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Archived: The Rosewood

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Inspection report

Date of Inspection: 2 January 2014
Date of Publication: 25 January 2014
Inspection Report published 25 January 2014 PDF | 78.31 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 2 January 2014, observed how people were being cared for and talked with people who use the service. We talked with staff.

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 checked records and policies regarding the general running of the home. We saw that records were maintained and reviewed periodically. The registered manager signed and dated documents to show when reviews had been completed.

The registered manager explained the process she used for reviewing and updating care plans for the person who used the service. We saw that care plans had been reviewed and amended to ensure they reflected changes in the person’s needs. We saw that daily records were maintained which detailed food and drink intake as well as any activities or unusual occurrences. This meant that information was available to professionals to help them assess the health and welfare of people who used the service.

The registered manager explained that the doctor and relatives of the person had discussed how to proceed should their relative be taken ill. She explained that she had not been directly involved in the discussions but understood that due to the person’s health issues it had been decided that it would not be in their best interest to attempt to resuscitate them if this became necessary. In these circumstances it is usual for the doctor to sign a do not attempt resuscitation (DNAR) form. The provider may wish to note that there was neither a DNAR form, nor any information available to emergency services or hospital staff within the care records to show that this decision had been made. The registered manager assured us that she would source the required documentation.