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Inspection report

Date of Inspection: 24 February 2012
Date of Publication: 27 March 2012
Inspection Report published 27 March 2012 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

Our judgement

We found that there was a record keeping system in place that ensured people's safety and well being. The care records belonging to people using the service contained sufficient, clear, accurate and up-to date information about their care and treatment.

User experience

We talked to people who use the service during our inspection and they told us that they were happy living in the home and with the care that they received. People told us that staff were generally good and that they were consulted about the support that was provided and that their views were listened to.

Other evidence

When we carried out a routine visit on 8 November 2011 it was noted that people's safety and well being may not be fully maintained because their care records did not contain sufficient clear, accurate and up-to date information about their care and treatment. Within twenty four hours of our site visit the manager emailed us and provided details of action they had already taken to improve the care plans with a target for completion of one week.

We conducted an inspection visit on 24 February 2012 to review this outcome.

The acting manager told us that she felt that there had been “significant improvements in the service since the new owners came.” She explained that a new system of assessment and care planning had been introduced by the new owners from May 2011. She informed us that she had been trained in the use of the documentation by the area manager and that she was providing the training for her senior care staff. The acting manager said that making sure that all of the people using the service had the new assessments and care plans in place had been time consuming but was confident that the system was now working well. The acting manager told us that all of the people using the service now have a full set of assessment and care planning documentation in place.

The area manager explained that the new documentation was a recognised ‘Mulberry’ system, which was also being used in other homes run by the same provider. The area manager said that she had trained the acting manager in the use of the system and had also assisted in carrying out the assessments and writing the care plans. The area manager told us that senior care staff had been trained in the basics of using the documentation and that further training on assessment and care planning was to be provided.

A senior carer said that using the new documentation was difficult to start with. “It’s more in depth than the old system but I’m getting the hang of it”

She explained that the acting manager had provided the senior carers with training in how to use the documentation, and that she was aware that there were plans for more training to be provided on care planning.

The senior carer said that “keeping records is very important and this needs to be done properly.” “The new record keeping system helps us to make sure that the residents are happy, well looked after and their needs are met.”

We were told that the providers of the service were working to ensure that people who use services and their relatives were able to influence and be involved in aspects of their care and welfare. For example, 'residents’ and ‘relatives’ meetings were held to discuss topics such as what activities people would want and the introduction of new initiatives such as the new assessment and care planning documentation.

We observed that a personalised record was kept for each person who used the service. The records were stored safely and securely in an office where they were easily accessible to care staff when required.

We reviewed a sample of care records and found them to be very comprehensive and detailed but rather complex. We found the care records were up to date and being reviewed regularly. The case files contained a broad spectrum of risk assessments and associated care plans including things such as mobility, hygiene, cognition and nutrition. We found one care plan relating to an identified risk of pressure area breakdown, did not clearly state the actions required by care staff to prevent a pressure sore from occurring. This was discussed with the acting manager and the area manager, who said they would update the care plan and continue to develop their skills in assessment and care planning through future training.

We found the assessments and care plans were in general, completed to a reasonable standard.

During our visit we observed visits by the district nurses and the documentation demonstrated that multidisciplinary visits were