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Archived: The Old Rectory Inadequate

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Inspection report

Date of Inspection: 26, 27 June 2014
Date of Publication: 9 August 2014
Inspection Report published 09 August 2014 PDF

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Enforcement action taken

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 26 June 2014 and 27 June 2014, 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, reviewed information given to us by the provider and reviewed information sent to us by other authorities. We talked with other authorities.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

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 not fit for purpose.

The provider told us that, “Paperwork was not the home’s forte but they [the home] were good at care”. The provider added that they had “Not been good at paperwork for 32 years”. No changes had been made by the provider to ensure ‘paperwork’ improved.

There were gaps in the daily care records one person’s daily notes that had been written between April 2014 and June 2014. Several entries that were blank so there was no record of what care, choices and support had been given.

Staff had not filed some people’s records correctly so they were not easily accessible. There were loose documents and paperwork which could get lost or damaged.

Some care and support plans referred to out of date information so were not current. For example, one care plan dated June 2014 referred to information about changes in the person’s needs following an admission to hospital. The hospital admission had occurred in December 2011, so this information was no longer relevant.

We discussed the content of some of the plans with staff, who informed us that some people were not currently participating in recorded activities. Staff told us that they had included the information in the plan as there was a risk that it may occur again. The historic nature of the behaviour was not clear in the records and appeared to be current even though it was not current. This meant that there was a risk that people may not receive appropriate support as staff and other professionals referring to the plans did not always have up to date information.

Health professionals, such as specialist nurses and psychiatrists had written guidelines and documents, which they stated “serve as care plan documentation”, for staff to follow to make sure people had the right support. This information had not been referred to in the plans and risk assessments written by the service. For example, one person had a strategy in place for when they went out, written in consultation with their family, doctor and other health and social care professionals. This was not referred to in their care plan. All the staff we spoke with were able to tell us how they had followed the strategy but we could not be assured that new staff or staff returning to the service would have access to current guidance about people’s needs and the care and support they required.

We reviewed records related to safeguarding concerns and found that the action taken had been recorded in daily records and other confidential records. However, these records did not contain the times that actions were completed and were not signed. This meant that the service had not maintained detailed records demonstrating the action they had taken in response to an allegation of harm or abuse.

The service had a process in place to ensure that records and other information were kept confidential. Records were stored in locked rooms and access was restricted to authorised staff and other professionals who required them. Staff were able to locate the information we requested promptly. Staff had recently been reminded of their responsibilities in relation to confidentiality. This meant the service had suitable processes in place to keep people’s personal information safe.

Staff records and other records relevant to the management of the services were not accurate and fit for purpose. The service was unable to provide CQC with up to date lists people who used the service or staff. Policies had not been updated to reflect changes in legislation and best practice guidance. This meant that people who used the service and staff could not be confident that their personal records were up to date, reviewed and properly managed.