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Cellular Pathology Services Limited

All reports

Inspection report

Date of Inspection: 23 January 2014
Date of Publication: 5 March 2014
Inspection Report published 05 March 2014 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 23 January 2014, observed how people were being cared for 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

We found that a unique reference number was applied to each specimen which was used for tracking throughout the process to the final results. The number was applied to the initial log sheet and appeared on all records. This ensured that there was a full audit trail and ensured that the correct diagnostic tests were reported on. Two members of staff were present when tests were undertaken to ensure that records were accurate. One member of staff carried out the test and dictating the process while the second member of staff made notes and ensured the records were correct.

Records of equipment maintenance, risk assessments and confidentiality agreements signed by staff were present and up to date.

Personal records, which included the actual specimens and final test results were kept securely on the premises for a period of 30 years. We noted that the original request form which travelled with the sample throughout the process was scanned onto the computer system once the results had been delivered. The paper copy would then be shredded once there was authorisation to do so by the laboratory manager.