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Archived: Moorgate Lodge Good

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Inspection report

Date of Inspection: 19 March 2012
Date of Publication: 1 May 2012
Inspection Report published 1 May 2012 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

Our judgement

People did not always have an accurate record including appropriate information and documentation in relation to their care and treatment.

User experience

We did not speak directly with people regarding this outcome.

Other evidence

We looked at three plans of care and other records of care, including food and fluid charts, moving and handling records and visiting professional records. We found that the care plans detailed most needs and abilities of individuals, likes and dislikes. However were very difficult to follow or find relevant information to be able to meet people’s needs.

One plan we looked at gave details that the person had developed a pressure ulcer, however there was no details of what dressings were to be used or how often it required redressing. It was written in care plan, ‘under the care of the tissue viability nurse’. This was not detailed to ensure the person’s needs could be met.

Each care plan we looked at had communication as a care need. The plans did not detail if people were able to communicate verbally or non verbally. They did not detail people’s capacity to understand what they were asked or requested.

Some care plans identified a care need but the actions did not relate to the need, for example one persons care need was personal hygiene. The actions told us about poor mobility and low motivation, it did not detail how to maintain the person’s personal hygiene. It also did not give information on the person’s capacity to understand the need to maintain their personal hygiene.

Food and fluid charts and moving and handling charts we looked at were not always completed. They also did not give accurate amounts of food eaten, it was written, ‘ate half’ or ‘ate all’ but no quantities recorded.

We looked at falls and body mapping these were completed and gave clear details of improvement and actions taken to maintain safety.

The manager told us the new plans of care in place still needed improving, they had achieved a standard that was acceptable, but staff would continue to be trained in care planning and at each review the plans would continue to be improved.

The manager also informed us that she wanted to improve the care plans and include more information on people’s capacity to understand care needs and make decisions. They were also going to include evidence of involvement of people in the development of their care plan.