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Inspection report

Date of Inspection: 4 October 2013
Date of Publication: 30 October 2013
Inspection Report published 30 October 2013 PDF | 79.62 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 4 October 2013, observed how people were being cared for and talked with people who use the service. We talked with staff, reviewed information given to us by the provider and talked with commissioners of services.

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

We examined five records and found they contained the appropriate information required to meet each person’s care requirements. Each person had a detailed assessment and we saw that a person centred care plan was initiated from the information contained in the assessment documentation. There was clear information and guidance to staff recorded in each record to ensure that people's needs were met appropriately. Care plans identified risks and detailed how these should be managed. Care plans were based on the needs, choices and preferences of each individual.

Each file contained detailed risk assessments and where risk had been identified there was clear instruction to staff on how those risks should be managed. This meant that people were supported by staff who had access to documentation about each person’s needs and risks.

There was detailed documentation about discussions with other health and social care professionals and information was held and shared appropriately which meant that people's personal data was protected.

We saw that changes in people's care needs was updated in their care plans in a timely manner which meant that information about people's care requirements was always up to date and relevant.

We saw that records were stored securely in each of the nursing stations for each unit and were easily accessible when required.

Staff and maintenance records were held securely in the manager’s office.

Records were kept for the appropriate length of time as per the company policy.