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Fountain Nursing and Care Home Limited Good

All reports

Inspection report

Date of Inspection: 7 August 2013
Date of Publication: 4 October 2013
Inspection Report published 04 October 2013 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 7 August 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, talked with staff and were accompanied by a specialist advisor.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

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

Records were kept securely and could be located promptly when needed. We found that all files and records were kept securely in the manager’s office and were stored safely when not in use. Records and care plans could be located promptly when needed.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. We found that documentation, care files and staff records were all well-ordered and maintained. Documentation was neat and the information recorded was legible and easy to understand. People’s personal records including medical records were accurate and fit for purpose and securely stored to protect people's privacy and right to confidentiality. We saw that care plans were checked and reviewed regularly by the manager.

Staff records and other records relevant to the management of the services were accurate and fit for purpose and retained securely. We found that there was detailed information about the scheduling of services and the deployment of staff.

The provider had written policies and procedures for carrying on all aspects of the service and these were well organised and periodically reviewed.

We concluded people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained