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Inspection report

Date of Inspection: 15 October 2013
Date of Publication: 11 January 2014
Inspection Report published 11 January 2014 PDF | 77.95 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 15 October 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

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

At our last inspection on the 12 June 2013 we were concerned that people’s personal records including medical records were not always accurate. At this inspection staff told us that the system of care planning had been reviewed and that all people’s care plans had been reviewed and updated.

We looked at the care plans for five of the people who used the service. We saw that they were accurate, up to date and gave clear instructions to staff to follow in order that care was provided consistently. This meant that staff were aware of people’s needs and planned care accordingly.

During our visit we looked at staff records and other records relevant to the management of the home. The homes policies and procedures were up to date and well maintained. The records were held securely and could be located promptly when needed.