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Archived: The Calthorpe Clinic

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All reports

Inspection report

Date of Inspection: 20 January 2012
Date of Publication: 5 April 2012
Inspection Report published 5 April 2012 PDF | 67.17 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met 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 reviewed all the information we hold about this provider, carried out a visit on 20/01/2012, observed how people were being cared for, looked at records of people who use services, talked to staff, reviewed information from stakeholders and talked to people who use services.

Our judgement

Improvements are needed in the quality and accuracy of record keeping.

User experience

We did not talk to people who were using the service about the quality and accuracy of records.

During our visit, we saw that records relating to people who used the service were stored in a secure way.

Other evidence

We visited the service on 20 January 2012 and found that improvements were needed to the systems in place for the completion of records. We made a second visit to the clinic on 9 February 2012 to look in more detail at the quality and accuracy of record keeping in relation to how the clinic complies with the Abortion Act.

At our first visit we found that the quality of recording in theatre registers varied. We found gaps in information recorded and times were not always clear. We also identified that entries in the registers were being completed in advance. This meant we could not be assured that entries made were consistent with what actually happened.

At our second visit to the clinic, we looked at the records of 17 people who had undergone a termination of pregnancy at the clinic. In each case, we looked at the certificate that had to be completed by two doctors to show that the patient was suitable to undergo a termination before any procedure takes place. We found that improvements were needed to all 16 certificates that we looked at. An accurate record of decision making and medical practitioner approval to the termination of pregnancy was not being maintained. Some were not dated correctly or did not record the full name and qualifications of the doctors completing the certificate. A minority of forms were not clear if one or two doctors had seen the person and assessed they met the criteria for a termination. There were examples where the details of the patient had not been recorded on the certificate.

A written procedure was not in place about the expectations of record keeping in respect of the certificates so that all staff were clear about their responsibilities. The clinic was not monitoring the quality of the completion of these certificates.