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Archived: Steps Care Limited

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Inspection report

Date of Inspection: 27 February 2014
Date of Publication: 20 March 2014
Inspection Report published 20 March 2014 PDF | 74.2 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 27 February 2014, 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

We looked at three people's care files. Their assessment and care plan provided the information care workers needed to ensure people's needs could be met in a safe way. The information was easy to find and clear to read. This meant that information was kept in a secure way and people's care and treatment were recorded to assist the staff.

All records were kept securely in a locked office in the shared supported living house. These records were accessible for the staff that required them. The records were sufficient to protect people against the risks of unsafe or inappropriate care.

The agency kept records of all maintenance carried out in the shared house. We also saw completed audits of fire equipment testing and accident and incident forms.

The agency’s complaints procedure and safeguarding policy was displayed for people to access. This showed the home was monitoring people’s wellbeing through the use of effective records.