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Archived: Active Smile

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Inspection report

Date of Inspection: 20 November 2013
Date of Publication: 3 January 2014
Inspection Report published 03 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 20 November 2013, checked how people were cared for at each stage of their treatment and care and sent a questionnaire to people who use the service. We talked with people who use the service 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

The Practice Manager showed us the treatment and care plans for some of the patients at the Practice. The records were kept on a wholly computerised system.

The records were updated by staff at the time of treatment. The information retained on the patient records included personal contact details and relevant medical information.

We looked at some of the records in detail. All of the records we saw were accurate, up-to-date and gave staff good clear information about the previous treatment and on-going requirements. The patient information was easily accessible to staff across the practice.

This meant that people’s personal records, including medical records were accurate and fit for purpose.

Any physical, paper records were appropriately and securely stored in locked filing cabinets as required. Staff records and other records relevant to the management of the services were accurate and fit for purpose. This meant that records were kept securely and could be located promptly when needed.

The Provider had a policy and procedure for the management, storage and disposal of information. Clear timetables for the appropriate storage and retention arrangements were available. This meant that records were kept for the appropriate period of time and then destroyed securely.