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Inspection report

Date of Inspection: 23 October 2012
Date of Publication: 21 November 2012
Inspection Report published 21 November 2012 PDF | 90.43 KB

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 23 October 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

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

People’s personal records including medical records were not accurate and fit for purpose. We looked at three care files. We saw that everyone had a care plan. These contained good details about people's lives and what their care needs were. We saw that monthly reviews were now being carried out. Although some review records showed that significant changes had occurred, the care plans were not updated to reflect this. Changes recorded included the need for two carers with personal care instead of one. This meant that some staff may not know about the changes and this could affect people's safety and well being.

We saw risk assessments were on place on all files. We noted that although risks had been identified such as falls and choking, the action described as needed for many of the risks was 'be vigilant'. This did not give staff clear guidance on how risks could be reduced. Not all known risks had been assessed. These included using the stairs.

We saw a care record that included a risk assessment for falls. There was no specific detail on how to reduce risks. The person had had multiple falls. Some of these were not recorded in the accident book. Some of them were in the accident book but not the daily record. This meant that the true number of falls was difficult to determine. The risk assessment was not updated following falls. The provider told us that on the day of the inspection an alarm was fitted on the person's chair to alert staff when they tried to stand up.

We saw that some, but not all falls had been recorded in the accident book. The completed accident records had not been removed and put with people's individual records. This meant that information about people was not kept

in a way that respected people's right to confidential records. This also meant that the accident book was not being evaluated by the manager to identify any individual trends. This would allow measures to be put in place to reduce the risk of reoccurrence.

On one plan we saw that there had been problems with challenging behaviour. We saw that appropriate medical advice and support had been sought and followed but there was no risk assessment in place to keep staff or other people safe during this time.

We saw that one person had a recurring medical problem that affected their well being. There was no risk assessment in place for this and no guidance for staff on how this could be avoided. One person's mobility had worsened and they had experienced difficulty in using the stairs. Daily records showed that staff on at least one occasion had to ' lift the person's feet up and push'. There was no risk assessment in place relating to the safety of the person or staff.

One record noted that the person 'talked gibberish'. This showed a lack of professional knowledge about their medical condition and did not afford the person respect or dignity.

The provider told us that daily records were not kept. Entries were made of significant events. These included activities, trips out, visitors and if people were unwell.

We saw that the service had a 'communication 'book. This was used to record all sorts of information about what happened at the home. It included personal and medical information about all the people who lived at Southview. This meant that people would not be able to see their records without breaching someone else's confidentiality.