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Archived: Yorkshire Rose Home Care - 6 Carr Furlong

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Inspection report

Date of Inspection: 26 September 2012
Date of Publication: 30 October 2012
Inspection Report published 30 October 2012 PDF | 64.95 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 reviewed all the information we hold about this provider, carried out a visit on 26/09/2012, looked at records of people who use services, talked to staff, reviewed information from stakeholders and talked to people who use services.

Our judgement

The provider was not meeting this standard. We judged this had a minor impact on people using the service and action was needed for this essential standard.

People were not protected from the risks of unsafe or inappropriate care and treatment.

User experience

We spoke to people using the service but their feedback did not relate to this standard.

Other evidence

We added this outcome area to our inspection after identifying some concerns, that people’s personal records were not accurate, fit for purpose and could not be located promptly when needed. This meant people were not protected against the risks of unsafe or inappropriate care. This was because in one case file the service had obtained a list of tasks to be carried out for the person from the placing authority. Some of those tasks were not identified on their own assessment or care plan provided by the agency. The care needs assessment was dated 2010 – 11. A moving and handling risk assessment identified the next review should have taken some months earlier, but this had not been carried out. Actions identified to minimise risks in the moving and handling risk assessment were not included in the plan of care. A further risk assessment was in place to assess a number of potential risks that may be present regarding the property and the care provided, with the actions needed to reduce potential risk identified. However, the risk assessment was not signed or dated by either the person undertaking the assessment or the person using the service and the action taken to reduce the potential risk had not always been met. For example, in the medication risk assessment it stated, ‘staff involved in the administration of medication to undergo training and follow assisting with medication policy’.

We spoke to both the manager and member of staff about the care provided to the person using the service, to identify whether the written documentation supported the care they provided. They provided conflicting information about the care provided to the person compared to what was recorded in the person’s case file.

The provider/manager said a task sheet that was up to date was in each of the people’s homes that described the tasks to be completed on each visit and communication sheets to confirm whether or not those tasks had been carried out. We asked to see a copy of that information but these were not readily accessible in the office.

We looked at another care file and found those records also had a lack of proper information and did not provide an accurate record of the care provided.