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Archived: InSafeHands Limited

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All reports

Inspection report

Date of Inspection: 14 December 2012
Date of Publication: 11 January 2013
Inspection Report published 11 January 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 14 December 2012, 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 not maintained.

Reasons for our judgement

A set of care records were held by the people who used the service. They included a copy of the contract that detailed the care package to be provided and daily records that documented the support provided by care workers during their visits. Completed daily records were collected on a monthly basis and added to people’s individual files and stored in lockable cabinets in a locked room at the service’s head office. This meant records were kept securely and could be located promptly when needed.

All records pertaining to the service were held in one central office and were managed by the management team all had responsibility for specific areas of the service. For example care planning and risk management, training, staff deployment, health and safety and general administration.

Care records looked at were well organised and had the required information in place including care plans, emergency contact details including people’s doctors and other healthcare professional involved in their care and support.

The staff team had a staff handbook that provided detailed information about key areas of their work including safeguarding vulnerable adults, health and safety responsibilities and confidentiality.