You are here

All reports

Inspection report

Date of Inspection: 13 September 2012
Date of Publication: 28 September 2012
Inspection Report published 28 September 2012 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

Our judgement

The provider was meeting this standard. People were protected from the risk of unsafe or inappropriate care and treatment. Seclusion records were accurate and fit for purpose.

User experience

We did speak with patients during the inspection, but this did not include the accuracy of their written records.

Other evidence

Our inspection of 1 August 2012 found that there were significant gaps in some of the seclusion records. We issued a warning notice which required the provider to ensure they became compliant with this outcome. The provider wrote to us and told us how they had ensured that seclusion records were improved and audited. At our inspection of 13 September 2012 we found the seclusion records were accurate and fit for purpose. They were clearly written and sufficiently detailed. The format had been improved to provide a clear picture of the care and treatment provided to patients whilst they were being nursed in seclusion. This included information about food and drinks offered and provided to patients. There was evidence that the records were properly reviewed by the management team and any issues regarding the seclusion or the way it was recorded were followed up and addressed.

We spoke with a unit manager who told us the seclusion policy had been reviewed and was part of the reading list for staff. They told us that at recent staff handovers and meetings, staff had been reminded of the importance of good record keeping regarding observations and assessments during seclusion.