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Archived: The Chestnuts Nursing and Residential Care Home

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Inspection report

Date of Inspection: 9 April 2013
Date of Publication: 11 May 2013
Inspection Report published 11 May 2013 PDF | 86.79 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 9 April 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information sent to us by commissioners of services.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

We spoke with the manager and she told us where to find relevant documentation. We saw that this was filed securely, with regard to people’s confidential and sensitive information. The cupboard containing care records was locked and all other documentation was securely stored in the office and the nurses’ room. We spoke with staff who said that they understood records must be kept confidential.

We asked the manager what had been done in response to concerns raised at the last inspection about the recording of money used by people. The manager told us that this had been addressed. She said that in addition to people’s personal money, there was an amount that could be accessed if they spent more than they had available. The manager showed us a file used to document expenditure and she said there was now a clear audit trail of monies.

We saw care records and saw that information was indexed and orderly, Accident and incident records were in place as were documents to support the management of the premises. We looked at the complaints record and noticed that no complaints had been recorded. We spoke with the manager, who told us that there have been no complaints, but said she would record them should they arise.