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Archived: Caremark (Redbridge)

This service was previously registered at a different address - see old profile

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Inspection report

Date of Inspection: 16 January 2014
Date of Publication: 1 March 2014
Inspection Report published 01 March 2014 PDF | 76.03 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 16 January 2014, 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

People’s personal records including medical records were accurate and fit for purpose. We looked at ten care records and found that care plans were accurate and updated as required. Staff told us they maintained nutritional, catheter, medication and log sheet records .

The provider may wish to note that we found some people's agreed times to receive care, were not always up to date. This was because some care staff were visiting people at a different time. We saw this on some call monitoring sheets. While this had been updated on the care workers rota it was not updated on the care plan. This may impact on people’s care, particularly if a new care worker visited, as the record had not been updated.

There were instances where the service had been contacted by people to change the time they received care. The registered manager did show us where they documented this on the computer system.

Staff told us the importance of maintaining accurate records and that where they saw any mistakes in the log sheet or medication record they would bring the sheet to the office and inform the next care worker at handover. Staff advised that they checked what they had written for accuracy and ensured they had put the correct date and signed the record. We asked people if they viewed their records and some told us they did and one person said "I don't read what X wrote I trust her."

All records relevant to the management of the service were accurate and fit for purpose. In all the ten staff records we looked at we found the information about staff was stored in their file and records were complete. Where we needed to see confirmation of a criminal records check for a newer member of staff the registered manager was able to provide this to us immediately.

Records were kept securely and could be located promptly when needed. We observed that the key to access people and staff files was held by the manager and locked at all other times. All information requested from the provider was easily located by staff.

Records were kept for the appropriate period of time and destroyed securely. We viewed the provider's policy on the retention of documents and the manager confirmed their knowledge of the policy.