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Inspection report

Date of Inspection: 29 January 2013
Date of Publication: 26 April 2013
Inspection Report published 26 April 2013 PDF | 82.03 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 29 January 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

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 dentists told us that they obtained a medical history at every visit and wrote their notes contemporaneously. We saw evidence of this looking at patient notes written following their visit. The practice manager showed us evidence of record keeping audits carried out every six months, the last one dated October 2012. The audits show a high degree of compliance but improvements made included the recording of basic periodontal examinations at every checkup by computer prompts. There were obvious alerts for medical condition.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. We looked at staff files and saw evidence of General Dental Council registration, pre employment references and criminal records bureau checks. The practice manager showed us the management system that the practice uses which gives automatic prompts for renewal of policies and staff records. We saw the radiation protection file with updated evidence of the equipment checks in January 2011. We saw the Public liability insurance displayed dated May 2013.

Records were kept securely and could be located promptly when needed. All patient records are kept digitally on password protected computers with individual log ins. There was dedicated dental software and all records relevant to an individual can easily be located. Receptionists showed us that confidential information no longer needed was shredded. We noted coded door locks into certain areas.

Records were kept for the appropriate period of time and then destroyed securely. The practice manager was fully aware of the time necessary to keep records and told us they were stored safely in secured storage facilities.

The receptionists were fully aware of the Freedom Of Information act and were able to give clear examples of when information could be divulged. We saw evidence of Information Governance training for all staff members.