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Archived: Monet Lodge

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All reports

Inspection report

Date of Inspection: 20 December 2012
Date of Publication: 26 January 2013
Inspection Report published 26 January 2013 PDF | 94.92 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 reviewed information sent to us by other organisations, carried out a visit on 20 December 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with stakeholders.

We were accompanied by a Mental Health Act commissioner who met with patients who are detained or receiving supervised community treatment under the Mental Health Act 1983.

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

We spoke with four people who were being cared for in this hospital and four sets of relatives of people who were being cared for in this hospital about the care they received. They’re feedback did not relate to this outcome.

During our visit we looked at the care plans of four patients. Our review of the documentation and risk assessments showed that care plans and risk assessments were well collated and easy to follow. There were no gaps left in the records.

We saw a protocol for record keeping kept on people’s care file which provided guidance to staff to ensure they met their responsibilities on record keeping.

The Mental Health Act Commissioner looked at the Mental Health Act paperwork and confirmed that all the correct paperwork was in place and the files were exceptionally well ordered. The only exception they found was around the recording of authorised leave from the hospital during a change of responsible clinician. The Mental Health Act Commissioner has asked the hospital for an action plan to prevent this occurring again.

We saw employment records for people employed in the home. These were generally well ordered. Where information was not available in these files, it was located within reasonable timescales.

Records showed that the provider did regular checks on the quality of care. The checks involved speaking to people who lived in the home, reviewing incident reports, case tracking, reviewing complaints and checking other records.

The health and safety risks of the home were assessed and managed, including regular checks on equipment to make sure equipment was safe to use.

Meetings were held with people who used the service and their families. We saw records of these meetings which confirmed they took place.

We looked at the complaints log. This was indexed so that it could be clearly seen how many complaints had been received over any time period. We saw that the hospital had received a small number of complaints. We saw that the complaints were investigated and a response provided to the people raising complaints. There were many examples of compliments from families and people who use services.

We saw archived paper healthcare records. These were stored securely and were well ordered which meant that any record could be easily located. The registered manager had a very good understanding of the requirements relating to disposal of records relating to healthcare. The provider had not been providing services long enough to warrant the need to dispose of any healthcare records at this hospital. This was because the rules about health care and Mental Health Act records meant that they need to be stored for longer periods of time than in other care settings.