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Inspection report

Date of Inspection: 16 July 2013
Date of Publication: 2 October 2013
Inspection Report published 02 October 2013 PDF | 74.51 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 talked with staff. We reviewed information given to us by the provider and talked with other authorities.

Our judgement

People who use the service have records maintained and reviewed appropriately to enable treatment and care to be given as required. All records including people's individual records and medication records were stored safely and securely.

Reasons for our judgement

People’s care records included accurate and up to date information. We looked at the care records for the two people who lived at the service. There was accurate information kept for each person that enabled staff to provide appropriate care and treatment. Each person's file was sectioned to enable staff to find appropriate paperwork quickly. We saw evidence of a clear schedule to review and update records. Including archiving older care records safely and separately to current records.

People's care records were stored appropriately and safely in a lockable cabinet. When we spoke with the staff member they stated. "There were no issues with accessing care records."

Medication records and administration of medicines were up to date and had no omissions. Older medication records were stored separately and appropriately.

Staff Records are kept securely by the manager and contained relevant information, for example, information training, supervision, staff appraisal and staff rota.