You are here

Headingley Hall Care Home Outstanding

All reports

Inspection report

Date of Inspection: 14 August 2012
Date of Publication: 2 November 2012
Inspection Report - DN published 2 November 2012 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

Our judgement

The provider was meeting this standard.

People were protected from the risks of unsafe or inappropriate care and treatment.

User experience

We spoke with five people who told us they have seen their care plans and considered them to be kept up to date.

Other evidence

Are accurate records of appropriate information kept?

We looked at seven care files. People’s personal records including medical records were accurate and up to date. All nutritional screening was up to date. All care plans identified any risks relating to nutrition and hydration. All of those at risk had their food and fluid and weight monitored regularly. Care plans had information on people’s needs and their choices and preferences. The care files showed initial assessment and regular reviews of people’s health and wellbeing.

Documentation clearly showed the involvement of social workers, medical staff and other health professionals. All relevant telephone numbers of health professionals were clearly stated in the notes, together with any interaction and advice given. Care plans showed personal care, people’s history, care assessments, regular reviews, risk assessment and records of incident/accidents.

Are records storage securely?

Care plans and daily records were stored in an office, which was lockable to make sure they were secure and therefore kept confidential.