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Archived: The Hospital Group - Nottingham Clinic

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Inspection report

Date of Inspection: 13 August 2013
Date of Publication: 5 September 2013
Inspection Report published 05 September 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 13 August 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 and talked with staff.

Our judgement

Patients were protected from the risks of unsafe or inappropriate care and treatment because appropriate records were maintained.

Reasons for our judgement

Patients’ personal records including medical records were accurate and fit for purpose.

We spoke with one patient. They said, “No problems with the security of records and my records are well completed.”

We spoke with two staff members about this standard. They told us that records were stored securely and were well completed.

During our tour of the premises we saw that patients’ records were kept securely.

We looked at four patients’ care records. Documentation contained appropriate detail and was completed appropriately.