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Archived: Chaseley Bungalows

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Inspection report

Date of Inspection: 13, 21 August 2014
Date of Publication: 18 September 2014
Inspection Report published 18 September 2014 PDF | 107.7 KB

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 13 August 2014 and 21 August 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services. We reviewed information sent to us by other authorities, talked with commissioners of services and talked with other authorities.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had not been maintained.

Reasons for our judgement

People’s personal records including care plans were not accurate. Care plans seen had been reviewed monthly. We saw that reviews had been recorded as ‘no change’. However, this did not reflect changes to people’s care and treatment. We saw that one person’s covert medication care plan had not been updated to include changes. Another person’s care plan did not include any care plan or risk assessment in relation to alcohol, although instructions in relation to this were seen in the staff communication book. This meant that care records did not contain up to date relevant information to inform staff how to provide care safely and appropriately.

People with specific medical needs did not have up to date information in the care records. For example, catheter care and catheter changes had not been documented in a consistent manner. Although information was seen in people’s files this had not been consistently updated and care documented appropriately.

We found mistakes and poor documentation which identified staff had not followed policies and procedures. This included medication, reporting of accidents and incidents and documenting when people were in pain or unwell. This meant that people were not protected against the risks of unsafe or inappropriate care and treatment as accurate records had not been maintained.

We saw in care plans that new style ‘pen pictures’ were in the process of being implemented. However, these were not in place for all people living the bungalows. This meant that records were not up to date, and did not reflect people’s current needs. This meant that the provider had not ensured that service users were protected against the risks of unsafe or inappropriate care, as there was a lack of proper information about people living in the service.

We looked at accident and incident forms. We saw that not all incidents had been recorded on incident forms in accordance with the organisations policy and procedure. We saw hand written notes which had been written by staff. However, it was unclear from records seen what actions had been taken to address issues raised. This meant that there was no accurate and appropriate information in relation to the care and treatment people had received.