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Archived: Cheverells Care Home

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Inspection report

Date of Inspection: 22 June 2013
Date of Publication: 19 July 2013
Inspection Report published 19 July 2013 PDF | 83.9 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 22 June 2013, 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 staff and reviewed information given to us by the provider.

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

When we inspected the home on the 29 January 2013 we found that there were not always assessments in place regarding aspects of people’s health and welfare, for example nutritional assessments. We also found that there was inaccurate record keeping. We looked at this area at our inspection.

We looked at 11 care records in total and talked with the staff about people’s needs, their care plans and their risk assessments. We found care plans had sufficient information about people to enable staff to care for them. Where it was indicated we saw nutritional assessments in place and assessments about people’s skin. Where a problem had been identified, staff had liaised with the health professionals required and were following their advice and care plans. We saw some people had charts for staff to complete when they needed turning because they were at risk of pressure damage. These were completed accurately. We saw people’s diet had been changed or they had been prescribed supplements if the nutritional tool had identified a risk such as weight loss. These assessments helped to alert staff to people’s needs but staff were guided by the health professionals involved in people's care where there were risks.

The care records had information about all aspects of a person’s daily activities and where support was required and how this support and care was to be delivered. We found people were protected against the risks of unsafe care because the records were clear, easy to follow and reviewed monthly or as a person’s needs changed.