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Archived: Park Chambers Dental Practice

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All reports

Inspection report

Date of Inspection: 4 March 2013
Date of Publication: 25 April 2013
Inspection Report published 25 April 2013 PDF | 81.9 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 4 March 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information we asked the provider to send to us.

Our judgement

Patients were protected from unsafe and inappropriate care because the practice records kept were accurate, fit for purpose and held in a confidential and secure way.

Reasons for our judgement

Patient’s personal records including medical records were accurate and fit for purpose. Four sets of patient’s records were inspected for quality and were found to be fit for purpose. They contained patient details, updated medical histories, full oral assessments of both the teeth and gums with good contemporaneous notes of discussions with patients and procedures, drugs and materials used. Patient’s electronic records were password protected and the card records stored in a lockable cupboard so that patients can be confident that their personal information is stored securely.

We were shown that audits had been carried out on record quality as part of a rolling quality assurance program. This meant that the provider was monitoring the quality of their record keeping.

Staff records and other records relevant to the management of the service were accurate and fit for purpose. The practice records relating to health and safety, risk management, cross infection control, radiation protection, child protection, information governance, complaints, legislation and employment were all seen to be well managed and accessible to staff.