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Inspection report

Date of Inspection: 25 February and 3 March 2014
Date of Publication: 28 March 2014
Inspection Report published 28 March 2014 PDF | 73.93 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 25 February 2014 and 3 March 2014, 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

People's care plan and risk assessments were accurate and fit for purpose. We checked the care records of five people and saw that all care plans had been updated to reflect people's changing needs. For example, we saw from care notes that staff had requested further guidance to meet one person’s deterioration in their mobility needs. We saw that the person responsible for completing moving and handling assessments had responded the same day and had put guidance in the care plan for staff to meet the person’s needs. One member of staff told us that the person needed longer time for staff to meet their care needs. We checked the person’s care plan and staff visit schedule and saw that these records had been updated. One member of staff told us, “Care plans are clear and easy to use.” The provider may find it useful to note that staff told us how risks associated with someone’s diabetes and risk of falls were managed. However, there was no detail of this in the person’s care plan which meant there was a risk that not all staff would be aware of how to meet this person’s needs.

Daily records of the care that staff provided were completed. We looked at the daily records for five people. We saw that clear records were completed by care staff and they were all signed and dated. Everyone that used the service and their representatives told us that staff always recorded the care that they provided. One person told us, “They write everything that they have done.”

We checked other records relevant to the management of the service and saw that records were maintained. All of the records that we checked were kept securely. We looked at the last three months records of meetings with staff and senior management meetings. We saw that records had been completed. We checked the records of maintenance and safety inspections within the agency’s office. There were records of gas safety inspections of the boilers, testing of the fire safety panel, and risk assessment of the premises.

We saw that care worker’s visit schedule and details of care workers for people who used the service were accurate. Staff told us that they were sent their working schedule of visits in advance. People that we spoke with also told us that they received this information in advance so that they knew which staff would be visiting them. One person told us, “It arrives on a Thursday or a Friday for the following Monday.”