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Inspection report

Date of Inspection: 18 March 2014
Date of Publication: 13 June 2014
Inspection Report published 13 June 2014 PDF | 78.18 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 18 March 2014, checked how people were cared for at each stage of their treatment and care and reviewed information given to us by the provider. We were accompanied by a specialist advisor.

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

The service used paper records. At the previous inspection we found that people's personal records were not stored securely in a lockable cabinet in a lockable room which meant people's confidentiality was not protected. We also found that information within the files was not arranged in chronological order, which made it difficult to ascertain if the records were complete.

At this inspection we found that people's files were stored safely and securely. The ten files that we looked at were filed in an orderly and chronological manner, which meant the dental nurse could show us the sequence of people's care and treatment.