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Inspection report

Date of Inspection: 13 August 2013
Date of Publication: 19 September 2013
Inspection Report published 19 September 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 13 August 2013, talked with people who use the service 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

People’s personal records including medical records were accurate and fit for purpose.

Our inspection of 12 February 2013 found people's personal records including medical records were not complete. It was difficult to track patients' care from initial consultation through to treatment because the medical notes were often illegible. There was no evidence that patients' medical histories where taken during consultation or before treatment. There was no documented information outlining the risks and benefits of the procedures discussed with patients.

During our visit on 13 August 2013, we looked at four sets of medical records and found significant improvements since our last inspection. Each person's medical record was divided into specific sections including the patient's consultation with the consultant, results of tests, and communication with the patient's general practitioner (GP). Consultants' notes were not always legible but staff could read and understand them. A detailed summary of the consultation, results of tests, and treatment were clearly typed in a letter to each patient's GP.

As in our previous inspection, we found patients' needs were documented and there were records in relation to consent and treatment. Medical notes were contemporaneous. They were signed and dated by the consultant who provided the consultation. There was evidence of good communication with patients' general practitioners.