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Inspection report

Date of Inspection: 10 October 2013
Date of Publication: 8 November 2013
Inspection Report published 08 November 2013 PDF | 76.38 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 10 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

People were protected from the risks of unsafe or inappropriate care and support because accurate and appropriate records were maintained.

Reasons for our judgement

At our last inspection in November 2013 we found that people's care records were not accurate and did not include all the information required to meet their needs and did not maintain the dignity of the people who used the service.

During this inspection we reviewed people's care records. We found that people's personal care records were accurate and fit for purpose. Records had been appropriately reviewed and updated to ensure staff had access to the most current information to deliver appropriate care and support and meet people's needs.

The records about care and support were written in a way that maintained the dignity of the person using the service and stored appropriately to maintain their confidentiality.