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Inspection report

Date of Inspection: 2 October 2013
Date of Publication: 29 October 2013
Inspection Report published 29 October 2013 PDF

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 looked at the personal care or treatment records of people who use the service, carried out a visit on 2 October 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

Reasons for our judgement

We looked at the personalised care and medical records of four people who used the service. The records contained information such as risk assessments on people’s ability to perform tasks such as bathing themselves, self-medicate and mobility. Additionally we saw assessments for people to determine whether they had the capacity to make informed decisions about their care.

In each of the care plans we looked at we found that people’s personal records, including medical records, were not always accurate or fit for purpose. For example, the daily records in each care plan did not always contain sufficient information explaining what had occurred for that person throughout the day. We saw entries restricted to a few words and in all cases there were extensive gaps in the notes.

In one of the care plans we looked at we saw there had been no entry in the records for seven days. There were similar gaps in the other care plans we looked at. The manager explained that on occasions people were in hospital so entries were not made. However we saw no entries within the notes that showed that any of the four people had been to hospital during these periods.

The registered manager told us that entries were not always made in people’s daily records unless there was something they deemed essential for staff to be aware of. They also told us that they did not always check the quality of the entries made by staff. They acknowledged that they needed to ensure that this was done and would ensure a process was put in place to regularly check the quality of the notes.

In all of the care plans we looked at we could not assess whether the person’s needs were being met due to the inconsistent recording of daily activities.

The registered manager told us that they were confident that people’s needs were being met in spite of the inconsistent record keeping. However they agreed that as a result of the lack of adequate records this could not be fully evidenced.

We saw that the care plans for people who used the service were stored securely and could be located promptly when needed. Staff we spoke with were aware of where the plans were located and how to access to them.

The registered manager told us records were maintained and disposed of in accordance with the Data Protection Act 1998. They told us that all records relevant to the management of the business were kept for a period of at least five years and were then securely destroyed. The provider may wish to note that the length of time they are required to retain records differs depending on the type of records. Some records are be retained for longer than five years whilst other less than.

We saw that the registered manager had ensured that a Criminal Records Bureau (CRB) check (now known as the Disclosure Barring Service) had been conducted prior to staff members commencing their employment. We checked the CRB records of three members of staff. Two of the three staff members had not had a CRB check conducted since 2004 and 2006 respectively. The manager told us that they did not conduct further CRB checks for staff once they had commenced employment. This meant that people who used the service could be at risk of receiving care from staff members who had committed an offence which would prohibit them carrying out their role.