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Salisbury District Hospital Good

All reports

Inspection report

Date of Inspection: 2 October 2013
Date of Publication: 8 November 2013
Inspection Report published 08 November 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 2 October 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

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

During our previous visit we noticed there were a number of occasions on wards in the hospital where we found patient records left unattended by staff. This included full sets of patient notes unattended on nurses' stations, on patient tray tables (including beside unoccupied beds). We saw them left outside patient bays, for example on trolleys where they were not supervised by either the patients, or the hospital staff. We also saw patient drug charts left on nurses' stations without supervision. The Trust sent us the action plan to address this and we took this opportunity to check it had been implemented.

Staff we spoke with confirmed they had received training this year on keeping patient records safe and confidential. The new staff we met confirmed the subject had formed part of their induction training. In all the areas we visited staff we spoke with knew their responsibilities to ensure patient information was stored correctly to prevent unauthorised disclosure.

We had been told by the Trust it had introduced cover sheets for any patient records which were to be stored outside of patient’s immediate bed space. This was intended to prevent any patient identifiable information being seen. We saw these covers used in two of the wards we visited and they clearly identified the information was confidential. However, the provider may wish to note in one ward we visited these cover sheets were not used for every record outside patient’s rooms.

The Trust had also started a monthly audit of safe storage of information which involved senior managers visiting different parts of the hospital to check on compliance. We were shown the records of these visits and the actions taken to remedy any shortfall. An example was where on one ward all patient records were now stored in one designated area. We saw this arrangement during our inspection, and staff on that ward told us they thought it had been a positive improvement to help maintain confidentiality of records.