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Archived: Choice Healthcare - Barnsley

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Inspection report

Date of Inspection: 5, 11 February 2014
Date of Publication: 15 March 2014
Inspection Report published 15 March 2014 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 5 February 2014 and 11 February 2014, talked with people who use the service and talked with staff. We talked with other authorities.

Our judgement

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

Reasons for our judgement

We included this outcome during our inspection due to a number of concerns we became aware of relating to records.

At our first visit to the service, we established that some important information was not present at the office. The manager said that personnel files were being audited at head office, which led to us returning a second time to be able to view a sample of these files. The care co-ordinator had told us the files were always kept there. The service did not have a current policies and procedures file and the complaints file could not be located, despite senior staff telling us they had recently seen these files in the office.

Whilst looking at care plans we asked to see some specific records for an individual for the preceding months. These could not be located. The care co-ordinator and administration staff showed us how information from care files, such as MAR charts and daily records, was filed. Records were not filed individually for each person and were in no logical order. Information was difficult, or not possible, to locate which meant important records were not always able to be accessed promptly.

We looked at minutes of recent staff meetings and found within these, minutes of a meeting that contained confidential information relating to a staff member. The care co-ordinator confirmed to us that this file was kept in the office and accessible to staff. We requested that they remove the personal information and store it securely. This demonstrated that confidential information was not being stored appropriately by the service.

We viewed a sample of five care files at the office in addition to viewing four people’s care plans at their home. Some of the files at the office had dates omitted from the file’s checklist so that it was not always possible to see where some people had been referred to the service, had a care plan review or when they commenced using the service. We found that not every file at the office contained a care plan. The administration officer told us that staff were in process of transferring people’s care plan to new documentation and taken them out of the files. We saw the service used a computerised system called people planner which recorded certain information but we found this information was not always reflected in the actual files.

We noted that one person we visited at their home was reliant on medical equipment they used for an ongoing health condition. When we looked at this person’s care plan, this information was not recorded on their risk assessment which meant the information did not accurately reflect their situation. We saw risk assessments for two other people which stated that the person did not take medication when in fact their care plans evidenced that they did. This meant there was a risk of people receiving inappropriate or unsafe care as all risks had not been accounted for and documented correctly within their care files.

Staff files were not uniform and we had to obtain information from a number of different sources. For example, one person had no evidence that they had a current DBS check. We had to ascertain this information via the HR manager. Some files had written on them where references had been requested but the information was not signed or dated so we could not see when these requests had been made. This meant that important information was not always stored with the relevant records.

We saw pro formas of induction training records were available for new staff members but confirmed that senior staff were not all aware of the existence of these. Consequently they had not been completed so it was not possible to evidence that staff had completed an induction to a satisfactory level