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Springfield Court Nursing Home Outstanding

We have edited an inspection report for Springfield Court Nursing Home in order to remove some text which should not have been included in this report. This has not affected the rating given to this service.
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Inspection report

Date of Inspection: 16 September 2014
Date of Publication: 11 October 2014
Inspection Report published 11 October 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 16 September 2014, 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, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

An effective records management system was in place, which helped to ensure confidential information was retained in a secure manner.

Reasons for our judgement

At the time of our visit to Springfield Court the registered manager was on duty, and she was co-operative and helpful throughout our inspection. Records required to be kept were available for inspection and documents we requested were provided promptly. Policies and procedures were in place in relation to data protection, confidentiality and access to information. This helped to ensure records were retained securely, in accordance with current legislation and good practice guidelines.

We found accurate records were maintained in respect of each person who used the service. Appropriate information and documents in relation to people's care and support were consistently maintained. Staff we spoke with were aware of the importance of confidentiality, in order to protect the personal information of those who used the service.