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Archived: Care Purbeck

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All reports

Inspection report

Date of Inspection: 14 February 2013
Date of Publication: 11 May 2013
Inspection Report published 11 May 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 14 February 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

The registered manager could not ensure that the people who use the service were protected against the risk of unsafe or inappropriate care and treatment because there was a lack of information held about the care needs of people who used the service.

Reasons for our judgement

The registered manager could not ensure that the people who use the service were protected against the risk of unsafe or inappropriate care and treatment because there was a lack of information held about the care needs of people who used the service.

We saw a checklist of identified risks but some risk assessments were missing. The risk assessments were needed to identify how individual risks could be managed. We saw one persons care plan that identified that they were at risk from falls but there was no risk assessment. Another person had difficulties with swallowing but there was no risk assessment. Three had medication administered by staff but there were no risk assessments. It would therefore not be possible to ensure the safety and welfare of the people using the service. The registered manager said that there were missing risk assessments and that these would be written without delay.

We saw two medication administration records (MAR) which had been signed correctly by staff. However the records did not have dosage to be given, the amount of medication received and sent back to the pharmacy, medication was not signed as checked by staff before administering, there was no record of signatures that was needed to identify who had signed the MAR. The welfare and safety of people could therefore not be ensured because information regarding the medication was missing.

Staff told us that they felt confident in supporting to move people safely. Staff told us that they had received training on the use of hoists. We could not see evidence of moving and handling certificates.