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Inspection report

Date of Inspection: 1 April 2011
Date of Publication: 4 May 2011
Inspection Report published 4 May 2011 PDF | 90.01 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 reviewed all the information we hold about this provider, carried out a visit on 01/04/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Records about people’s needs are accurate and up to date. This ensures people receive the care and support they need and are monitored.

User experience

On this occasion we did not speak to people about this outcome.

Other evidence

We looked at the records of the food eaten by people that use the service. They were completed and up to date. They indicated the preferences of the people that use the service and contained good information with regard to how food needed to be prepared as well as information in relation to the type of food people did not like or could not eat. This assists to ensure that clear information is recorded to indicate that people’s nutritional needs are met.

We also looked at people’s weight charts and they had been completed. It is now possible to monitor if people’s nutritional needs are sufficiently met.