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Inspection report

Date of Inspection: 8 March 2013
Date of Publication: 3 April 2013
Inspection Report published 3 April 2013 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Meeting this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

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 8 March 2013, checked how people were cared for at each stage of their treatment and care and talked with staff. We received feedback from people using comment cards and reviewed information sent to us by other authorities.

Our judgement

People experienced care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

No patients who were attending the practice during our visit wished to speak with us on this occasion.

We asked to see the records of five patients who had been examined on the day prior to our visit. We found in each case that medical history updates and treatment plans were completed prior to treatment commencing. Each medical history and treatment plan had been signed by the individual patient, or their parent / guardian to confirm the information that they had provided and to consent to the treatment plan.

After obtaining the signed medical history update and treatment plan consent, the practice kept a record about the nature of the examination undertaken and any treatment and advice given to each patient. These records were kept on computer and we looked at five examples of these. We also checked the handwritten patient information against what had been recorded on computer and found that these matched the type of examination undertaken, any subsequent treatment required and the advice that was given to each patient. In three cases the people attending only required a check up and this was recorded with the reason why no further treatment was required as a result of their consultation.

The practice had written procedures for responding to emergencies and the emergency drug box, defibrillator and oxygen were properly stored, in date and certificated.