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Archived: Swiss Cottage Care Home

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All reports

Inspection report

Date of Inspection: 14, 22 November 2013
Date of Publication: 4 January 2014
Inspection Report published 04 January 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 14 November 2013 and 22 November 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, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

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 inaccurate and incomplete records were maintained. Records were not always stored safely and securely.

Reasons for our judgement

During our inspection we looked at the procedures in place to ensure personalised and medical records were kept and maintained for each person. We saw complex and incomplete care records which placed people at risk of unsafe or inappropriate care and treatment arising from a lack of proper information about them. We looked at four of the care files of 22 people living on Cedar unit and two for people living in the nursing unit. There was an ‘outcome profiles tracker’ which took the place of daily record reporting as staff ticked whether they had made any changes to the relevant attached sections of the care plan. We found gaps in one person’s personal care record of 13 days during the first part of November 2013. An appointment attended by one person on the first day of our inspection had not been recorded within their file so there was no record of this visit or the outcome. Some entries in the care plans lacked detail, and had not been written in a way that promoted individualised care.

In addition to the care plans, each person had a separate ‘My Journal’ and health monitoring forms such as food/fluid intake charts and repositioning charts. The ‘My Journal’ had a section to record people’s preferences. Three of the four we looked at in the dementia care unit had not been completed, so staff could not be clear about people’s preferred daily and sleep routines, social routines, significant life events, what they liked to do and wear and their interests.

Where information had been recorded regarding people’s preferences, this was very brief. One person raised concerns about the accuracy of the information recorded about them. The records did not demonstrate that the individual had been involved in the care planning process.

We brought our concerns to the attention of a regional manager at the time of our inspection who agreed that records required more detail and personalisation. She told us the organisation was piloting the use of some new electronic records in another region, but acknowledged that some of the concerns we had found were more to do with how well staff were completing records.

We found that mental capacity assessments had not always been completed accurately. For example, one assessment did not conclude whether the person had capacity or whether a further assessment was required.

During the second day of our inspection we noted the care records for three people left unattended in the nursing unit, making them visible and accessible to people not authorised to view them. This did not ensure that personal information about people remained confidential.