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Ellesmere Port Hospital Good

This service was previously managed by a different provider - see old profile

All reports

Inspection report

Date of Inspection: 20 November 2012
Date of Publication: 18 December 2012
Inspection Report published 18 December 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 20 November 2012, 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.

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

Patients were not always protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

Reasons for our judgement

We looked at the nursing and medication records for a number of patients. Some of the nursing records were held on a computer database called Meditech and some charts, including the medication records, were kept in paper form at the end of the bed. Only authorised personnel had access to the database.

We saw that each patient had a full assessment recorded on the database with nursing directions and daily progress notes. Daily progress notes were completed regularly, but we saw that nursing directions weren't always updated promptly. For example, one patient had been seen by the tissue viability nurse specialist and dressings changed to alternate days. The frequency of the dressings had not been updated on the nursing directions, although staff had been told verbally and knew how often they should be changed.

We looked at how individual information within patients' care records on the database supported medicines administration. We found individual information on the medicine charts was not always incorporated into the nursing directions on the database to ensure medicines were given in a person-centred way. One record showed that a patient was regularly refusing a prescribed nutritional supplement. There was no record of this refusal being brought to the attention of the prescriber, or of any advice given about this. Medication records for another person recorded that medicines should be given with yoghurt to assist with swallowing. This advice from the speech and language therapy team had not been incorporated into their nursing directions to help ensure consistency in approach.

Two staff we spoke with were less confident in using the database than others. There were a number of new staff in the hospital who were new to the electronic records system. The head of nursing confirmed that additional training would be implemented for these staff and that in the future the hospital would be looking to upgrade the electronic records system.

A patient and carer communication record was kept in a folder at the end of each bed for staff to update the patient or their relative on any investigations or changes to care planning. Patients and carers could also record comments or any information they wished to communicate to staff. We saw that staff sometimes used abbreviations and acronyms in these records that patients and relatives may not understand.