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Maxted Meaden Dental Practice

All reports

Inspection report

Date of Inspection: 25 February 2013
Date of Publication: 11 May 2013
Inspection Report published 11 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 25 February 2013, observed how people were being cared for and talked with people who use the service. We 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 and records were kept securely and could be located promptly when needed.

The practice stored patient records on paper and computer. We observed that the method that the practice used to back up the records was appropriate. We saw that security of patient records was enhanced because each member of staff had their own computer login and password. The practice manager was able to show us evidence that the practice had registered with the data protection agency. We saw that the practice had a policy in place to ensure that patient medical histories were collected and updated appropriately.

We looked at the records of two patients and noted that they were completed contemporaneously. We asked the practice manager whether the practice had conducted any record card audits. We were advised that they had not as yet, but planned to do so soon.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. The practice manager showed us files which contained various records, including those on waste management, radiation protection and steriliser certification. We asked the practice manager how long the records would be kept and she advised us that these would be kept indefinitely.