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We are carrying out a review of quality at Chesterfield Royal Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.
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Inspection report

Date of Inspection: 17 May 2011
Date of Publication: 12 July 2011
Inspection Report published 12 July 2011 PDF | 155.41 KB

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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 reviewed all the information we hold about this provider, carried out a visit on 17/05/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Records with personal information about people are kept securely and remain confidential. Not all care records are up to date or have sufficiently detailed information to ensure people receive appropriate care and treatment.

User experience

We saw that records containing confidential information about people were stored securely on the wards. The electronic ‘white boards’ in use were sited away from public view so the information could only be seen by nursing and medical staff. The ‘white board’ on the children’s ward was sited on a corridor in public view, but the information on view was restricted. Staff told us the information on view was useful for parents.

Staff on one ward told us that care records currently in use were not altogether appropriate for the services provided. New care records had been drafted for people requiring day surgery. The manager said that staff would be given the opportunity to trial and comment on these before they were presented to senior managers for approval. The manager said that the new records reduced the duplication of information and included triggers to prevent people from having to undergo excessive tests.

Other evidence

As noted in Outcome 4, we found that care plans were generally brief and did not provide a clear and accurate record of how people’s needs were being met.

We found that not all care plans were updated following changes to a patient’s care and treatment. For example one person’s care plan stated they may need assistance with personal care due to shortness of breath. This person told us they were no longer short of breath, though did need assistance as they were unable to weight bear following surgery to their leg. For another person their care plan said that they used a rotunda to help them to move between a chair or bed and wheelchair. However, a recent assessment said the person now needed a hoist for all transfers and the daily nursing notes showed that the hoist was being used.