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Archived: Individual Care Services - 14 Marble Alley

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All reports

Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 4 January 2014
Inspection Report published 04 January 2014 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 10 December 2013, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information sent to us by commissioners of services.

Our judgement

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

Reasons for our judgement

People we spoke with told us their care plans were in a book at their home. People told us that staff wrote in the book every day. They told us they could read the book if they wanted to. One relative we spoke with said, “Yes, we have a written care plan.”

Support workers we spoke with told us that people’s records were updated daily. They said they always knew what happened when they had a day off, because the previous staff kept thorough records. A support worker said, “The records are realistic and effective.”

We found that copies of people’s care plans were kept in locked filing cabinets in the office. The care plan files we looked at contained sufficient information for us to understand people’s needs and abilities. The instructions for staff clearly explained when and how staff should care for and support people.

Support workers told us they read people’s care plans before they started working with them. They told us the care plans gave them a good understanding of the person. This meant that people’s personal records were accurate and fit for purpose.

The three staff files we looked at were well organised and easy to read. The manager kept records of staff’s recruitment, training and supervision. The files were kept in locked cabinets in the office. This meant that staff records were accurate and fit for purpose.

The manager told us that when people’s care plans and records were no longer required at their homes, they were brought into the office for archiving. This meant that records were kept securely and could be located promptly when needed.