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Inspection report

Date of Inspection: 19 July 2013
Date of Publication: 23 August 2013
Inspection Report published 23 August 2013 PDF | 78.07 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 19 July 2013, sent a questionnaire to people who use the service 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

Records were kept securely and could be located promptly when needed. We looked at a number of records that the service maintained. We found they were stored securely. Staff we spoke with understood the need for confidentiality. Electronic records were password protected, which meant only staff with authorisation could access confidential records. The electronic records were firewall protected to prevent them being accessed inappropriately. Computer screens used by reception staff faced away from the public to prevent breaches of confidentiality.

We viewed four paper patient records at random. They had been completed contemporaneously and were detailed. All were up to date. Records highlighted important and relevant risks such as allergies or current medical treatments.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. Records we looked at included staffing recruitment records, patient assessment and treatment records, patient survey results, policy and procedures documents. We found that records were up to date, well ordered, clear, legible and factual.

The provider had patient information leaflets in the waiting area regarding confidentiality of their records and their rights of access to their personal records. People could be reassured that their records remained confidential. Patient’s treatment records were stored in a lockable facility in a staff only area.