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Archived: The Old Rectory Inadequate

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Inspection report

Date of Inspection: 25 September 2014
Date of Publication: 4 November 2014
Inspection Report published 04 November 2014 PDF | 74.32 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 carried out a visit on 25 September 2014, observed how people were being cared for, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

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

During the last inspection of 26 and 27 July 2014 care plans were not up to date and did not contain all the relevant and current information that was important to enable staff to meet people’s needs effectively. People's care and treatment records had not been filed correctly and could not be located promptly when they were required. There was a risk that loose documents and paperwork would not be kept securely or be available to staff and other professionals when they required them.

Since our last inspection care plans were now updated monthly and care plans were written in first person. People knew they had a care plan and knew what was in them. One person said “I go through it with my key worker”. Care plans were easy to read and outdated notes had been archived. We checked the daily notes from August and they were consistent with no gaps. Risk assessments had been amended and updated to reflect each persons current risks.

Risk assessments were in place for the environment and included areas such as the fish pond, use of fire escapes, gardens and grounds and there was a maintenance record which showed that works for the top floor had commenced. Risk assessments had been completed around fire procedures and emergency plans. All windows to the upper floors had restrictors and risk assessments were in place.

There were current lists of staff and people who used the service and all staff were included in the training records.

Records were kept securely and could be quickly located.