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Inspection report

Date of Inspection: 20 March 2013
Date of Publication: 25 April 2013
Inspection Report published 25 April 2013 PDF | 189.35 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 20 March 2013, talked with people who use the service and talked with carers and / or family members. 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

The manager told us there was a process in place to monitor the standards of documentation completed by staff. The manager reviewed all the daily communication sheets every three months to ensure that information was accurate and adequate details were being recorded. This was supported by the visits the manager made to the person’s home. In some instances these visits took place every week but not less than, every month. We looked at three daily reports for each of the five care plans that we reviewed. We saw that the information recorded was detailed and informative about the tasks that had been completed. Additional information relating to the person’s well-being was included when it was appropriate to do so.

People’s personal care records were accurate and fit for purpose. The provider showed us two care plans that were kept in the person’s house and these records were complete with daily records, up to date reviews, medicine administration records and risk assessments. The provider may find it useful to note that the care records held in the office of the agency did not contain a copy of up to date information relating to the person.

We saw that records were stored securely. Staff records and other records relevant to the management of the service were accurate and fit for purpose. Staff were provided with confidentiality training and we saw there was a policy in place for protecting personal information.

The manager told us that records would be kept for the appropriate period of time and then destroyed securely. At the time of the inspection all the records had been retained.