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Inspection report

Date of Inspection: 23 January 2013
Date of Publication: 14 May 2013
Inspection Report published 14 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 23 January 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. Records were kept securely and could be located promptly when needed. Staff records and other records relevant to the management of the services were accurate and fit for purpose.

Reasons for our judgement

The patient records were computerised and were secured by password access only. Information such as written medical histories, referral letters, dental radiographs and NHS forms were scanned and uploaded onto the patients clinical records. This meant that people's records were kept securely and could be located promptly when needed. This also meant that patients could be assured that their confidential information is properly protected.

We were shown a well maintained radiation protection file. This file contained all the necessary documentation pertaining to the maintenance of the x-ray equipment. These included critical examination packs for each x-ray set along with the three yearly maintenance logs. A copy of the local rules was displayed with each x-ray set. Quarterly radiographic audits were available for inspection along with a quality assurance system for radiographs. This meant that the practice was acting in accordance with national radiological guidelines. A dosimetry (the measurement of radiation) report detailing staff exposure doses for radiation was reviewed demonstrating that dental staff were not exposed to harmful levels of radiation. Patients and staff were protected from unnecessary exposure to radiation.

A current public liability insurance certificate was displayed in accordance with current Health and Safety legislation. We also saw that statutory signage was also in place. This means that the practice conforms to current health and safety legislation and patient safety was assured.

We saw evidence that the registered manager maintained a full range of general operating policies and procedures for the practice. We saw evidence of a well maintained information governance file which demonstrated that the practice staff were fully conversant with information governance protocols and procedures. This meant that staff records and other records relevant to the management of the services were accurate and fit for purpose. The file also demonstrated that staff have received proper training in all areas of information governance. This meant that staff understood fully the principles of confidentiality and the processing of sensitive patient data. This meant that patients could be assured that their confidential data was protected.

A sample of three patient records were observed. The clinical entries were completed by the dentists themselves. The written medical history was signed and dated by the patient and the dentist. The records contained assessments and details of the treatment provided which included details of the local anaesthetic given along with batch numbers and expiry dates. This meant that people’s personal records including medical records were accurate and fit for purpose.