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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 8 January 2014
Inspection Report published 08 January 2014 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 10 December 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

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

The provider had a range of policies and procedures in place to ensure records were managed appropriately in relation to information governance and data protection guidance. The director of clinical services was the nominated Caldicott guardian (a senior person responsible for protecting patient information and enabling information sharing.) The ‘Imaging manager’ was the nominated “Information security coordinator” for this hospital. This role had been developed by the provider to ensure and give assurance that all records and data was correctly managed and secured. The management team explained how patient records were managed during the patient journey. There were secure third party contractual arrangements in place for the scanning, archiving and confidential disposal of documents. This meant there were systems in place to ensure records were securely managed and protected.

We found patient’s care records were accurately maintained. The nurse, doctor and other staff completed a range of specifically designed and printed forms to assist in ensuring patient’s received consistent care. For example, on admission the nursing staff completed an ‘adult risk assessment documentation’ booklet which included a range of individualised risk assessments of areas such as nutrition, pressure sore risk score, mental health and falls. We found the standard of record keeping was reasonable and records reflected patient’s individual assessed needs. The provider had conducted regular medical records audits to ensure they had been adequately completed and maintained.