Wendy Afford

1. The risk assessment for Mrs Afford in respect of her skin integrity did not record her high risk of developing pressure damage and it was entirely unclear how the risk was assessed in the first place.
2. It is not clear whether body maps were completed as often as required by the carers and therefore there is a concern that they were not monitoring Mrs Affords pressure areas properly.
3. It was not clear whether the carers were properly following the care plan and the records showing whether or not Mrs Afford was repositioned were incomplete. The records that did exist only recorded her position or stated ‘repositioned’ they did not record whether she was moved, for example, from left to right. The facility within the electronic care record system to highlight the need for carers to reposition Mrs Afford, and record the move, were not used reliably and I heard evidence from a manager which suggested they were not aware of the ability to set repositioning as a mandatory task for each visit.
4. The management of the care company did not appear to carry out audits of records and compliance with care plans nor have any other effective means of oversight.
5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans, record keeping and importance of monitoring skin integrity. This report is not intended as a punitive measure but rather to highlight the areas of concern so that the care company can address them and improve the quality of care for their clients.