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Archived: Right at Home (Sutton & Epsom)

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Inspection report

Date of Inspection: 4 June 2014
Date of Publication: 28 June 2014
Inspection Report published 28 June 2014 PDF | 82.04 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 4 June 2014, checked how people were cared for at each stage of their treatment and care 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

People’s personal records including medical records were accurate and fit for purpose. We looked at the records of five people using the service. There was current information about each person on their individual files. Each person had a plan of care which had been reviewed by appropriate senior staff. Where changes to people’s needs were identified, people’s care plans were updated appropriately to reflect this.

We saw risk assessments for each person had been carried which identified known risks to their health, safety and wellbeing. There were instructions for staff on how to manage risks that had been identified to keep people safe. These had also been recently reviewed by senior staff.

Staff kept daily records about each person detailing the care and support they had received as well as noting any issues or concerns they had. This meant staff had access to up to date and accurate information about people’s current care and support needs.

Staff records and other records relevant to the management of the service were accurate and fit for purpose. We noted staff records were audited regularly and appropriate actions were taken by senior staff to ensure records contained up to date and relevant information.

The service had current policies and procedures in place so staff had up to date information and guidance about their roles and responsibilities when providing care and support to people using the service.

Records were kept securely and could be located promptly when needed. We observed people’s records and other records relevant to the management of the service were stored in lockable cabinets in the main office. Staff were able to locate records promptly during the course of our inspection. We saw evidence that all staff received appropriate training about the importance of confidentiality and data protection and signed confidentiality agreements when they joined the service to ensure people’s personal information was protected.