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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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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

Our judgement

We found that the location is not fully complying with this outcome. We found that the ongoing use of paper based and electronic records carries some risks; including there may be potential failure to consistently document clear, factual and accurate records for individual patients. We also found the current systems limit the accessibility of records because it was difficult to find specific items of information, such as the current status of a person’s capacity.

User experience

It was not possible to gain the direct views of people who use the service for this outcome on this review.

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. Our provider level QRP for this outcome contained mostly positive information. None of the external stakeholders referred to within outcome one who responded raised any areas of concern specifically relating to this location or outcome.

As part of the assessment of this location the provider submitted a provider compliance assessment which explained in detail how the outcome was being met. For example, the provider explained how a suite of information governance policies, procedures and other systems provides compliance. The provider also explained how it had recently completed a Data Protection Act audit follow up report with the Information Commissioners office who stated a level of “reasonable assurance”.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report included information regarding records management, which raised no particular concerns.

On the site visit to the Michael Carlisle Centre conducted 6 January 2011 staff members on Stanage and Burbage wards spent considerable effort with our help in trying to find documented records of an individual’s assessment of capacity relating to our assessment of outcome two. This was not helped by the complex system of records management the provider currently has in place due to a rolling changeover from paper based records to the electronic NHS Insight system. Staff members had informed us when they had to compile a report for any appeal to the mental health tribunals it took considerable time as it was difficult to find information in the NHS Insight system. Our experience showed us that the system contains a series of individual records rather than a facility that would allow an easy view of a chronological flow of nursing and medical records. Similarly the ‘acute care pathway’ was captured in the Insight system via long list with no detail of the pathway. For example, we looked at one patient’s pathway record and the capacity entry just contained a date it was assessed but not the actual outcome of the assessment. A large number of the acute care pathway individual prompts were left blank giving no indication if the item was applicable or had been assessed. Most nursing records were transferred to the Insight system with the exception of individualised care plans.

On the site visit conducted 11 January 2011 to Maple and Rowan wards we found that medical staff were at different stages regarding the transfer of record keeping from paper based records to the Insight system. On Maple ward we reviewed a sample of notes that showed most medical notes were still hand-written. On Rowan ward we talked to the consultant psychiatrist who explained that doctors on this ward had decided to proactively move medical notes to the Insight system over twelve months ago. We asked the ward managers and the consultant if there was an identified end date for the transfer of all records to the electronic system and none were aware of specific dates. We asked the consultant what they thought were the biggest difficulties or weaknesses of the electronic Insight system. They outlined what we had also experienced in that the system is very difficult to search for specific items of information and thought that it would be a real struggle in future to identify which junior doctor had completed certain medical records (junior doctors do a 4 month rotational placement). The ward manager on Rowan ward felt that the system was difficult to use when reviewing records to complete an incident investigation report.

We found that the ongoing use of paper based and electronic records carries some risks; including there may be potential failure to consistently document clear, factual and accurate records for individual patients. We also found the current systems limit the accessibility of re