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Archived: Harpers Villas Care Centre

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Inspection report

Date of Inspection: 25 June 2013
Date of Publication: 25 July 2013
Inspection Report published 25 July 2013 PDF | 92.18 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 25 June 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with commissioners of services.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

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 looked at various records to find evidence that people who lived at the home were protected against the risks of unsafe care arising from a lack of proper information about them. At our last visit to the home in October 2013; one of the care plans that we looked at had not been reviewed or updated for approximately seven months. At this visit we looked at the care files for two people who lived at the home. We also looked at other records associated with their care such as daily task sheets completed by staff, food and fluid intake records, information regarding visits undertaken by external professionals such as doctors and dentists. Risk assessments had been completed which highlighted a risk to the person, for example risk of falling, developing a pressure area or self-administration of their medication. We saw that all records were fully completed, easy to read and understand and had been kept up to date.

We discussed audits that took place at the home and looked at records completed. We saw that accident audits were completed on a monthly basis. An analysis of the results of the audit also took place.

We saw that systems had been put in place to ensure that toilets and bathrooms were clean and hygienic and stocked with liquid soap and paper towels. Records to demonstrate this were up to date. Cleaning schedules were in place to demonstrate cleaning duties undertaken.

We saw daily records completed by staff which recorded information about each person who lived at the home. This gave staff a record of the person’s health and wellbeing and informed them if they needed to monitor any specific aspects of care for an individual. We saw daily task sheets, which clearly recorded the task to be completed with the name of the staff member responsible for undertaking the task.

At our last visit we saw that ‘turn charts’ had not been completed correctly. These records were particularly important for those people at risk of developing a pressure area. People who are unwell and in bed may be at risk of developing a pressure area and therefore may require to be regularly turned to reduce pressure on a specific area of their body. Staff should keep a record of these turns on a turn chart. At this visit we saw that records were kept to demonstrate when someone was turned in bed, when they were stood up or walked when they were in the lounge. These records helped to demonstrate that pressure area care instructions were being followed.

At our last visit, care plan information and wound charts had not been updated. At this visit, the two care files that we looked at had been reviewed and updated. Care plan information had been changed to include more ‘person centred’ details which helped to ensure that the care was provided according to the wishes and needs of the individual.