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Moorlands Grange Requires improvement

All reports

Inspection report

Date of Inspection: 20 September 2013
Date of Publication: 26 October 2013
Inspection Report published 26 October 2013 PDF | 80.42 KB

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 20 September 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

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

Reasons for our judgement

We looked at the care records of four people who used the service. In one person's record we saw it stated they required their food and fluid intake to be monitored due to recent weight loss. We looked at the daily record sheets for this person and we found that these had not been completed. We saw that for a period of a week in August 2013 recordings made by staff showed the person had not received an adequate level of nutrition. For example 10 August - no breakfast or lunch was recorded, 12 August - no lunch was recorded, 13 August - no dinner, evening meal or supper was recorded, 15 and 16 August - no evening meal was recorded.

We looked at the nutritional charts from 8 - 19 September which staff were to complete after each meal for five other people who used the service. We saw there were gaps in the recording. This meant it was not possible to see if the individuals concerned had received adequate levels of nutrition. We looked at the care records of one of the five people who required their food and fluid intake to be recorded. We found the record did not provide clear guidance to staff with regard to this issue.

In three of the records we looked at we saw the service used a body map document to record any injuries or wounds the person sustained. We found there were multiple entries and dates on each document which did not include any detail of action taken by staff, or detail of when the injury/wound had healed.