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High View Care Services Limited Good

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Inspection report

Date of Inspection: 12 September 2013
Date of Publication: 15 October 2013
Inspection Report published 15 October 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 12 September 2013, observed how people were being cared for and talked with people who use the service. 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. The care plans we looked at included suitable information such as people’s medical conditions, current medications and any known allergies to ensure the care provided was appropriate and met the individual’s needs. We saw that people had consented to their care and treatment in areas such as substance misuse and alcohol management and some people had signed documentation to be searched and breathalysed after they had been out in the community. The care plans included contact details of relevant professionals involved in people’s care and treatment. This included people’s GPs and social workers staff could contact in the event of an emergency. We saw that end of life care had been discussed with people to ensure that appropriate actions were taken when required.

Records were kept securely and could be located promptly when needed. All care plans were kept securely in the staff office and we saw that the door was locked when the office was not being used by staff. People we spoke with told us that they could access their care plan when they needed it and that they had monthly meetings with their key worker to talk about their care and support needs. Staff records were kept in lockable cabinets in the home manager’s office. All records were provided promptly when required.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. Staff induction, training, team meeting and supervision records were mostly up to date. Other records relevant to the management of the service such as resident’s monthly meetings, legionella test, quality checks, policies and procedures, health and safety checks and maintenance records were mostly up to date.

Records were kept for the appropriate period of time and then destroyed securely. The home manager told us that records such as people’s care plans were kept for six years. However they were unable to show us any records retention policy, therefore we were unable to evidence whether records were being kept for the appropriate duration of time. We were shown a shedder at the home which was used to destroy records that had exceeded their retention period.