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Holbeche House Care Home Requires improvement

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 22 October 2012
Date of Publication: 4 December 2012
Inspection Report published 4 December 2012 PDF | 94.61 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 22 October 2012, 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, talked with carers and / or family members, talked with staff and talked with stakeholders.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

We spoke with people living at the home but their feedback did not relate to this standard.

Our inspection of 28 June 2012 found that records were not accurate, complete, or accessible. During this inspection, we looked at people’s care records and found that there was contradicting information about the location of sore skin. One document stated it was the right foot and other document stated it was the left foot. The deputy manager told us she might have written the wrong location in the notes. We found another person had two entries describing their sore skin for the same date, although both descriptions were different. This meant that records were not always an accurate reflection of people’s care needs and conditions.

We looked at people’s food and fluid intake charts, which tell us how much people have had to eat and drink throughout the day. We saw that these were not completed to show what people had to eat and drink. In one instance, we were made aware that the deputy manager had given a person fluid and asked another staff member to record this, which was recorded incorrectly by the staff. This would provide inaccurate information about how much the person has had to drink. Staff must ensure that they record entries in people’s care files that they have delivered.

We found that staff did not always complete all sections in people’s care records, as they should. For example, in one person’s repositioning records, staff were not recording the mattress setting which is important in the healing of sore skin. We found that although this had been highlighted, staff continued to complete documentation incorrectly. We found that many entries in people’s care records were not clear and legible. In some instance, we had to ask staff or the regional manager to read records for us. This meant that records were not accurate, complete or clear which continued to pose a risk of people not receiving the care they needed.

We will be taking action to address continued non compliance of this Regulation through Regulation 10, outcome 16.