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Inspection report

Date of Inspection: 28 July 2014
Date of Publication: 3 September 2014
Inspection Report published 03 September 2014 PDF | 87.98 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 28 July 2014, talked with people who use the service and talked with carers and / or family members. We talked with staff and reviewed information given to us by the provider.

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 reviewed three care records and found they were well organised and easy to navigate. There was an index at the front of each file and information was organised into separate sections which meant information could be promptly located by staff when required. All the care records we looked at were up to date and provided detailed information about the level of support each person required. The provider had a process in place for reviewing and monitoring records such as care plans and risk assessments. This meant they were accurate, relevant, complete and up to date.

We saw that personal records were kept securely within the locked manager's office to maintain confidentiality. The Team Leader on shift had a key to the office to ensure staff could access information regarding people's care and treatment when required. The staff we spoke with confirmed this.

The deputy manager explained there was a system in place to ensure documentation was securely archived each month and kept for appropriate periods before being securely destroyed. The provider also had a data protection policy and confidentiality in place which described how it looked after data safely.

We saw appropriate records were in place in relation to the management of the service. This included audit documentation and policies. An up-to-date training plan was also in place, which showed when each staff member required training updates in a number of subjects. This allowed management to quickly identify if people were up-to-date with training.