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Wythall Residential Home Requires improvement

All reports

Inspection report

Date of Inspection: 7 November 2013
Date of Publication: 11 December 2013
Inspection Report published 11 December 2013 PDF | 77.72 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 7 November 2013, 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 carers and / or family members and talked with staff.

Our judgement

Accurate record keeping meant that people were protected from the risks of unsafe or inappropriate care and treatment.

Reasons for our judgement

At our last inspection of the care home we identified that the home was not compliant with this regulation and that the non-compliance presented a minor risk for people using the service. Improvements in the quality and accuracy of care records were needed. The provider wrote to us and told us how improvements had been made. The findings of this inspection on 7 November 2013 showed that these improvements had been made.

We checked the care records of three people who were using the service. We saw that information was well organised and records were held securely. We found that in the care plans we reviewed, information reflected the actual care being provided. This is because they had been updated regularly. Care plans included written guidelines for staff about the care and support to be provided to each person, so that their individual care needs would be met.

Fluid charts and food intake charts had been implemented for people assessed as being at risk of poor nutrition or dehydration. We found that an accurate record of dietary and fluid intake had been kept. Daily reports had been written. We found that these outlined the care and support that people had received and how they had spent their time.

During our inspection we also asked to check records relevant to the management of the service. We found that these were accurate, fit for purpose and were located promptly on request.