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Inspection report

Date of Inspection: 18 September 2014
Date of Publication: 20 November 2014
Inspection Report published 20 November 2014 PDF | 105.22 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Enforcement action taken

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 18 September 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and reviewed information given to us by the provider.

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 added in this outcome as we were concerned about the poor standard of records we observed during our inspection.

We looked at four care files for people who lived in the home and found poor monitoring and recording in all of them. For example we looked at one person's file and saw that there was a care plan for their pressure areas. The care plan identified them as being at high risk from pressure sores. This care plan had not been reviewed since October 2013 and prior to that in March 2012. This meant that this person was at risk from receiving inappropriate care as they were not being monitored at regular intervals. We also saw from the care records that this person sometimes behaved in a way that put other people at risk. Their risk assessment regarding this behaviour had not been reviewed since June 2014. We were aware from looking at other records that an incident had occurred in August 2014 but their care plan had not been updated to reflect this or inform staff how they needed to support the person.

We looked at the care records for another person and saw that their care plans were last reviewed in November 2013. This person had some health concerns and some behavioural issues that could impact on other people who lived in the home and these issues were not being monitored. We also noted that all of their care plans had been written in March 2011 and had not been rewritten or updated since. This person had last had an 'in house review' in September 2011. We spoke with staff and they told us that this person's needs had changed significantly and that their care plans did not reflect their current needs.

We saw one person in the home whom we had observed required significant support from staff to meet their personal care and mobility needs and to support them to eat and drink. We looked at their care records and saw that they had not been updated to meet their current needs and had not been evaluated since March 2014. We were concerned as their needs had changed considerably but the records did not reflect any of these changes.

We looked at training records but found it difficult to interpret the information as records were stored in different places in the home and some contradicted others.

All of the policies and procedures that we saw were old and required updating. They were also stored in various different places in the home and when we asked staff they were unaware which records were the most up to date.

We spoke with staff regarding our concerns about the records. They all agreed that the records were poor. One staff member said; "My key persons' records are very poor. The only time I get to update them is on my break on a late shift."

We spoke with the manager on the day following our inspection and we told them that the records were inadequate and that people who lived in the home were at risk from receiving unsafe care and that immediate action needed to be taken to improve them.