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Inspection report

Date of Inspection: 19 December 2013
Date of Publication: 17 January 2014
Inspection Report published 17 January 2014 PDF | 89.35 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 19 December 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 were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

The hospice had systems in place to monitor, review and update people's records.

We looked at the daily recordings of people's records and found the entries to be comprehensive. Each person had an allocated key worker who co-ordinated their care and acted as a point of contact for them. Each time people attended for day therapy they would spend time with their key worker who would later record the discussion they had about the person's well-being. We looked at four records from day therapy and found all had been fully completed. We looked at three records from hospice at home and found all had the completed forms showing people's personal details for example medical and care details. This meant that the provider had systems in place to ensure the appropriate care and treatment of people who used the service

There was a medicine policy in place which outlined the procedure for administering medicines. People attending the hospice for a day service usually managed their own medicines but in some circumstances it was necessary for staff to assist them. People had a self-medicine assessment record with regard to the taking of medicines. The hospice had secure storage for medicines brought into the service with arrangements in place for "controlled drugs." This meant that the provider had systems in place regarding the management of medicines.

The provider reviewed the quality of the service which included care plans, supervisions, medicines and the premises. Hospice staff received six monthly reviews and management informed us they were currently reviewing the clinical supervision reviews for hospice at home staff. Staff we spoke with confirmed they received reviews and annual appraisals. The staff records we looked at had all the relevant information for example application forms, signed contracts and enhanced Disclosure and Barring Service check (DBS).

The provider had in place a rolling training programme and we saw in place identified training for 2014. Staff confirmed they had received training as well additional training for example, end of life care.

The provider had a complaints policy. We looked at the complaints records and found that all complaints had been completed in line with company policy. Staff and relatives we spoke with said they would be able to make a complaint if necessary. People who use the day therapy service us told us should they have any issues or concerns they would "speak with their key worker." The provider had in place accidents and incidents recording sheets. We saw that all accident/incidents had been addressed with identified outcomes. Staff told us that any concerns were written in the daily recordings.

Records were found to be stored securely. The provider had policies and procedures relating to the transmission of patient information which provided guidelines for staff in the use of fax machines. The confidentiality policy provided guidance to staff for example, confidential information should only be "passed on when it is necessary to avoid harm to the patient."

The hospice had a storage and destruction policy in place for maintaining records which provided guidelines to staff regarding computerised held records, the completion of daily records and the destruction of records.