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Archived: Caremark (East Riding)

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All reports

Inspection report

Date of Inspection: 24 March 2014
Date of Publication: 30 April 2014
Inspection Report published 30 April 2014 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 24 March 2014, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with carers and / or family members and talked with staff.

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

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had been maintained.

We had found during the inspection in October 2013 that care related documentation was not always detailed. One of the files we looked at did not contain a care plan. There were discrepancies in some of the files we looked at. Some plans had been written in 2011 and had not been altered since. There were many sections of notes missing from the files we looked at.

During the inspection in December 2013 we looked at six care plan files and records of reviews that had been carried out since our last visit. The provider also submitted information on a two weekly basis between October and December 2013 regarding the reviews completed. We found that the amount of detail recorded in the review paperwork was inconsistent. The quality of the information gathered at these care plan reviews appeared to be dependent on the individual field care supervisor. The provider agreed that further work was required.

At the inspection in March 2014 we found that there had been improvements within the files regarding review and care plan documentation. We looked at five files and found that four of them had full records of reviews, and care plans including updates following the review. One required a little more detail but the information contained in it was factual and adequate.

All the files we looked at showed that the person had a review of their care plan within the last four months and where changes in care or needs had been identified these had been transferred into people’s care plans. The compliance manager explained that when changes were needed, the subsequent update to the plan was then monitored and reported to the senior field care supervisor through the weekly meetings with the field care supervisor staff. This system had now had time to bed down and was proving to be extremely effective as there was regular monitoring at each stage of the process. This meant that when any issues were raised in terms of the service being delivered to the individual it was being actioned immediately. If any actions were highlighted regarding the quality of recording information, this was also picked up quickly and rectified.

As part of the inspection in October 2013 it had been highlighted that plans were task orientated and did not give details about how the person wanted to be supported. In December 2013 we found that the level of detail and information regarding personal preferences was dependent on the field care supervisor that had written the plan. During the inspection in March 2014 we found that as a result of the documentation monitoring systems which were now in place there was improved consistency in the documentation that we looked at. Where generic statements or sparsely detailed statements were used, this was then picked up on by the senior field care supervisor or the compliance manager and queried further with the field care supervisors to ensure there was further clarification.

We had previously identified when looking at records that there was a lack of information in people’s files about conditions such as dementia. We found that this area had not been fully addressed yet, but discussed with the provider, registered manager and compliance manager about the development planning that was going on in this area and the intended implementation of specialised work specifically around dementia related conditions. The provider explained that now that files were improved and review work was up to date this would now be further developed. The provider may wish to note that this may have meant that people’s individual needs and conditions were not known by staff and were not considered in the way support was delivered.

We had found in October 2013 that there was a lack of records relating to action taken following complaints, concerns, safeguarding events, accidents and incidents. As part of ou