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Inspection report

Date of Inspection: 17 January 2014
Date of Publication: 18 February 2014
Inspection Report published 18 February 2014 PDF

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 17 January 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 carers and / or family members and talked with staff.

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

Records maintained were not accurate and up to date. This meant that people who used the service were not always protected from the risks of unsafe or inappropriate care and treatment.

During our inspection we looked at the care records of three people who used the service. We found that there was a lot of information contained within care records detailing the delivery of care. We saw that care assessments were reviewed on a regular basis but that where these assessments identified changes to people’s care needs, care plans were not updated to reflect these changes. For example we saw in one person’s care records that an assessment had been carried out and identified that this person was asthmatic but the care plan had not been amended to reflect this change of needs.

We saw that nutritional screening tools were not being completed accurately and that they contained gaps. For example, we saw that BMI (Body Max Index) was not being completed. This is required to ensure that the overall screening calculation is correct.

We spoke with the manager of the home about this. They informed us that the home were in the process of changing the care record documentation and that they were aware that some of the records required action to be taken to bring them up to date. We saw evidence that the care records were being transitioned from an old format to a new one.

This meant that the home had failed to develop and maintain accurate records which protected people from the risks of unsafe or inappropriate care and treatment.

We found that records relating to the persons employed by the service and those relating to the management of the regulated activity were stored securely and could be located promptly with issue.