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Pinhoe Dental Centre Limited

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Inspection report

Date of Inspection: 31 October 2013
Date of Publication: 7 January 2014
Inspection Report published 07 January 2014 PDF | 89.19 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 31 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We sent a questionnaire to people who use the service, talked with people who use the service, talked with staff and reviewed information given to us by the provider.

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

Patient’s personal records including medical records were accurate and fit for purpose. The six electronic and paper records we looked at were maintained well and up to date. Records highlighted risks such as allergies or current medical treatments. Electronic records were regularly backed up throughout the day to prevent records from being deleted. Records indicated how patients liked to be reminded about appointments, for example by text messages, letters or phone calls. The patients we spoke with told us they received reminders about appointments in the way they chose. This showed that the provider took steps to ensure information about patients remained current.

We saw evidence that the provider carried out record audits to check that the right information was recorded and that information was up to date. We heard how reception staff and dental nurses checked patient’s personal information to ensure it was accurately recorded and saw them updating records as required. The patients we spoke with told us they were asked about their personal information routinely by the providers’ staff. Medical history checks were completed by patients at recall appointments or before emergency treatment.

In all the records we looked at we saw how medical alerts were highlighted to ensure dentists were aware of any concerns. For example, where a patient was taking medication to thin their blood or was taking medication to control their epilepsy this was recorded. We saw that soft tissue examinations were recorded as well as risk assessments for caries, gum disease and oral cancer. Appointment records showed that recall appointments were based on risk assessment and need and not just for standard annual or six monthly check-ups.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. In the four staff records we checked all information related to recruitment and registration was in place and current. Checks on decontamination equipment was completed daily and monitored through routine audits carried out by the practice manager. Maintenance records showed routine repair or replacement of damaged items. These checks showed records were routinely audited to ensure they contained the most up to date information about the practice.

Records were kept securely and could be located promptly when needed. Prescription pads were held securely in the practice manager’s office and were not pre-signed. Where paper records were needed we saw patient paper records were stored in a secure area of the practice to protect confidentiality. The electronic patient records on the providers’ computer system were password protected to ensure information was held securely. Computer screens used by staff faced away from the patients to prevent breaches of confidentiality. This ensured that records were easily available but held securely to ensure patient privacy.

Records were kept for the appropriate period of time and then destroyed securely. We saw that the provider had a current records management and access policy which outlined a description of the systems in place for storing patient records for current and archived records. We saw information in the waiting rooms about how patients could apply for access to their records. The provider told us they kept records for NHS patients for six years, which is in line with contractual arrangements and no longer than the 30 years as described in the Code of Practice on Retention/Disposal of Records under the NHS. This meant that patients could access their records where they requested to do so and that records were held no longer than required.