You are here

The provider of this service changed - see old profile

All reports

Inspection report

Date of Inspection: 7 July 2014
Date of Publication: 20 August 2014
Inspection Report published 20 August 2014 PDF

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Enforcement action taken

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 7 July 2014, 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

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

Reasons for our judgement

We carried out an inspection at Eastbourne Grange on 23 April 2014 and 25 April 2014 when we also met with the provider. We found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate records were not maintained. We issued a warning notice, which stated that the Care Quality Commission required Eastbourne Grange to have achieved compliance with the warning notice by 24 June 2014.

We carried out a further inspection on 7 July 2014 to ensure that concerns identified in the warning notice had been addressed. We found that from the information gathered during the inspection some improvements had been made in relation to records. However, the provider had not met the specific requirements of the warning notice.

We looked at two of the specific care plans where concerns had been identified in the warning notice. To ensure that we could assess and make a judgement about the maintenance of accurate records, including documents in relation to the care and treatment provided for each person, we looked at three additional care plans and associated documentation.

We were told that reassessments had taken place for everybody who lived at the home and care plans were in place that reflected people’s assessed needs. The provider had introduced a computerised care planning system. This had been used for the assessments and care plans seen.

There were a range of assessments and risk assessments in place. These were completed using a ‘tick box’ system with a space for staff to write supporting notes if required. These had been completed but there were inconsistencies and gaps throughout. It was not clear what a number of assessments and risk assessments related to or why these assessments had been undertaken. For example, we saw that two different pressure area risk assessments had been undertaken for people in all care plans reviewed. Whilst these assessments were useful tools in their own right it was unclear why both had been used. These tools used different assessment criteria and there were inconsistencies between the two assessments. There was no evidence from the care plans reviewed, discussions with staff and people who lived at the home that four of these people were at risk of developing pressure ulcers. This meant there was conflicting information for staff which could leave people who lived at the home at risk from harm or injury through inaccurate documentation.

There was a scoring tool in place for a ‘care needs’ assessment tool. However there was no guidance in place for staff to interpret the scores to assist them in identifying people’s needs. It was not clear if staff had received appropriate training in relation to using the computerised system or whether use of the system had not yet been fully embedded into practice. This meant the provider had failed to ensure that people were protected against the risk of harm or injury because accurate and appropriate records were not in place.

There were “This is me” booklets in place in three care files we viewed. Two of these had not been completed. Staff told us that these were no longer being used by the home however they had not been removed from the care files. This meant that staff could not be sure that information in people’s care files was current. People could be at risk of harm or injury because accurate and up to date records were not in place.

Care documentation for one person at our inspection on 23 April 2014 had not been reviewed or updated since August 2013. At this inspection, 7 July 2014, we saw that this person’s needs had been reassessed and care plans were in place that reflected this person’s assessed needs. A reassessment had taken place in May 2014 and the next review date was recorded as June 2014. However, this reassessment had not taken place. This meant people could be at risk of harm or injury from inappropriate care because their records did not contain up to date or current information.