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Archived: Nelson Mandela House

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Inspection report

Date of Inspection: 7 August 2014
Date of Publication: 4 September 2014
Inspection Report published 04 September 2014 PDF | 84.17 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 August 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and 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 inspected the service on 7 January 2014. At that time we found that people were not protected from the risks of unsafe or inappropriate care and treatment. This was because some care plans had sections that had not been signed or completed. Monitoring charts were completed inconsistently and daily records were not completed appropriately or accurately. People's likes and dislikes that had changed had not been recorded. During this inspection we found that improvements had been made.

We saw that care plans reflected people’s individual needs and preferences. People's likes and dislikes were recorded. For example, people were asked what activities they liked and what time they liked to go to bed and get up. People had signed their care plans where they were physically able to. This meant that people received care the way they wanted.

We saw evidence that managers were regularly checking new daily journals. This meant that any issues with recording could be quickly identified and action taken. We found that most monitoring information was now recorded in the daily journal and could be cross referenced with the care plan.

We saw that weekly and monthly summaries had been introduced to quickly identify and record any issues or changes to people’s needs. Where changes had taken place, people’s care plans were updated. However, we were not always able to see why some decisions had been made. For example, the frequency of a person being weighed had been changed from monthly to daily and then to weekly. There was no explanation of these changes in the records we looked at. We discussed this with the registered manager who said they would ensure the reasons for decisions made were recorded in the persons care records.

We found that systems were in place to ensure the safe management of people’s records. Systems were also in place for safe archiving and disposing of records no longer required. This meant that people’s records were kept securely ensuring people’s confidentiality was respected.