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Archived: Rocklyn

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Inspection report

Date of Inspection: 4 February 2014
Date of Publication: 28 February 2014
Inspection Report published 28 February 2014 PDF | 71.43 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 4 February 2014, 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 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

We last visited this service on 2 May 2013. We told the provider that they were not meeting this essential standard. We said, “People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.” At our last inspection we were concerned that people’s care records were not accessible and could not be easily located.

In response to our concerns, the provider wrote to us and told us what actions they had taken to improve.

During this inspection, we found improvement had been made and people’s care records were accessible and could be easily located. We also found people's personal records and staff records were accurate and fit for purpose.

We looked at four care records of people who used the service. We found that the care plans contained detailed information and an assessment of needs undertaken by the organisation. This meant that staff had precise instructions to follow.

The registered manager told us, and we saw that people's care records were reviewed monthly. The registered manager told us that if there were significant changes, then care records would be updated more frequently. People's daily records had been completed every day and were up to date. Care plans contained details and contact numbers for people's next of kin, their likes and dislikes, the person's GP and other professionals involved in people's care and support.

We looked at four staff records. We found that these were complete and up to date. Records contained information about people's recruitment, confirmation of their identity and copies of training and qualifications. For example, we saw certificates to confirm that people had undertaken training in relation to moving and handling, emergency first aid and fire safety.

Records were kept securely and could be located promptly when needed. Care records and staff records were stored appropriately in lockable filing cabinets in the provider's main administrative office. Information stored on computerised systems at the service was restricted and password protected to prevent unauthorised access. The provider had policies and clear procedures in place for staff in relation to confidentiality, accessing records and record keeping. The provider told us that records were only kept for the length of time required and then destroyed securely.

The registered manager showed us documents relating to the operation and management of the service. These included essential maintenance records, accident and incident reports, firefighting equipment, emergency lighting and electrical safety checks. The records were current and showed all equipment had been maintained and serviced at the appropriate times.

We noted that the provider had a nominated data controller who was currently registered with the Information Commissioner's Office (ICO). The Data Protection Act 1998 requires every organisation that processes or handles personal information about individuals to protect that information and to register with the ICO, unless they are exempt.