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Inspection report

Date of Inspection: 3 October 2012
Date of Publication: 31 October 2012
Inspection Report published 31 October 2012 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 3 October 2012, 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 and talked with staff.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment.

Reasons for our judgement

In the four care plans we looked at we noted that the plans resulted from an appropriate risk assessment of people’s abilities and support needs. Instructions for staff were detailed and staff we spoke with understood exactly how people needed to be supported. We saw that staff recorded when doctors, nurses and other health professionals were asked to visit people. They told us they read people’s care plans during their induction programme. This meant that people’s personal records including medical records were accurate and fit for purpose.

We saw that people’s care plans were kept in the care staff office. One care staff we spoke with told us, “Care plans are accessible to read at any time.” We saw that staff completed a record of tasks undertaken in ‘summary plans’ and shared other information, about people’s activities, moods and behaviours, at a handover meeting. We saw that senior care staff entered all this daily information onto a dedicated IT system. This meant that the records of care and support given were kept securely and could be located promptly when needed.

We looked at two staff records and saw that they contained information that confirmed the staff’s identity and their training and supervision records. We saw that staff records were kept in a lockable filing cabinet in the registered manager’s office. We saw a training matrix which showed when staff received training and when refresher training was needed. The matrix matched the staff records we looked at. This meant that staff records and other records relevant to the management of the services were accurate and fit for purpose.