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Inspection report

Date of Inspection: 5 October 2012
Date of Publication: 19 October 2012
Inspection Report published 19 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 5 October 2012, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with stakeholders.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Records could be located promptly when required.

Reasons for our judgement

When we inspected the home on 22 August 2012 staff records and other records relevant to the management of the services were not always accurate and could not be located promptly when needed.The manager who was on annual leave at the time of our inspection had not made provision for staff to access training and supervision records relating to staff employed at the home. The staff were also unable to access the requested quality assurance documents and a medication audit was undated.

At our inspection on 5 October 2012 we found records were stored securely and could be located promptly. The manager had ensured that staff training and supervision records were stored in the staff office and confirmed these could be accessed by senior staff should the manager not be present at the home. The environmental audits and other quality monitoring audits were accessible in the staff office. The medication audit had been dated for 16 August 2012 which ensured that staff were aware of when to repeat the audit.