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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: 26, 27 November 2013
Date of Publication: 9 January 2014
Inspection Report published 09 January 2014 PDF | 89.32 KB

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 looked at the personal care or treatment records of people who use the service, carried out a visit on 26 November 2013 and 27 November 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by local groups of people in the community or voluntary sector. We talked with other regulators or the Department of Health, were accompanied by a specialist advisor and used information from local Healthwatch to inform our inspection.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Our judgement

People were generally protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

At our last inspection in June 2013 we found that records of people’s care and treatment were not accurately maintained. This meant that people were not protected from the risks of inappropriate or unsafe care and treatment. We told the provider that action was needed. The provider told us in July 2013 about the action they had already taken and the action they planned to take to achieve compliance by the end of August 2013.

At this inspection we found that records were generally kept securely and could be located promptly when needed. We saw that people’s medical records were stored in trolleys on the inpatient wards we visited. The trollies had lockable flaps, though these were not always used because staff needed frequent access to the records. People’s nursing records were kept at the end of their bed. We saw that people’s medical records in the outpatient department were kept in locked storage until required. We saw that there was a system to keep track of where each record was within the hospital. Staff we spoke with in all areas we visited told us people’s medical records were usually available when needed.

We found that people’s personal records were mostly accurate and had appropriate information in relation to their care and treatment. We saw that new nursing care documentation was being introduced on the inpatient wards. This documentation included more detail regarding people’s needs and personal preferences. We found that the new documentation was not fully in use and that some staff were unsure about how to complete it. The role of documentation champion had been created for each inpatient ward. The role included educating and supporting staff in using the new documentation. The role also included checking that people’s records were accurately completed.

We looked at the nursing care records for 20 people on the inpatient wards. We found that the care records were up to date and mostly included sufficient detail of the person’s needs and how these were to be met.

At our previous inspection we found that some records were not well completed and this was putting people at risk of receiving unsafe or inappropriate care. These records included assessments of the person’s nutritional needs, assessments of their risk of skin damage, and records of food and fluid intake and output. At this inspection we found that completion of these records had generally improved.

We looked at the medical records for 12 people in the outpatients department. We saw that the records were updated during or immediately after the person’s attendance in the clinics. The records included relevant information, such as their contact details, medical history and any allergies.

The provider should note that we found Do Not Attempt Resuscitation (DNAR) forms were not completed in line with national guidance. DNAR forms are used to record the reasons why and how a decision has been made not to attempt cardiopulmonary resuscitation for a specific person. Guidance on completion of the forms is produced by the General Medical Council and the Resuscitation Council (UK). We saw seven DNAR forms and only one of these was fully completed in line with the guidance. This meant that people may not be protected against the risks of unsafe or inappropriate care and treatment.

We also saw that unsatisfactory completion of records was noted in the provider's own audits. We have judged the provider as compliant with this standard because we found them largely compliant during our inspection. We have reported on the lack of effective risk management in relation to records elsewhere in the section "Assessing and monitoring the quality of service provision."