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Archived: Marion House Good

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Inspection report

Date of Inspection: 1 October 2013
Date of Publication: 30 October 2013
Inspection Report published 30 October 2013 PDF | 78.37 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 1 October 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 staff and reviewed information given to us by the provider.

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

Records were kept securely and could be located promptly when needed. When we requested information, this was provided without delay. The offices where records were stored were organised and files could be located immediately.

Records were stored securely in lockable cabinets and records held on computer were password protected. Care records were clearly formatted and the information contained within them accurately reflected the support people needed to meet their needs. For example, when an individual required assistance to mobilise the plan detailed equipment used and the number of staff required to support them.

Records showed that care had been delivered as detailed in the care plan. For example promotion of healthy eating or personal care was being carried out according to the person’s wishes.

Care plans and assessments had been reviewed regularly and any changes in care had been recorded. For example, one person had been seen by a speech therapist that was developing a communication passport the person could use to improve their communication.

However, the provider may find it useful to note that some care plans were dated 19 October 2013, which was after our inspection and staff had signed to indicated they had read them in October 2013. This meant that the accuracy of records could not be guaranteed.