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Inspection report

Date of Inspection: 15 February 2013
Date of Publication: 29 May 2013
Inspection Report published 29 May 2013 PDF

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 15 February 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 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.

We saw records of audits and maintenance logs which evidenced our judgement. Clinical records were seen to be compliant.

Reasons for our judgement

Patient's clinical records were accurate and fit for purpose. It was observed that these records were written contemporaneously, and that confidentiality was being observed. We noted that a computerised system was in place for digital radiography and for practice management procedures, but the individual wallet files for patient record keeping proved more appropriate for the provider. We looked at a sample of six of the patient record file wallets which contained letters, radiographs from referring dentists, treatment plans showing consent and costs involved, and other information.

We saw that the dental records were kept in locked cabinets in the practice manager’s office, behind reception, not accessible to patients. We were told that all computers were password protected.

We saw staff records and other records relevant to the management of the services were accurate and fit for purpose. These included certificates showing continual professional development and further training.

We saw records relating to the practice equipment which showed that a robust system for servicing and maintenance was in place. We noted that a contract was present with an appropriately registered company and a diary system set up to show when servicing was due. This was further checked by the provider and practice manager. We saw records to show that the autoclave had been serviced in September 2012 and the critical examination of the X ray unit was done in August 2012. This demonstrated that the equipment was being serviced and maintained correctly.

We also saw that the electrical testing of portable appliances had been done in November 2010 and the fire safety risk assessment in May 2011. We observed that fire-drill records were present. We also saw that the water systems were checked for Legionella. All of these records were kept securely and could be located promptly when needed. Records were kept for the appropriate period of time and then destroyed securely.