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Archived: Lifestyles Care & Support Limited - 30 South View

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Inspection report

Date of Inspection: 5 December 2013
Date of Publication: 3 January 2014
Inspection Report published 03 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 5 December 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 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

Three care records were examined during the inspection.

We spoke to four staff members on the day of our visit and found them to be very knowledgeable about the people in their care without the help of documented records.

We found that people’s care records contained lots of relevant information on a variety of forms. This made it difficult to find particular information relating to an individual. The manager agreed that the care records were difficult to follow. The home had recently merged with another provider and staff were not sure if care records would change format because of this. The provider should note that records need to be updated and fully reviewed with relevant archiving taking place as soon as possible to ensure that staff can easily access, up to date information on people.

On the notice board at Southview was a risk assessment relating to one of the people now living at a nearby property run by the same provider. The risk assessment should have been on the person’s care records and not on the notice board where staff and people living at the home had access to. Staff confirmed that it should not have been there and took it down from the notice board while we were there. Provider should note that any records relating to people, particularly those from other services; should be kept within that person's care file.

People and staff records were stored securely in locked filing cabinets and were easily accessible to staff.

We saw the provider had systems in place to assess and monitor the quality of the service being provided. These systems were not being followed monthly and the last one which included quality of care planning was completed on 4th March 2013.

From care records examined, people's personal records including medical records were not always accurate and fit for purpose.