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Archived: Care Management Group - 361 The Ridge Requires improvement

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Inspection report

Date of Inspection: 29 May 2014
Date of Publication: 2 July 2014
Inspection Report published 02 July 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 29 May 2014, observed how people were being cared for and talked with people who use the service. We 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

At our last inspection in November 2013 we found that accurate records were not maintained for people who used the service. This was because of a lack of up to date information in people's records. The provider wrote to us after the inspection and told us they had taken action to make improvements.

At this inspection we found that the care record of people who used the service were comprehensive and kept up to date. Information for each person was kept in three files. We found that the information held reflected people's current needs, was accurate and fit for purpose.

Other records relating to the management of the service were up to date and easily accessible. These included training records, team meetings, quality audits, supervisions, policies and procedures. A system was in place to check that daily diary notes for people who used the service were filled in correctly. This meant records relevant to the management of the services were accurate and fit for purpose.

We saw that confidential files about staff were kept in a lockable cabinet in the office which was only accessible to those that needed to use them. Care records were also located in the office and were accessible by staff when needed. The office was kept locked when not in use. This meant that records were kept securely and could be located promptly when needed.