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Archived: No 31 First Row

All reports

Inspection report

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, reviewed information given to us by the provider and reviewed information sent to us by other authorities.

Our judgement

The person was protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

During our previous visit to this service on 10 June 2014, we told the provider they were not meeting this regulation. We said “The provider had not ensured that the person was protected against the risk of unsafe or inappropriate care and treatment arising from a lack of proper information about their care and support needs.” In response to our concerns, the provider wrote to us and told us what actions they had taken to improve.

We requested information from the provider and spoke with the registered manager. We saw that the new care planning system had now been fully implemented. This provided clear information about the person’s needs and how these were met by staff. Information was recorded under headings such as, health needs, communication, medication, personal hygiene and accessing the community. We saw evidence of appropriate plans in place to meet the person’s needs and of risks being appropriately assessed. The registered manager told us they regularly reviewed the plans and updated them as necessary. We saw advice from healthcare professionals was incorporated into the plans so that staff were clear about any changes in the person’s care.

We spoke to the care manager who told us the plans reflected the person’s needs and they were satisfied records were updated as necessary.