You are here

Archived: Donness Nursing Home Inadequate

All reports

Inspection report

Date of Inspection: 19 September 2013
Date of Publication: 15 October 2013
Inspection Report published 15 October 2013 PDF

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 19 September 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

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

Our inspection of 14 February 2013 found that people were not protected by the way the home managed records. The provider wrote to us and told us how their record keeping would be improved.

People did not tell us anything about record keeping at the home when we spoke with them but they did say that staff discussed their care with them. We looked at four people's care files and saw that they were well organised so that information was readily available for staff use. This meant that care arrangements were more likely to be well organised. We saw examples of where people using the service, or their family representative, had signed to say that they had agreed the person's plan of care. We also saw that a staff record of people's daily care was detailed, signed and dated and therefore available to inform staff of the person's current well-being.

We saw from a notice displayed in the staff office that staff had been informed that record keeping must be improved and how this was to be achieved. We asked staff if they had seen improvement or changes at the home since our last visit and two said that record keeping was an improvement they had noted.

We looked at medicine administration records because during our visit February 2013 gaps and incorrect recording had the potential to put people at risk. We found during this visit that the records had been completed correctly, with no gaps in information and codes, which should be used to record additional information, were being used correctly.

We asked to see some records relating to a person now deceased. The registered manager was able to find that information without difficulty. This showed that storage arrangements for archived files were in place. We also saw that people's care files were kept securely in the staff office so that only people with a right to view them could do so.