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Hilldales Residential Care Home Good

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All reports

Inspection report

Date of Inspection: 16 July 2013
Date of Publication: 21 August 2013
Inspection Report published 21 August 2013 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 16 July 2013, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff and reviewed information sent to us by commissioners of services.

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 not always maintained.

Reasons for our judgement

People’s personal records were mostly accurate and fit for purpose. We saw for one person who was new to the service, there was no care plan. We were assured one had been written but could not be located. Care files and care plans should always be accessible to staff to enable consistent care and support to be delivered.

We found however other records were not accurate or up to date. For example the fire training and test book was not accurate. There were no records of what fire training had occurred for staff over the last few years. We heard how the service had a training DVD which all new staff had to watch but they were less clear how often established staff members had fire training. We heard there was an external company they used on an annual basis for fire training but there were no records of this. The manager agreed to address this as a matter of urgency. It is important to have accurate records of training so the service can plan for gaps in people's learning and know when updates in their training may be required. This ensures staff have the right skills to do their job safely and competently.

We heard how checks on cleaning and infection control were completed but were not recorded. We concluded not all records were accurate or fit for purpose.

Records relating to people and their care, such as care plans were kept securely and could be located promptly when needed, with the exception of one.