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Archived: St George's Nursing Home Requires improvement

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Inspection report

Date of Inspection: 10 September 2013
Date of Publication: 27 September 2013
Inspection Report published 27 September 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 10 September 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 carers and / or family members, talked with staff and reviewed information sent to us by commissioners of services. We reviewed information sent to us by other regulators or the Department of Health, reviewed information sent to us by other authorities, talked with commissioners of services and talked with other regulators or the Department of Health. We talked with other authorities.

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

The quality and accuracy of records relating to people's care protected people from the risk of unsafe or inappropriate care.

Reasons for our judgement

We inspected this outcome because we received information that raised concerns that records may not always be an accurate reflection of people’s care and health needs.

We found that important records about the care and support provided to people were treated as confidential. Records that related to people's care were kept secure and staff only brought them out when they needed to. The records we saw were mostly complete, which meant the information we needed to see was available.

We found that people's care plans and risk assessments described people's care and support needs and were mostly changed when people's needs changed. This ensured staff knew how to support people and how to respond to keep them safe. When changes were made to people's care plans, the information that supported the changes was recorded. This meant it was clear why changes had been made.

Daily updates were written, which provided information on people's day and any incidents or changes in needs. This ensured a record of people's daily life and the care and support provided to people was maintained.

There were records kept where required, of people's food and fluid intake, wound care and when staff helped people to change their positions in bed. In addition to these records the management team had brought in another system to check that each person, where required, had received sufficient drinks due to the concerns raised. This daily audit system was checked alongside the records staff had made during the day to ensure each person had drunk what they needed to that day. This helped to ensure people’s needs were met with risks to their health and wellbeing reduced.