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Inspection report

Date of Inspection: 29 January 2013
Date of Publication: 18 April 2013
Inspection Report published 18 April 2013 PDF | 82.71 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 have gathered about Tripletrees, looked at the personal care or treatment records of people who use the service, carried out a visit on 29 January 2013 and observed how people were being cared for. We checked how people were cared for at each stage of their treatment and care, 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

People’s personal records including medical records were accurate and fit for purpose. We looked at the care plans five of the people who used the service. We saw they were accurate, up to date and gave clear instructions for staff to follow in order to provide care for people in the way they wanted.

We looked at staff records and other records relevant to the management of the home. Records seen included policies and procedures, duty rotas and training records. Policies and procedures seen included, but were not limited to those regarding complaints, whistleblowing, medication, staff supervision, record keeping, admission and discharge.

We saw that records were kept in the office, but were not located promptly when requested. Staff spoken with were not clear about whether certain written policies existed. For example we were told by one of the staff members responsible for carrying out pre-admission assessments that the home did not have a pre-admission policy, but one was located within the policy and procedure manual.

We saw that the policy and procedure manual was written in 2002 and had not been reviewed since that date. The policies and procedures made reference to old legislation and were not up to date. This meant that staff did not have clear written guidance to ensure that the service was delivered and managed appropriately and consistently.