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Inspection report

Date of Inspection: 16 September 2013
Date of Publication: 2 October 2013
Inspection Report published 02 October 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 16 September 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, reviewed information given to us by the provider and took advice from our pharmacist. We took advice from our specialist advisors.

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. We saw how each patient record was updated with medical conditions and any changes to medication when patients arrived for appointments. This information was recorded onto the providers’ computer based patient record systems.

In the twelve patient records we checked we saw how notes relating to the current days appointment had been recorded in a timely way. Where information was not fully recorded in one record we looked at the dentist told us he was waiting for specialist advice from an external dental professional. There were records showing previous appointments and the choices and treatments each person received. Where people had received treatment we saw copies of their treatment plans in their records as well as signed copies they had received themselves. Where patients X-rays were taken, we saw the images taken were scanned immediately into the computer based patient record.

Electronic records were well maintained and up to date. Paper records were also available and generally only held historic patient information. Records highlighted risks such as allergies, current medical treatments or whether the person had a specific medical condition. For example, where a patient was indicated as being susceptible to anxiety this was clearly available to the dentist and nursing team. Electronic records were regularly backed up to a central computer/data base throughout the day to ensure information available to the dentist was current and up to date. This showed that the provider took steps to ensure safe record keeping and patients received appropriate treatment based on accurate records.

Records were kept securely and could be located promptly when needed. We saw patient paper records were stored in lockable cabinets in a secure staff only area of the practice to protect confidentiality. The electronic patient records on the providers’ computer system were password protected and ensured information was only available to staff who required access to personal or sensitive information.. Computer screens used by staff faced away from patients to prevent breaches of confidentiality; only the current patient’s data was visible during consultations. We spoke with the dentist and they explained that they completed electronic records immediately after seeing individual patients. Where more complex treatments had occurred or referrals needed writing these were done during natural breaks in the day. We observed record keeping taking place once appointments were over.

The provider had a data protection and recording policy which all staff were required to read and demonstrate they understood their responsibilities regarding confidentiality of people’s records and their rights of access to personal records as part of their induction. People could be reassured their records remained confidential and were stored securely.

We saw records were kept in regard to maintaining safety in the dental practice. These included emergency response equipment was checked daily. Records relating to the hygiene and maintenance of each consulting room were also routinely updated. Other records ensuring the safe disposal of waste, use of sharp objects such as needles and stock control were maintained in line with the provider’s policies. We saw records showing how fire alarms were checked regularly as were fire extinguishers. During our inspection a fire evacuation training session was carried out; records showed prompt staff actions had taken place.

Certificates showed that water supplies to medical equipment met current safety guidance standards; daily and weekly checks were also recorded. Records of accidents were recorded in accordance with the provider’s policy and were routinely checked by the practices management team; actions taken to avoid repeat incidents were recorded.

Detailed records of complaints and the actions taken were also maintained by the provide