You are here

Laser and Light Ltd Also known as The Laser and Light Medical Skin Clinic

All reports

Inspection report

Date of Inspection: 19 February 2013
Date of Publication: 8 March 2013
Inspection Report published 8 March 2013 PDF | 86.87 KB

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 19 February 2013, checked how people were cared for at each stage of their treatment and care 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. We looked at medical records for six people using the service. The records showed that a record of every appointment was made, whether the appointment was for assessment, treatment or solely for reassurance. Records showed people had been asked for their views about their course of treatment. They showed that staff providing the treatment made an assessment of the effectiveness of treatment at each appointment. This meant people received safe effective care because each visit was recorded and changes to treatment plans were made in accordance with their views. We found minor omissions in four of the six records we checked. The provider and a staff member told us the provider regularly checked treatment records. There was no written record of these audits so we could not see whether the omissions we had identified had been noted. The provider agreed they would introduce a system to record their checks and any action needed to improve the accuracy of medical records.

Records were kept securely and could be located promptly when needed. The person using the service was aware that records about their care were kept. They had seen these were kept securely. We saw that all medical records were kept in a lockable filing cabinet. We saw that a staff member had a key to the cabinet. They told us the cabinet was locked and the key stored safely at the end of every day. The records were kept in the reception area so the receptionist could check records when they took calls. This was also immediately outside the treatment rooms, so staff providing treatment could easily and promptly locate records. This meant people’s personal and confidential information was kept securely, but was available to ensure they received safe treatment.

Records were kept for the appropriate period of time and then destroyed securely. We asked the provider how long records were kept for. They were aware how long medical records should be retained and they had systems to ensure records were not destroyed early. There was space to keep all the medical records, so the provider had not needed to make any arrangements for archiving or destroying records. People received safe treatment because their treatment records continued to be available to the provider after they had finished treatment.