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Archived: Blackberry Orthopaedic & Sports Clinic

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Inspection report

Date of Inspection: 26 November 2013
Date of Publication: 1 January 2014
Inspection Report published 01 January 2014 PDF | 72.94 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 26 November 2013, talked with people who use the service 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

We saw that people’s records were held in an electronic format and that they were password protected. We were told that each practitioner had their own log in, and that staff had different levels of access to records dependent upon their job role. People’s records that had previously been held in a paper format had now been scanned onto disk for retrieval if required at a later date. We saw that shredding machines were available if any confidential waste required destruction. We found that records were kept securely and could be located promptly when needed.

We found that the’ patients guide’ and some of the policies we looked at required updating as they contained information that was no longer current for example, staff names or contact details of external agencies.

We looked at the records of six people and found that accurate and up to date records had been kept. Of the six records we looked at none of the people had any health concerns. We were told that when people did have a condition such as diabetes this was 'flagged' on the computer system as an alert for staff. This meant that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.