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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 7 January 2014
Inspection Report published 07 January 2014 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 10 December 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 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

We found that the manager and staff were keeping up to date and accurate records regarding the people living there. This included personal care records, care plans and risk assessments that were being stored securely to maintain people's confidentiality. The care and medication records we saw were properly maintained and an accurate reflection of people's needs.

There were records of work done in the home and of servicing and the maintenance of equipment in use to make sure it was safe for use. This included emergency equipment and lighting, call systems and alarms. Gas and electric checks were completed annually through service level agreements. We saw there were also records of service users monies kept on their behalf by the home. We saw a copy of the fire risk assessment that had been completed by an external professional.

The provider had an established internal system to assess and monitor the quality of the services that people living there received. A system of checks or 'audits' helped the management to identify and manage gaps or risks in the service provision and the completion of records within the service. This helped to make sure that a consistent level of service provision and record keeping was maintained.

We looked at staff records and found these to be filed securely in a locked cabinet in the manager’s office which was locked with a key pad lock.

We saw that the service had clear policies and procedures that were updated annually by the Abbeyfield Society to ensure they were kept in line with legislation.