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Archived: The Chestnuts Nursing and Dementia Care Home

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Inspection report

Date of Inspection: 18 July 2011
Date of Publication: 29 September 2011
Inspection Report published 29 September 2011 PDF

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

Meeting 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

Our judgement

Suitable arrangements were in place to manage and secure records held about people. However, some personal records relating to peoples’ care and welfare were not always accurately maintained and stored.

User experience

We did not ask people directly about their records, but we saw that monitoring records left unattended in lounge areas at various points in the day. We observed staff who moved in and out of the lounges leaving the records lying around as though it was custom and practice. We discussed this with the manager and it seemed that the case of convenience was given a higher priority over the importance of confidentiality. We told her that this needed to improve. In speaking with some of the people using the service, they told us that they saw their care plans and records and were happy with them.

Other evidence

We looked at four care records and found in at least three, that they were not maintained accurately. These documents included various aspects of care plans, which the manager instructed the staff on duty to rectify. It is important for these documents to be used as working tools by the staff in delivering peoples’ care and support needs. There was also evidence of various key monitoring charts relating to peoples’ care that were not properly maintained. They were brought to the manager’s attention during the course of our inspection. Improvements were required in how records were maintained in the home.

We noted that there were appropriate storage facilities for records and peoples’ personal belongings in the home. We did not look in detail at policies and procedures in the home, but saw that they were last reviewed in July 2010. We were told that some policies were being developed and should be completed by September 2011.