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Inspection report

Date of Inspection: 25 July 2013
Date of Publication: 23 August 2013
Inspection Report published 23 August 2013 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 25 July 2013, observed how people were being cared for and talked with people who use the service. We 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

Staff records and other records relevant to the management of the services were accurate and fit for purpose.

People did not comment directly to us about their personal records that were held in the office. We saw a variety of records that included patient records, staff training certificates, and policies and procedures. They were neat, legible and fit for purpose. Records requested as part of the visit were produced promptly. These records were comprehensive and up to date. There was a confidentiality policy in place for sharing information with other agencies.

We saw that records were stored securely when not in use. This meant that records required to be kept to protect people’s safety and wellbeing were maintained and held securely where required.