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Inspection report

Date of Inspection: 8 August 2013
Date of Publication: 6 September 2013
Inspection Report published 06 September 2013 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 8 August 2013, 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.

Our judgement

People had not been protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had not been maintained.

Reasons for our judgement

During our inspection we looked at care records relating to four people who lived at Roebuck Nursing Home. They all lacked up to date information relating to some aspects of the care, treatment and support provided to the people concerned. This meant that people who lived at the home may not have been adequately protected against the risks of unsafe or inappropriate care and treatment because accurate records had not been properly maintained.

In one of the records we looked at, charts used to record and monitor the personal care provided on a daily basis had 31 unexplained gaps between 1 January 2013 and the date of our inspection. We looked at the other records and saw that one contained 28 unexplained gaps for the same period, while another had 19 and the fourth had nine . It was therefore, unclear from these records whether or not personal care and support had been delivered to the people concerned for a total period consisting of eighty seven days.

We saw that the providers own policy recommended that key aspects of care records should be reviewed and updated on a monthly basis or more frequently if necessary. However, we found a number of examples in the records we looked at where this had not been followed.

For example, one record we looked at showed the person concerned had been identified as having risks concerned with nutrition, hydration and pressure sores. However, we saw that charts used to record and monitor progress against these risk assessments had not been completed, updated or reviewed since March 2013. A mental capacity assessment contained in the same record had not been reviewed since 2011 and a ‘do not resuscitate’ (DNR) form was incomplete.

In another of the records we looked at, a dependency profile used to assess the needs of the person concerned had not been completed or reviewed for a three month period. In addition, despite the person having been identified as having had risks associated with the development of pressure sores, the charts used to monitor progress in that area had not been updated between September 2012 and May 2013.

Records relating to another person showed that a number of risks had been identified. These included issues around mobility, infections, falls and nutrition. We saw that the risk assessments and charts used to monitor progress in those areas had not been updated or reviewed since February 2013.

This meant that records relating to people’s care, treatment and support had not been accurately maintained in all cases and therefore, may not have been fit for purpose.