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Archived: Ryecroft Private Residential Care Home Inadequate

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Inspection report

Date of Inspection: 26 June 2014
Date of Publication: 1 August 2014
Inspection Report published 01 August 2014 PDF | 84.07 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 26 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and talked with commissioners of services.

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

At our last inspection in February 2014, some of the information in people’s care files about their needs and care was disjointed, unclear and difficult to follow. There was also no evidence that care plans and risk assessments had been regularly reviewed and updated to reflect significant changes in people’s needs or care. Following February’s visit, we asked the provider to send action plan outlining the action they were going to take to ensure each person’s care record contained proper, up to date and accurate information about them. We reviewed the records of the provider again during this visit and saw that sufficient improvements had been made.

We reviewed three care records. We saw that all assessment and care plan information was in the same format making it easy to read and follow. Information and guidance in relation to people’s needs and care were clear and people’s risks had been adequately identified and assessed. All the care records we looked at showed evidence of regular monthly review and had been updated with significant information as required.

At our last visit, the communication records in relation to appointments made with other healthcare professionals such as GP’s, mental health, hospital services contained disjointed information in relation to people’s needs and the advice given. During this visit, we saw that communication records had been simplified. There was a communication record now in place which clearly recorded people’s appointments with other healthcare professionals and the advice given in relation to their care. We reviewed the entries made on the communication records and saw that the advice was clearly documented and easy to understand.

The provider may find it useful to note however that one person’s medical information indicated the person’s had an allergy to certain types of medication. This information was not clearly documented within the person’s care file.