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Inspection report

Date of Inspection: 8 March 2011
Date of Publication: 19 August 2011
Inspection Report published 19 August 2011 PDF

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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

Our judgement

The records of patients who use the service are fit for purpose, regularly updated and confidentially stored.

User experience

Patients told us that they had a personal copy of their care plan which had been agreed with their primary nurse and when changes were made these were recorded in the electronic record.

Staff confirmed that they updated the patients electronic care record daily or after any significant intervention.

We saw that paper records were stored securely in locked cabinets.

Other evidence

The trust provided training to all staff to ensure the electronic clinical care record system was used to maintain an accurate record that protects patient’s wellbeing. Information security and confidentiality training was provided by the trust at induction and ongoing through mandatory training to ensure staff were aware of their responsibilities. Policies and procedures were available for staff to support the record keeping and safe storage processes in the trust.

The trust periodically audits record keeping and where issues were identified put in place additional safeguards to ensure patients’ records contain the full, accurate record of a patient’s treatment and care.