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Archived: Bellerose

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Inspection report

Date of Inspection: 9 July 2013
Date of Publication: 2 August 2013
Inspection Report published 02 August 2013 PDF | 69.81 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 9 July 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, talked with staff, reviewed information given to us by the provider and were accompanied by a pharmacist.

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 our review of the service in April 2013, we had concluded that the provider was not compliant with this standard because the staff recruitment files and the Medication Administrative Record charts had not been appropriately maintained.

We noted at the time that not all the staff recruitment files had been kept consistently. Further, there were inconsistencies in the way the Medication Administration Record (MAR) charts had been completed.

During the follow-up inspection on 09 July 2013, we checked the recruitment folders of existing staff and of two new staff who had joined the organisation since our last inspection. We found that the recruitment records had been appropriately maintained. We also found that the MAR charts had been accurately recorded with no gaps found. We further noted that people’s care plans and daily records had been reviewed regularly and maintained appropriately. This meant that people had been safely cared for by reliable, fit and experienced staff.

The staff we spoke with confirmed that they had received training on record keeping and the Data Protection Act 1998. The manager stated that the safe storage and handling of confidential information had been discussed and reinforced at supervision and staff meetings. This had ensured that all staff followed the company's policy and procedure on record keeping appropriately and in accordance with the Data Protection Act 1998.