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Archived: Mrs Elaine Sandra Ward - 15 Sorrel Drive

All reports

Inspection report

Date of Inspection: 27 February 2012
Date of Publication: 21 March 2012
Inspection Report published 21 March 2012 PDF | 51.01 KB

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

We reviewed all the information we hold about this provider, carried out a visit on 27/02/2012, checked the provider's records, observed how people were being cared for, talked to staff and talked to people who use services.

Our judgement

The people using this service cannot be confident that their personal care, treatment and support records are accurate and current because verbal communications between staff are not recorded within their personal records.

User experience

The people we spoke with did not make any comments about this outcome.

Other evidence

As recorded in outcome four of this report we looked at the care and support plans of two people who lived in the home. One person we spoke with told us that the information in their plan was an accurate reflection of their care and support needs. We noted however that both plans we looked at had not been reviewed for over twelve months.

As the registered person was not available during our visit we spoke with her about this via telephone at a later date. She told us that she had reviewed the care plans of all three people that lived in the home in November 2011, and they were available on the homes computer. We were subsequently provided with information that confirmed that people's care plans had been reviewed.

We saw, as recorded under outcome four in this report, that information handovers between the staff, agency staff and registered person were undertaken on an informal verbal basis, rather than being written down. We were also told that the outcomes from people’s health care appointments were also handed over on a verbal basis.

We discussed the informal nature of handing over pertinent or key information about the people living in the home with a staff member on duty. We were shown individual diaries belonging to people, but noted that information was not being recorded on a regular basis. The member of staff we spoke with was knowledgeable about people’s needs. The lack of documented information however meant that staff could not be sure that information they received was an accurate reflection of events.