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Archived: True Care

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All reports

Inspection report

Date of Inspection: 22 November 2011
Date of Publication: 11 January 2012
Inspection Report published 11 January 2012 PDF

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

Not met 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

Our judgement

People who use services cannot be confident that accurate records are maintained which protect their interests and ensure that they are not at risk because of a lack of appropriate information.

Overall we found that improvements were needed for this essential standard

User experience

We received information relating to people’s concerns and the lack of well maintained and accurate records. This included care plans that did not reflect changes to people’s needs and daily records, which lacked sufficient information to ensure the health, safety and welfare of people.

A health care professional described how records did not provide an accurate account of a person’s needs. This included nutrition, fluid intake, skin integrity and mobility needs. The manager said that turn charts, fluid and nutrition charts were used by care staff when needed. She said that staff received training in basic nursing such as pressure care and nutrition. The manager showed us records which indicated a person had been eating and drinking and therefore a need for a fluid and nutrition chart had not been identified.

We discussed how the manager would ensure daily records detailed sufficient information to ensure any changes would be identified and clearly documented. This information would then be reflected within the care plan. The manager said she would develop more detailed daily records, which would be randomly audited.

Following from our last visit in September 2011 when we identified that care plans needed to be more detailed; the manager told us that in accordance with their previous action plan, they had recently reviewed all care plans. We saw an example of how care plans had been developed further to provide more detail about the delivery of care. The manager told us care plans would be reviewed yearly or as the person’s needs changed. Once changes had been made to a care plan it would be sent out to the person receiving the care and/or their representative. When agreed with the person the care plan would be signed and returned to the office. The manager said care staff also received a copy of the revised care plan. We saw that the manager had developed care plan tracking forms, which enabled her to keep a record of all care plans sent out and whether they had been agreed and signed.

Other evidence

The manager told us they planned to change the daily recording forms to allow for more detail to be documented. There had been concerns raised that staff had not recorded important information, such as changes in skin integrity, mobility and nutritional needs. The manager recognised that once the new forms had been developed she would ensure that all staff attended a training session on how to record information accurately and report accordingly. She said an attendance log would be maintained so she could ensure all staff received the information.