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Archived: Angels Community Homecare Services

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All reports

Inspection report

Date of Inspection: 15 December 2011
Date of Publication: 2 March 2012
Inspection Report published 2 March 2012 PDF | 43.04 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met 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 reviewed all the information we hold about this provider, carried out a visit on 15/12/2011, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Systems are not in place to ensure that records are accurate and can be located promptly when required.

User experience

There is no other evidence.

Other evidence

Records detailing care were not always completed, clear, accurate or systematically stored. One person’s care records were missing since June 2011. The manager told us the remaining notes would be at the person’s house and must not have been collected monthly, as it should have been. This means that notes are not stored securely and that staff may not always have all the information they need.

We saw that people’s daily record entries were either not dated or were not legible. The records were not in consecutive order and it was difficult to understand which entries were recent and which were entries from previous years. This means that peoples care records were not always understandable or stored in a way that would be easy to access.

We looked at medication records which should record what medication was administered and when. Two separate sheets were used to record what medication people were administered. There was some information of the person’s daily record and a separate medications sheet to complete. There were discrepancies between both sources of information. This means that there was inaccurate recording of medicines administered to people.

Staff described a management system that was agreed and used in relation to daily records. The archiving and filing of the records did not take place as was arranged. This means that there were no systems to identify shortfalls with the system being used and the quality of records.