 2014 PDF

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Meeting 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 27 February 2014, talked with carers and / or family members and talked with staff.

Our judgement

Overall the service had made some progress on monitoring people's daily notes and the standard of staff's record keeping. They had taken appropriate actions where poor record keeping had been evident to ensure accurate records in relation to the care and support provided were maintained.

Reasons for our judgement

When we visited SSA Quality Care in July 2013, we the service was non compliant in this outcome area. This was because records were not accurately maintained and the provider had not ensured people were protected against the risk of unsafe and inappropriate care. Although people received the care and support they needed, records did not always reflect this. We also found inconsistencies in the times of visits recorded in daily notes to those on the electronic monitoring system and also noted some visits had not been recorded or logged on the electronic monitoring system to show they had been undertaken.

Following the visit in July 2013 the provider wrote to us and provided us with an action plan. This informed us they would review the standard of record keeping and put a system in place to regularly monitor people's care records to ensure records were accurate, person centred and the timing of the visits reflected those on the electronic monitoring system. This had entailed the recruitment of a care manager to assume these responsibilities. We were also supplied with a copy of a memorandum which had been circulated to staff. This ensured staff were reminded of their responsibilities in relation to maintaining accurate records.

At this inspection we were informed the appointed care manager had resigned in December 2013 and had not been replaced. However, the service had begun auditing daily notes and medication administration records which were returned to the office each fortnight. We viewed a recent audit undertaken in January 2013 which involved monitoring sixty three sets of daily notes and corresponding medication administration records, where staff assisted with medication administration. Of the sixty three audited, twelve were found to be not up to standard. Examples included the lack of detailed accounts of the care given, failure to sign, date and time the daily notes and writing the notes up in pencil. We saw actions had been taken and documented where poor record keeping had been evident. These included supervision sessions and discussions with staff. We saw evidence of documented supervisions to evidence this. This showed the provider was monitoring the standard of record keeping and had taken actions where necessary.

We reviewed four people's care files and found there had been some improvements made however this was not consistent. The provider may wish to note that whilst assessments of people's care needs were completed with no gaps, there were instances in which these still did not detail the level of support and what people were able to do themselves. Similarly daily notes informed of the care provided but were not always written in a person centred way. We found two people's care plans did not reflect the number of visits detailed on the referral documentation from the funding authority. We were assured the number of visits detailed in the care plans were correct. This meant information in relation to the number of calls they required was not accurately reflected in their care plans. The provider made a call to the funding authority to request a copy of the variations. They informed us these would be placed in the individual's files so information held in their files were up to date, accurate and reflected their care plans. Following our visit we received a copy of the variation forms which showed the number of visits detailed in the care plans were correct.

One of these two files contained a referral from the local funding authority. This referral informed us the individual was prone to seizures. Whilst reviewing the individual's care plan there was no risk assessment or detailed plan of action staff were to take if the individual had a seizure. We also noted the person could become aggressive and verbal yet there was no risk assessment in place, or specific detailed instructions for staff to refer to in such situations. At the time of writing this report we received amended documentation which detail