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Westgate House Care Centre Good

All reports

Inspection report

Date of Inspection: 19 August 2014
Date of Publication: 11 September 2014
Inspection Report published 11 September 2014 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 19 August 2014 and talked with staff.

Our judgement

People were not always protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

Reasons for our judgement

At our previous inspection of Westgate House Care Centre on 11 and 12 June 2014 we found that people were not protected from the risks of unsafe or inappropriate care because accurate and appropriate records were not maintained. Our concerns were such that we issued a Warning Notice to the provider.

When we inspected Westgate House Care Centre again on 19 August 2014 we found that some improvements had been made.

We saw that records for people who required the support of a dietician had been reviewed to ensure that they were accurate and provided clear instruction for staff to follow to support people safely. For people that were not assessed as being at risk of poor nutrition the fluid and food charts had been discontinued.

We found that records for people admitted into the intermediate care unit included an assessment of their needs undertaken on the day of their admission. This meant that staff had the information they needed to provide appropriate support.

We found that care plans and risk assessments were regularly reviewed and contained relevant and up to date information. However, we noted that there were no risk assessments in place relating to the management of diabetes. Nursing staff we spoke with confirmed they were aware of the risks associated with this condition however there was no information available for care staff to alert them to the potential risks of high or low blood sugars.

We noted that a person who used the service sometimes demonstrated aggressive behaviours when care staff supported them with their personal hygiene needs. Care staff we spoke with gave us conflicting information about how this person would be supported in this instance. The care plan did not include instruction or guidance for staff to follow to meet the person’s needs when they became agitated or aggressive. This meant the person was at risk of receiving inconsistent care that did not meet their needs.

We saw that pressure mattress settings throughout the home were checked daily to ensure they were maintained at the correct pressure to maintain people’s skin integrity.

We reviewed cleaning records on individual units and confirmed that daily task allocation schedules had been signed as completed. This included cleaning items such as hoists, over chair tables, dining tables, kitchenettes, cushions, and rails in corridors.