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Howard Goble House Requires improvement

All reports

Inspection report

Date of Inspection: 5 February 2013
Date of Publication: 27 February 2013
Inspection Report published 27 February 2013 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 February 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

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 usually protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

People’s personal records including medical records were accurate and fit for purpose. We saw that people's records were usually updated in line with any changes in their support needs or medical needs. For example, we saw a risk assessment and challenging behaviour guidelines that had been updated immediately after an incident had occurred to reflect the persons current condition.

However the provider may wish to note that there was an inaccurate copy of the staff rota available on unit one on the day of our inspection. When we arrived on unit one on 05 February 2013 staff were unclear about who was in charge for the day, and which staff were expected on shift. According to the rota kept on unit one the home manager was on a training course. However when the manager arrived they showed us the correct rota kept in the office, which clearly indicated which member of staff was the lead person on shift for the day, and that the manager had changed their training day. The manager told us the unit one rota would be updated to identify the shift leader and an accurate list of which staff were expected on duty. The manager said that staff had access to the master copy of the rota at all times. The rota on unit two was accurate.

Records were kept securely and could be located promptly when needed. People's individual support plans had a statement on the front which said "please don't read this unless you have my permission or are involved in my daily support" and we saw that people's care plans were kept locked in their bedrooms or else in a cupboard on the unit. Staff, and some of the people who were able to speak with us, knew exactly where to find the care plans.