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Watford General Hospital Requires improvement

All reports

Inspection report

Date of Inspection: 17 December 2013
Date of Publication: 21 January 2014
Inspection Report published 21 January 2014 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 17 December 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider, reviewed information sent to us by other regulators or the Department of Health and talked with other regulators or the Department of Health. We were accompanied by a specialist advisor.

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

During this inspection we examined the records of 41 people who used the service. We found that records of care provided to people who used the service were not well maintained and were not fit for purpose. In two cases we saw that papers in the records related to other people. For example we found blood test results and a request for a scan in the records that were not for the person whose records were being examined.

We found in the case of four people, each person had been given a malnutrition screening assessment rating (MUST) score of 0 which meant they were at low or no risk of malnutrition risks. However we found that vital information had not been included as part of the assessment, for example the person’s height and weight. We saw that each person had been given a body mass index (BMI) score but their height and weight had not been recorded. All four patients had a food and fluid chart in place to monitor their nutritional intake despite being assessed as not being at risk of malnutrition or dehydration. These records of assessment did not support the treatment in place.

One patient had been visited by the intensive care (ITU) outreach team who recorded that the person’s fluid balance had not been maintained. The patient had also been referred to the dietician because their appetite had dropped. The dietician reported that it was difficult to complete an assessment because there was a lack of information on the food record chart and fluid balance chart. Our examination of the records supported what was recorded by the dietician. The food chart for this patient indicated that they ate very little over a period of days. We found that information was not always recorded. This meant that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

The fractured neck of femur pathway paperwork had been developed by the trust but was not in a secure format. The papers were stored loosely in a file and could easily be misplaced. For seven of the 17 records we examined for people on the fractured neck of femur pathway, the paperwork had not been fully completed. We found that data entries were missing, pages were incomplete and information relating to the person’s care was missing. Therefore we were not assured that the records format chosen for the recording of the pathway maintained the security of the documents and was not fit for purpose.

We viewed the internal audit on fractured neck of femur and pressure ulcer management. The recording of care and quality of records was raised as a concern in both audits. We spoke with members of the executive team during feedback who acknowledged and recognised that the records were currently of a poor quality and required improvement.