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Archived: Mount Avenue

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Inspection report

Date of Inspection: 30 April 2014
Date of Publication: 3 June 2014
Inspection Report published 03 June 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 30 April 2014, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with commissioners of services.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment.

Reasons for our judgement

At our last inspection in November 2013 we made a compliance action in this outcome area because we found a number of issues which had a moderate impact on people who used the service.

At this follow up inspection we found the provider had made improvements.

There was a staff training matrix in place, which made it clear when refresher training was due. We saw staff supervisions had begun to be recorded. We also saw the minutes for recent staff and resident meetings were now recorded.

We found although there had been an improvement in record keeping in relation to staff training, supervisions and meetings; the care records still contained out of date information.

In the two care records we looked at, we saw work had begun on creating person centred plans to include a clear reflection of people's dreams and wishes. There were clear records of people's health checks and health related appointments and a record of professionals involved in people's care. People had easy to read ‘VIP hospital passports’ but these were undated. This meant it was not clear whether the information was kept up to date and when it required reviewing.

People’s personal records were not accurate and fit for purpose. Although the care records were easier to navigate round, we saw out of date information remained in the care records. There was evidence in one of the care records we looked at to show reviews had been carried out. However, when changes were identified this was not reflected in the relevant care plan. For example, this person required a frame when walking outside or a wheelchair if finding walking difficult, but this had not been transferred to the care plan. The manager told us this person had deteriorated since moving into the home in 1991. However, we saw that care plans created in 1991 remained in place and were still being used. This meant there was a risk that people may not receive the appropriate care or support. The manager told us they would fully review and create new care plans.

At the previous inspection, we found records were not held securely and were left on the cupboard in the hallway. At this inspection we saw a new lockable cupboard had been purchased. However, we checked to see whether this cupboard was secure and found it was unlocked. This meant people’s records were not kept securely. Due to the redecoration of the hallway we found this cupboard had been stored in a person’s bedroom. The person told us they did not object to this. However, this was not an appropriate storage solution. We requested this cupboard was moved out of the person’s bedroom.