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Inspection report

Date of Inspection: 4 December 2012
Date of Publication: 29 December 2012
Inspection Report published 29 December 2012 PDF | 84.76 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Meeting 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 4 December 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

At the last inspection we found the provider was not protecting people from the risks of unsafe or inappropriate care and treatment. This was because people’s personal records, including medical records, were not accurate and fit for purpose.

The provider sent us an action plan which had been completed following our visit. We returned to inspect again on 04 December 2012 to review improvements the provider had made. During our inspection visit we looked at the records which the provider kept to ensure they were accurate, up-to-date and stored securely in accordance with the Data Protection Act 1998.

We did not speak with people directly about this outcome, however people did say they were aware records about them were maintained by the provider. They also knew they could ask to see them at any time, however the people we spoke with told us they hadn’t felt the need to do this.

We found comprehensive care records were kept for each person who lived at the home. These were securely stored but were readily accessible to staff, should they be needed. This meant people who used the service could be confident their personal records including medical records were accurate, held securely and remained confidential.

The registered manager showed us the provider had a policy file. We found staff were able to access this at any time. The file contained a broad range of policies and procedures which included guidance on what records should be kept to ensure effective care for people and governance of the home.

We spoke with staff about access to the various records held within the home. They said they were aware of the location of care records and policy files and knew how to use the information contained within these records. All of the staff we spoke with told us each person who lived at the home was entitled to view their own care records.

We saw the manager carried out audits of care records. Each audit was documented, with comments and action to be taken clearly recorded within the record. We saw measures had been taken by the manager to improve record keeping. This meant people were being protected against the risk of receiving inappropriate care and treatment.