You are here

All reports

Inspection report

Date of Inspection: 11 October 2013
Date of Publication: 1 November 2013
Inspection Report published 01 November 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 11 October 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

Accurate records about peoples health and social care needs were not always maintained.

Reasons for our judgement

We spoke with people who lived at Kilmar House; however, their comments did not relate to this outcome.

We saw the provider had policies in place relating to particular aspects of Kilmar House. We saw that these policies had been updated and were available to staff.

We saw people’s personal records were kept secure and there was a system in place to ensure only people authorised were able to access paper or electronic records.

We looked at three people’s care plans. Care plans are a tool used to inform and direct staff about people’s health and social care needs. The provider had changed the care plan format since our previous inspection.

We saw from peoples care plans, that people’s health and social care needs were included in care plans. Care plans were in place for each person. However, in one care plan we saw that the person had a history of diabetes, falls and urinary tract infections, but there were no care plans in place to address these areas and give staff direction about how to meet these needs.

We found in the accident file that one person had fallen on 28 April 2013. However, there was no risk assessment in place relating to the management of this persons’ falls. A risk assessment is a tool used to identify a hazard and how the hazard can be minimised and to reduce any associated risk to a person. It is important that peoples care plans are reflective of peoples current care needs.

We saw that two people shared a bedroom; the provider told us discussions had taken place with both people and their families to ensure they consented to this; however, this documentation had been archived. It is important relevant information is accessible.