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Inspection report

Date of Inspection: 12 December 2013
Date of Publication: 7 January 2014
Inspection Report published 07 January 2014 PDF | 72.46 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 12 December 2013 and talked with staff.

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

During the inspection, we looked at a number of paper based records, including people’s medical records, correspondence letters, staff records and policies and procedures. These were complete and up to date, with no missing information and few documentation errors. The provider had processes in place for reviewing and monitoring records such as medical records, to ensure they were accurate, relevant, complete and up to date.

Paper copies of the provider’s policies and procedures were available in the staff office. The policies were reviewed and updated on an annual basis by the registered manager, who had arrangements in place with an external consultancy to maintain and update policies and procedures.

We found that medical records and staff files were stored in lockable cabinets in the staff offices. The registered manager told us that access to confidential and personal records was restricted and monitored. The provider had policies in place for data protection and confidentiality that staff had to adhere to.

The registered manager was able to provide the records we requested in a timely manner. There was a policy in place for retaining and archiving records to ensure documents were retained in line with national guidelines. The registered manager told us they retained records for up to eight years and archived these at an external location. Access to the archived records was controlled and restricted.