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Archived: Cedar Lodge Care Home Ltd

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Inspection report

Date of Inspection: 30 October 2013
Date of Publication: 29 November 2013
Inspection Report published 29 November 2013 PDF | 84.15 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 30 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service and talked with staff.

Our judgement

The provider had not protected people from inappropriate and unsafe care and treatment because they had not maintained accurate records.

Reasons for our judgement

We found that the provider had made appropriate arrangements to store information securely. This included information about people’s care and support as well as information about the staff that worked at the home and the provider’s policies.

We saw that records were available for staff to read. The manager and the providers were able to provide us with records when we asked for them. We found that care records for each person who lived at the home had been completed by staff when required. However, we found that not all the care plans we looked at had been kept up to date. We could not be sure the care records we looked at provided an accurate account of the care that people received.

We found that although staff had a good knowledge of the care needs of the people whose care records we looked at. We could not be sure this matched the information recorded in the care records, as these had not been reviewed and updated regularly for some people. For example, one care plan had not been reviewed and updated since May 2013. This care plan had not reflected the changes in this person’s needs that staff told us about. This meant that the provider could not be sure that staff provided care in a consistent way that ensured people’s needs were met.

We also found that the care plans had not provided staff with the guidance they needed to recognise any deterioration in people’s health. For example, we saw that people’s weight had been checked and recorded regularly. We found however, that a fluctuation in weight had been identified for some people. There were no records to show what, if any, action had been taken. There was no guidance available for staff to tell them what action they should take and when. Staff we spoke with confirmed this.

We found that risk assessments had been put in place where people had been identified at risk from situations such as their diagnosed health conditions. In one instance, we found these assessments had not been reviewed or updated since 2008. This meant that people could not be sure they would receive the care they needed whilst the risk of harm to them was minimised. We spoke with the newly appointed manager and the providers who assured us they would prioritise the review and update of the care plans for everyone who lived at the home

This evidence showed us that the provider had not taken sufficient steps to protect people who lived at the home from inappropriate or unsafe care and treatment. This was because the provider had not kept accurate, up to date records about each person's care.