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Archived: Allied Healthcare - Plymouth

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Inspection report

Date of Inspection: 10 January 2013
Date of Publication: 12 February 2013
Inspection Report published 12 February 2013 PDF | 76.85 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 10 January 2013, 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 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

We saw that records were kept securely and could be located promptly when needed. We were told that the building was locked at night and had an alarm system in place.

We were told records were regularly sent to be archived and kept for the appropriate period of time in accordance with Allied healthcare policies and procedures.

Care plans are a tool used to inform and direct staff about people’s health and social care needs. Care plans should involve people and/or their relatives and representatives, if necessary, to ensure the information written about a person is individual, reflective of current care needs and up to date. We looked at four care plans and found these were sufficiently detailed and directed and guided staff of the action they needed to take in order to meet people’s assessed care needs

Risk assessments are a tool to identify any hazards and the action staff must take to reduce the risk from the hazard. They are used to reduce any identified risks while promoting the independence of people. We saw risk assessments were completed for people who used the service; they were up to date and had been regularly reviewed.

People who used the service who we spoke with told us that as soon as the “log book” in the house was completed it was collected by somebody from the office and a new one was left in its place. They added they knew it then “got checked” by people in the office to “make sure it was filled in properly”.