You are here

All reports

Inspection report

Date of Inspection: 19 February 2014
Date of Publication: 29 March 2014
Inspection Report published 29 March 2014 PDF | 79.26 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 19 February 2014, observed how people were being cared for and talked with carers and / or family members. 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

People’s personal records including medical records were accurate and fit for purpose. We reviewed the care plans for two people and saw that they were reviewed within the last year, they contained relevant information which enabled the carers to look after people adequately and the health records contained information relevant to managing people's health needs.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. We reviewed the staff files and saw that employment checks were completed and staff training requirements were kept in an online database which was up to date. Other records pertaining to the health and safety requirements of the home were up to date and easily accessible for staff.

Records were kept securely and could be located promptly when needed. All records for both staff and service users were kept within the manager's office, confidential records for staff were kept within a locked filing cabinet and the personal care plans for people were kept in the office but accessible for staff to use on a daily basis. The home was kept locked and people were asked to sign in and monitored by staff which ensured the safety of confidential records.

Records were kept for the appropriate period of time and then destroyed securely. We spoke with the deputy manager who told us all archived documents were taken off site by the provider and stored at secure location. They told us that an external company takes away any confidential waste for shredding and disposal off site.