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Inspection report

Date of Inspection: 11 February 2011
Date of Publication: 7 April 2011
Inspection Report published 7 April 2011 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

Our judgement

People are not protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them. People have not got accurate personal records regarding food. Records are not being fully completed and are not up to date. This means the Registered Person fails to ensure that people are protected from the risks of inadequate nutrition. Because personal records are not accurate, or fit for purpose.

People are not protected against the risk of unsafe or inappropriate care and treatment arising from a lack of proper information about them. People do not have accurate weight records containing documented information with regard to their care. Weight charts had not been recorded since October 2010. This means the Registered Person has failed to ensure that people’s nutritional needs are identified and addressed. Because personal records are not accurate, or fit for purpose.

User experience

On this occasion we did not speak to people about this outcome area.

Other evidence

We looked at the individual records of the food eaten by people who use services. A system was in place but records had not been sufficiently completed and were not up to date. This means that there was not a clear record of what people had actually eaten. This was discussed with the management team, who agreed that staff were not recording the information required.

We also looked at people’s weight charts. These had been completed monthly until October 2010 but three months had since elapsed where recording had not taken place. The management team told us additionally that the weight seat had been broken for a number of weeks. This means that the service has not been monitoring the weight of people who use services for three months, which is an unnecessary health and nutritional risk.

Given that both sets of these records had not been completed effectively it was difficult to monitor if people's nutritional needs were effectively met.

There were no records to confirm that the policy of two hourly checks on people in their bedrooms was taking place for those people that did not have a buzzer in their bedroom or could not use one. This means they may be at risk of checks not taking place which does not promote their wellbeing.

We were informed that the deputy manager completed night checks at the home which is good practice but the service could not provide documented information in relation to these visits.