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Inspection report

Date of Inspection: 27 December 2013
Date of Publication: 22 January 2014
Inspection Report published 22 January 2014 PDF | 77.76 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 carried out a visit on 27 December 2013, observed how people were being cared for, 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

During our inspection we looked at the care files for four people. These were in good order, easy to follow and appeared to be complete. Most information was typed. People living at the home and staff had signed, where appropriate, to agree the information was correct. All the information we saw in people’s files was up to date. Staff files, including training records, were also complete and up to date.

We saw that people were offered a copy of their care plan. Where they did not wish to have a copy of their record they signed to state this was the case. The manager told us that checks were carried out to ensure records were correct and completed to the required standard.

Records were kept in relation to the maintenance and safety of the building. These provided evidence that all necessary checks were completed and any action required was taken.

We found that people’s care files and staff files were stored securely. They were only accessible by people who were authorised to see them.

The manager was able to provide all the records we requested during our inspection in a timely manner. All the records appeared to be well organised and to hand when required.