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Inspection report

Date of Inspection: 13 June 2013
Date of Publication: 17 July 2013
Inspection Report published 17 July 2013 PDF | 84.14 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 carried out a visit on 13 June 2013, observed how people were being cared for, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with carers and / or family members 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

During this visit to Marsh House we examined a sample of the records required. We found that care plan records and entries indicated that care records had been reviewed each month. We could see that records were kept of the monthly checklist being used as a tool to make sure that all general observations, risk assessments, support needs, daily record evaluations and the actual care plans had been updated to reflect changes in people's needs.

We found that records to monitor and manage people's nutritional needs had been updated to reflect significant changes such as weight loss. Records indicated that staff had monitored and recorded food and fluid where assessed as needed, as well as checking body weight each week or month according to identified risks. There were records to demonstrate that this had been done and that relevant health care professionals, such as the dietician and speech and language therapist, had been contacted for help and advice.

The manager had retained records relating to the running and maintenance of the premises including, medical devices and moving and handling equipment, electrical testing, fire safety and monies or valuables being kept for people. Guidance was in place for staff regarding Data Protection legislation.

We found that the personal and care records of people were being kept securely in locked filing cabinets within the office or on each unit and staff personnel files were also kept securely. Staff records were in good order with all the necessary information regarding their ability to work in the home. All confidential information was stored correctly and securely but was easily available if required.