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Inspection report

Date of Inspection: 20 February 2013
Date of Publication: 21 March 2013
Inspection Report published 21 March 2013 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 20 February 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 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

People’s personal records including medical records were accurate and fit for purpose. Documentation we saw included care plans, supervision and appraisal matrices, staff rotas, meeting minutes, training and maintenance records. The records seen were completed and were up to date. Staff we spoke to confirmed that any changes to an individual’s needs was understood, acted upon and recorded without delay.

All confidential records were stored in the homes office within locked cabinets. These were accessible to staff at all times.