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Archived: Swallow Wood Care Home

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Inspection report

Date of Inspection: 6 July 2011
Date of Publication: 26 September 2011
Inspection Report published 26 September 2011 PDF | 68.87 KB

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

We reviewed all the information we hold about this provider, carried out a visit on 06/07/2011, checked the provider's records and talked to people who use services.

Our judgement

Records about people who use the service are used to plan appropriate care, treatment and support. Some of the information needed for this is not systematically recorded.

User experience

People who spoke to us did not comment on this outcome area.

Other evidence

As part of our inspection we looked at four care plans and other records of care. The care plans we looked at did not contain information about people’s capacity to consent to treatment or care and there was no evidence that staff had done risk assessments about mental capacity or potential deprivation of liberty.

We found that care plans focused on the physical aspects of care and were not significantly person centred in that they did not always record people's social and emotional needs.All of the people whose care plans we looked at had close family and friends who visited them, but little information was recorded about their interactions with relatives and significant others. We saw that each care plan had a section called a personal profile, which if completed correctly should have given detailed information about the life and family history of the person using the service. In three of the four care plans that we looked at, this was incomplete.

The care plans for two people with diabetes were checked by us after we found out staff were taking blood sugar samples on an infrequent basis. The care plans did not say why blood sugars were being taken. There was no written evidence of unstable diabetes and no action plan for staff to follow if the person’s blood sugar rose or fell from ‘normal’ levels.