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Archived: The Norfolk Hospice

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All reports

Inspection report

Date of Inspection: 3 September 2013
Date of Publication: 12 October 2013
Inspection Report published 12 October 2013 PDF

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 3 September 2013, 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.

Reasons for our judgement

Records were kept securely and could be located promptly when needed. We saw records that showed us regular monitoring of the service was carried out by the provider. Records showed that areas such as fire, health and safety, senior management and infection control were regularly reviewed and audited to maintain an acceptable standard.

We reviewed care plan records as well as other documentation that informed the development of all support that was provided. We saw that these were kept up to date and that these had also been reviewed regularly. This showed clear documentation that described the safe care and support the person who used the service required to meet their needs.

The provider kept accurate and comprehensive staff records. These records included recruitment documentation, security checks and staff training records. People’s care records and staff files were stored in a locked cabinet within a lockable room. This indicated to us that all confidential records were kept securely but could also be located promptly when required.

We saw that records relating to the maintenance of the building, the fire safety plus current certificates were easily accessed and had regularly been issued. Regular servicing of equipment was completed for such items as hoists to support the safety of people being supported. This demonstrated to us that the provider had clear and effective systems in place for maintaining records to prevent any risk to people who used the service.

A risk assessment of the building was regularly completed. Policies and procedures had been reviewed, dated and also showed a renewal date for future reference. This meant that staff had accurate and current guidance for all areas of the service.