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Inspection report

Date of Inspection: 10 May 2011
Date of Publication: 9 June 2011
Inspection Report published 9 June 2011 PDF | 139.03 KB

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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 reviewed all the information we hold about this provider, carried out a visit on 10/05/2011, checked the provider's records, observed how people were being cared for, talked to staff and talked to people who use services.

Our judgement

Records are accurate, fit for purpose, and kept securely to ensure the dignity and confidentiality of people using the service.

User experience

We received no specific comments from people that use the service or from other professionals about record keeping at Trewartha.

Other evidence

Policies for record keeping are in place and are reviewed annually or more often if necessary. These policies detail what information should be stored in each person’s records.

Care plan audits are done to ensure that the information within the files is accurate and has been reviewed. Data protection and confidentiality policies give guidance on how information can be stored and transferred safely. Consent to release information forms are available should they be needed.

People and their relatives are encouraged to contribute to the plans of care, and this can be seen with their signature on the plans and on the reviews.

Cornwall Care have advised us that records are disposed of in accordance with the Data Protection Act.