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Archived: Church Green Lodge

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Inspection report

Date of Inspection: 3 October 2013
Date of Publication: 30 October 2013
Inspection Report published 30 October 2013 PDF | 72.77 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 3 October 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.

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 looked at the records held at Church Green Lodge for two members of care staff and three people using the service.

We found that people’s personal records including medical records were accurate and fit for purpose. These records contained appropriate information about the person so that staff could meet their needs. These care records were updated every time the person returned to Church Green Lodge for respite, to ensure that they reflected people's current support needs.

We found that staff records and other records relevant to the management of the services were accurate and fit for purpose. The service was keeping appropriate records for the two staff members whose files we reviewed. These included information about the staff member such as qualifications, past work history, personal details, training records and CRB checks.

We found that records were kept securely and could be located promptly when needed. Records currently in use were kept inside the manager’s office, which required a passcode to access. Records for people not currently at Church Green Lodge for respite were kept in another locked room.