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Archived: Marie Stopes International Birmingham

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 10 January 2014
Inspection Report published 10 January 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 10 December 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, reviewed information given to us by the provider, were accompanied by a pharmacist and reviewed information sent to us by commissioners of services.

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

At our last visit in November 2012 we found that improvement in the quality and availability of some records was needed. At this visit, we found that improvements had taken place. Requested records were available. Previously there was no training matrix to show the training undertaken by staff. We found this had now been completed.

At our last visit we identified a number of shortfalls in the care records and medicine administration charts we reviewed. The clinic had now introduced a new electronic recording system and this had helped to reduce the risk of any incomplete information.

The Abortion Act 1967 requires that two doctors provide a certificated opinion, formed in good faith, that at least one of the grounds for a termination of pregnancy as set out in the Act, is met. One of the ways in which the regulations provide for doctors to certify this opinion is in an HSA1 form. If using the HSA1 form, both of the certifying doctors must complete the form as required and sign and date the certificate. The opinion of each doctor is required to relate to the circumstances of the individual person's case. During our visit, we looked at a random sample of medical records for people who had undergone a termination of pregnancy. We found no evidence that the forms were being signed by doctors prior to consultations taking place.

There had been some previous issues in doctors sometimes not filing in all parts of the HAS1 form. We found that action had been taken to address this and that regular audits of records were being completed to ensure they met the required standard. We looked at eight HSA1 forms and found the majority had been appropriately completed. The provider may find it useful to note that on one of the forms the doctor had not recorded if they had or had not seen the person.