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Archived: Teeside CSS - Middlesborough

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Inspection report

Date of Inspection: 30 December 2013
Date of Publication: 25 January 2014
Inspection Report published 25 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 30 December 2013, talked with people who use the service and talked with carers and / or family members. We 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

During our inspection we looked at a number of different records held by the service to make sure they were fit for purpose.

We looked at records held about people who used the service and found that these had been reviewed and updated regularly to reflect individuals’ current support needs. They contained detailed and relevant information about people. Information was easily accessible and all the staff signed and dated each one to confirm they had read the support plan. There were no loose pieces of paper and entries were on the whole made in black ink, legible, signed and dated. This meant that the records were fit for purpose.

Some records about people were held in their own homes and were available for them to read at any time. The manager told us that some people did not want any records about them kept in their own homes and staff respected this and brought all records back to the office. We saw that records about people’s mental and physical and mental health as well as significant events were stored in the office. The records about significant events were detailed and contained relevant information.

We looked at some of the records relating to the management of the service such as recruitment files. We found that these were stored securely but were easily accessible to the relevant people. Staff records and other records relevant to the management of the services were accurate and fit for purpose.