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Archived: Kingsthorpe View Care Home Good

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All reports

Inspection report

Date of Inspection: 5 June 2013
Date of Publication: 10 July 2013
Inspection Report published 10 July 2013 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 5 June 2013, checked how people were cared for at each stage of their treatment and care and talked with carers and / or family members. We talked with staff, reviewed information sent to us by other regulators or the Department of Health and talked with other regulators or the Department of Health.

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

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 looked at the care plans and associated risk assessments for eight people using the service. A care plan is a document which should identify a person’s needs and how staff can meet those needs, including assessments or identified risks for each person.

In one person’s care plan we found two folders running in tandem, which meant it was difficult to locate information.

Risk assessments had not been reviewed at the appropriate timescales to ensure the plan of care was current and that staff supported people in a safe way. The lack or regular risk assessment reviews meant that updated information was not available in care plans and people could not be assured of receiving care appropriate to their specific care needs.

We also found daily records had been omitted within some people’s care plan, for four consecutive days on one occasion. This meant any records indicating any changes in a person’s health could be missed and not acted upon.