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Inspection report

Date of Inspection: 18 February 2013
Date of Publication: 20 March 2013
Inspection Report published 20 March 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 18 February 2013, observed how people were being cared for and talked with people who use the service. We 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 people living in the home care folders were kept in a secure cabinet. People could view these records if they wished. They and their families were involved in the developing of the care records. There was daily documentation in each persons care records.

Visits made to other health professionals and subsequent follow up actions and /or visits were documented in the care records.

All relevant data was kept in the current records folder. Older information was stored securely. The manager said they had stored all information for each person since they came to live at the home. The manager said they were unsure as to how long records were to be stored for; they will now follow CQC advice on record storage.

All staff personal files were locked securely. There was evidence of standardised recruitment process and regular appraisals.