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Inspection report

Date of Inspection: 24 July 2012
Date of Publication: 15 August 2012
Inspection Report published 15 August 2012 PDF | 52.12 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met 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 all the information we hold about this provider, carried out a visit on 24/07/2012, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

The provider was not meeting this standard. We judged this had a minor impact on people using the service and action was needed for this essential standard. People were not protected from the risks of unsafe or inappropriate care and treatement. People’s personal records were not accurate or fit for purpose.

User experience

We did not speak directly to people about this outcome. We gathered evidence of people’s experiences of the service by reviewing their care plans. During our visit we observed the care people received.

Other evidence

We were not intending to review this outcome. However when we looked at records within the home we found documentation was incomplete. We spoke with the manager about this who told us care plans were reviewed twice a year by the owner but not regularly audited by them.

We looked at two sets of care plans. Care plans did not contain enough information to fully describe the care people needed. For example, people received one to one time on a daily basis to help them work towards their goals. Care plan did not record what people’s goals were or if they had made progress towards meeting those goals. Personal care descriptions were very vague. For example, where people needed help with maintaining personal hygiene it was not recorded if they would like a bath or a shower, how much supervision they would require and how much help they needed to clean themselves.

There was no record of the semi formal interview held with people to gather their views on the service.