CQC criticises care records at Isle of Wight

The quality of patient records at a southern trust has been criticised by the Care Quality Commission (CQC).

In an inspection report published on 28 July 2017, the regulator found the care record system at Isle of Wight NHS Trust “remained a significant risk”.

The trust has been in special measures since April 2017, following an initial CQC report which detailed a series of failings at the organisation.

The new report said “the quality of care records continued to vary”, with inspectors finding “gaps in key information and poor evidence of appropriate assessment and management of risk in some records”.

The CQC reviewed 49 care records for patients under the community mental health teams and on a number of mental health inpatient wards.

“We found it confusing and difficult to track the risks and what actions had been taken in records”, the CQC said.

“The records system was time consuming for staff to use and there remained the risk that important information could be lost or overlooked.”

It was not possible, inspectors found, “to have a contemporaneous overview of the risks and subsequent care and treatment of a patient”.

The trust uses Civica’s Paris electronic patient record for mental and community health. But the report found staff on wards were not using the system for risk assessments, and instead creating handwritten documents.

“This meant there was a risk that vital information might not always be uploaded in a timely manner and be available to other teams.”

The trust’s June board papers said meetings had been held to understand the issues with the use of Paris, “regarding both how the system works and how it is used consistently”. A fortnightly task and finish group has been created, with the aim of resolving system and process issues by October.

The papers noted that mental health inpatient services “are using paper processes for core assessments, risk assessments and care plans in the interim whilst the electronic solution is improved and training completed”.

A spokeswoman for Civica said: “Paris has a successful track record with health and social care customers across the UK, supporting programmes to improve patient services and efficiency, for example with Cardiff & Vale University Health Board, Belfast Health & Social Care Trust, Tees, Esk & Wear Valley NHS Foundation Trust amongst others.”

The trust did not respond to requests for comment.