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Inspection report

Date of Inspection: 30 July 2013
Date of Publication: 3 August 2013
Inspection Report published 03 August 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 30 July 2013, observed how people were being cared for and talked with people who use the service. We 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

During our inspection on 30 July 2013, we found records were kept securely and could be located promptly when needed.

The care documentation was stored in a locked office. They were easily accessible to staff, and therefore enabled them to be used as effective working documents in the delivery of care. Staff completed people's daily progress records each shift to reflect the individuals well being and any extraordinary events that may have occurred. Visits from other health professionals were also clearly recorded.

Staff records, and other records relevant to the management of the services were accurate and fit for purpose. The home manager told us that regular audits were carried out, and records were maintained in relation to all aspects of health and safety in the home. We looked at some of these records including, staff training records, monthly infection control audit records, and fire safety and water temperature checks. These confirmed that monitoring systems were in place and where anomalies were identified these were addressed by the manager, and used to make service improvements.