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Inspection report

Date of Inspection: 27 April 2011
Date of Publication: 28 June 2011
Inspection Report published 28 June 2011 PDF | 110.55 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 27/04/2011, 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

People had experienced good maintenance of their personal and medical records, which had been kept secure and confidential. Other records to protect their safety and wellbeing had also been well maintained and kept secure.

User experience

We had not spoken directly to people who used services in assessing this outcome.

Other evidence

We viewed a sample of records held in peoples' case files and maintained in the office and found records had been accurately kept and were up to date. Staff in interview told us they had assisted in completing such as care plans, diary notes and risk assessments, while management told us they had identified the need to make sure such as training records and recruitment records had been maintained.