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Inspection report

Date of Publication: 14 February 2013
Follow Up Report published 14 February 2013 PDF | 66.61 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 reviewed information we asked the provider to send to us.

Our judgement

People were protected against the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

We visited Genesis Residential Home on 24 July 2012. We identified concerns around the completeness of information recorded in people’s care records. We looked at two sets of care plans. Care plans did not contain enough information to fully describe the care people needed. Care plans were not regularly audited by the manager to identify where information was missing.

The provider submitted an action plan in which they told us they would arrange supervision and training for staff around care plans. Review all the care plans and update them where necessary. Audit the updated care plans to ensure the improved standard of recording is maintained.

Records showed training had been provided for staff on using care plans, how to update progress reports and the importance of ensuring care was recorded accurately. The provider told us key support workers had their record keeping skills reviewed in their appraisals and objectives had been set around their performance in record keeping.

Records showed care plans had been audited by the manager. Any records that had missing information had been reviewed and updated.