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Inspection report

Date of Inspection: 16 July 2013
Date of Publication: 21 August 2013
Inspection Report published 21 August 2013 PDF | 77.22 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 16 July 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.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment.

Reasons for our judgement

People’s personal records including medical records were accurate and fit for purpose. Records were kept securely and could be located promptly when needed. We examined the records of four people who used the service. The provider used a care plan system which staff told us they found easily accessible and were able to locate information they were looking for. “We’re always able to check things out in the care plan, the information is there” a member of staff told us.

Staff records seen showed that training had been provided for staff in records management. Staff meeting notes we saw showed that prompts for reviewing care plans for individuals were given to staff. We found that care records were up to date and plans of care had been recently reviewed. We found that records were stored securely. We found that records for the monitoring of the care and welfare of people who were assessed as at risk were up to date and were monitored by the manager. This meant that that records held for people supported them to receive the appropriate care and treatment.