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Archived: Greenwich Primary Care Drug and Alcohol Service

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Inspection report

Date of Inspection: 14 January 2014
Date of Publication: 23 January 2014
Inspection Report published 23 January 2014 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 January 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service 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 paper files for ten people who used the service. The paper file which contained information such as their care plan, needs assessments, risk assessments, treatment programmes and prescriptions. There were also copies of correspondence sent to external agencies and other professionals involved in the persons care. The service also had an online case notes management system, which required all contacts with people to be updated on the system. We looked at the case notes for one person and found that details of group sessions, telephone contacts and letters had been logged on the system.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. We reviewed five staff paper supervision files and found that these files contained information regarding peoples' supervisions and appraisals. The registered manager told us that staff's main file was stored with the provider's HR department. We were also shown the providers online training records for twelve members of staff which showed training staff had undertaken.

Records were kept securely and could be located promptly when needed. During our visit we noted that confidential files were kept in locked cabinets when we went on a tour around the building. The registered manager told us that staff had access to the files of people who used the service and these were kept in a locked cupboard in the building. There was also different computer logins on the computer for staff and management and we noted this when we were shown some of the online information necessary for our visit.

The registered manager told us that if paper work needed to be destroyed it was put in a special bin. This was then collected and shredded by a contractor. Staff we spoke with confirmed this.