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The Priory Hospital North London Good

All reports

Inspection report

Date of Inspection: 21 October 2010
Date of Publication: 21 December 2010
Inspection Report published 21 December 2010 PDF

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

Our judgement

Generally patients’ clinical records were completed appropriately and contained all the necessary information. However, an audit of 10 patient records on the adolescent ward carried out by the hospital showed that all 10 records were ‘partially compliant ’ for legibility and only four records were compliant in terms of any alterations made in the record being signed appropriately. If care records cannot be read and understood easily by all members of the care team there is a risk to the continuity and quality of care and treatment provided and the safety of patients.

User experience

No comments on this outcome were received.

Other evidence

Three patient care records were examined in the adult ward. These contained detailed assessments, care plans and reviews. The nurse in charge informed us that regular reviews took place each week and a range of professionals were involved in their care. They also contained risk assessments and evidence that those people assessed as being high risk were closely monitored. Records of close observations carried out had been completed. The care plans and consent forms had been signed by the patients.

The provider gave us a copy of a medical records audit carried out by the Mental Health Act Administrator in May 2010 this stated that all the medical records were stored securely, the keys to the records were held securely and could be accessed ‘out of hours’ by clinical staff. It also stated that records were sent for external storage after three years but could be retrieved in one day; there was an approved contractor in place for the disposal of records.

A copy of a clinical documentation audit tool completed for the adolescent ward and dated 01/11/10 was also provided. This audit of 10 patient records showed that all of them contained daily care and progress notes made by all health professionals involved in the care of the young people, copies of incident and accident forms, completed observation sheets for all periods the young person was placed under observation and copies of section papers where the young person was detained under the Mental Health Act 1983. All the entries were dated and the individual levels of observation required noted. However all of the records were noted to be only partially compliant for legibility; only four of the records were stated to be fully compliant in terms of them being signed and accompanied by the name and designation of the signatory; four records were fully compliant in relation to the documentation of alterations or additions in the record being made, three were partially compliant and three were not compliant. All the records were said to be written in terms that could be easily understood by patients. There was an action plan attached to the audit which stated monitoring of clinical documentation would take place weekly.