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Archived: Lighthouse Homecare Inadequate

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Inspection report

Date of Inspection: 29 November 2013
Date of Publication: 8 January 2014
Inspection Report published 08 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 29 November 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

We also spoke with an external social care professional.

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 care plans and other documentation we looked at for people who used the service demonstrated generally good record keeping. We saw detailed, accurate and up to date records on specific risks for each person. The risk statements, support plans and agreements, where relevant, were in place. Pre-assessment records were available. There was clear guidance for staff to reduce risk to the people who used the service and themselves. We looked at two medication administration records and saw that they were well completed. This meant that people’s personal records were accurate and fit for purpose.

Staff files we looked at contained relevant information on, for example, identity, application forms, qualifications, references, supervision and training. We saw offers of employment records as well as job description and contracts. This meant that staff records were accurate and fit for purpose.

We saw evidence of good record keeping in the staff communication book. An example of the information provided was in respect of one person going on leave and their medicines management needed for the period. There was also general information for staff. Staff were required to sign that they had read the entries and we saw that this was in place. The diary was used for specific appointments on the day. We saw one dentist reminder that had been ticked as completed. The handover book was appropriately completed. We looked at the fire safety file and found that the checks and information were completed and up to date. This meant that records relevant to the management of the service were accurate and fit for purpose.