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Archived: Low Fauld

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Inspection report

Date of Inspection: 5 August 2013
Date of Publication: 20 September 2013
Inspection Report published 20 September 2013 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 August 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and 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

The home had systems in place to record, and securely retain information regarding the care delivered to people. These included care plan and assessment records, daily reports and information from visiting professionals. These records, although held in a locked cupboard, were easily available for staff to read and update. Personnel, supervision and training records were also kept securely in locked cabinets in the administration office.

The home kept records of incidents and accidents. These were monitored to identify any trends and record actions taken. The home carried out a range of audits such as for infection control, medicines management and the use of restraint. We noted that the audit documentation was detailed and identified any action required. These audits were completed by the registered manager. We saw that the home was submitting the relevant notification into us, CQC, as required by law.

The home had accurate and up to date records related to the running of the home which assisted in maintaining a safe environment for people and staff to live and work in. This included environmental checks regarding the fire alarm system, water hygiene, health and safety and electrical appliance testing. We found equipment testing and maintenance records were up to date. The home kept comprehensive records of activity and environmental risk assessments. These were detailed and included measures to minimise the risks identified.

The manager and the organisation were following the requirements of the Data Protection Act 1998 and were aware of the timescales for retaining records.