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Archived: Clanfield Residential Home Good

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Inspection report

Date of Inspection: 6 September 2013
Date of Publication: 30 October 2013
Inspection Report published 30 October 2013 PDF | 81 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 6 September 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We sent a questionnaire to people who use the service, talked with people who use the service, talked with carers and / or family members 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

The Provider had a written policy dealing with the management of records and information. The Provider will wish to note that the policy would benefit from review and updating in relation to the reference to data protection legislation and a clear schedule for the review and secure destruction of personal and sensitive information.

We looked at care plans for some of the people who lived in the home. We saw that the files had been updated with the most recent care assessment on a monthly basis, or more frequently if changes in care were appropriate. This meant that information available to carers was always accurate and the people who lived in the home received the appropriate care and support.

We saw that the care plans were stored securely and appropriately in lockable storage in an office, which could also be locked securely. This meant that the Provider had taken reasonable steps to ensure information was securely stored.

The Deputy manager and Assistant manager told us that records were routinely reviewed and information no longer required was appropriately destroyed as confidential waste. This meant that the information about the people who lived at the home was managed appropriately and their sensitive and personal information was destroyed confidentially.

Personal information about staff working at the home was stored in locked cabinets in an administrator’s office. The office was also securely locked when not in use. This meant that the sensitive personal information about staff and the people who lived in the home was respected and managed appropriately.