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Inspection report

Date of Inspection: 14 September 2010 and 11 July 2011
Date of Publication: 3 February 2011
Inspection Report published 3 February 2011 PDF | 320.95 KB

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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 reviewed all the information we hold about this provider, carried out a visit on 14/09/2010, 11/07/2011, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

Overall, we found that the Churchill Hospital was meeting this essential standard.

User experience

Staff at the trust outlined that while various companies have submitted tenders, the trust are still using a paper based system for patient records at the trust rather than an electronic system. Staff felt that an electronic system would make everyone’s job easier and they wouldn’t need to spend so much time ‘chasing paper’. Staff also commented that it would also allow more effective patient tracking both within and between hospitals.

The trust has statistically scored ‘similar to expected’ for aspects of the Department of Health’s information governance toolkit. The toolkit is an online system which allows NHS organisations to assess themselves against information governance policies and standards. The trust has a senior member of the trust board who takes ownership of the trust’s information risk policy. Other measures include whether the trust ensures that Registration Authority equipment (hardware and software) and consumables meet current specifications and are adequately maintained and securely stored. The trust scored ‘similar to expected’ against these measures. Overall, the trust has assessed itself as level three on the health records section of the Department of Health information governance toolkit (the highest rating being three). The trust has, however, identified in clinical governance meeting minutes, that staff attendance at information governance training requires improvement.

There are a number of areas where data held by the Care Quality Commission from various other sources indicates areas for improvement. Evidence from the Audit Commission’s data assurance framework show that the proportion of primary and secondary diagnosis and procedures recorded incorrectly was ‘tending towards worse than expected’. This indicates that there may be problems with coding issues and record keeping. However, following the last data assurance report from the Audit Commission, the trust has taken action and organised a repeat coding audit to be undertaken by the Audit Committee. This demonstrated a significant improvement.

Other evidence

Unspecified