Records Kept in Domiciliary Care Service Users’ Homes Policy
This policy sets out the values, principles and policies underpinning Focus Care Link’s approach to record keeping, data protection and access to records, which are kept in the service user’s home.
It is written in line with:
- Regulation 9: Person-centred Care, which requires care providers to consider fully the rights, wishes and preferences of the people receiving their services
- Regulation 17: Good Governance of the Health and Social Care Act 2008 (Regulated Activities 2014), which requires care providers to have secure record-keeping systems with policies on authorised access and sharing.
The policy should also be read and used in relation to other policies on record keeping, data protection and confidentiality of information.
Focus Care Link considers that all records required for the protection of service users and for the effective and efficient running of Focus Care Link should be maintained accurately and should be up to date, that service users should have access to their records and information about them and that all individual records and organisation records are kept in a confidential and secure fashion.
Record Keeping Policy
- With the service user’s consent, care or support workers should record, in records kept in the homes of service users, the time and date of every visit of to the home, the service provided and any significant occurrence.
- Where appropriate, records should include:
- assistance with medication — including time and dosage
- financial transactions undertaken on behalf of the service user
- details of any changes in the service user’s or carer’s circumstances, health, physical condition or care needs
- any accident, however minor, to the service user and/or care or support worker
- any other untoward incidents
- any other information that would assist the next health or social care worker to ensure consistency in the provision of care.
- All records required for the protection of service users and for the effective and efficient running of Focus Care Link should be maintained in an up-to-date and accurate fashion by all staff.
- Service users should have access to their records and information about them held by Focus Care Link; they should also be given opportunities to help maintain their personal records.
- Individual records and organisation records should be kept in a secure fashion, should be up to date and in good order; and should be constructed, maintained and used to comply with data protection and other statutory requirements.
- Records should be kept in the home for one month, or until the service is concluded, after which time they should be transferred, with the permission of the service user, to the provider agency or other suitable body (e.g. local authority or health trust, or other purchaser of the service), for safe keeping.
In Focus Care Link staff should:
- wherever practical or reasonable, fill in all care records and service user notes in the presence of and with the co-operation of the service user concerned
- ensure that all care records and notes, including service users’ plans, are signed and dated
- ensure that all files or written information of a confidential nature are stored in a secure manner wherever possible.
Access to Records Policy
Focus Care Link believes that access to information and security and privacy of data is an absolute right of every service user and that service users are entitled to see a copy of all personal information held about them and to correct any error or omission in it.
All staff receive training on Focus Care Link’s approach to record keeping as part of their induction training. They are expected to achieve the following Care Certificate Standards, particularly Communication and Handling Information.
All staff receive up-to-date training on data protection principles, access to records procedures, confidentiality and good practice in entering information on service users’ records.
All staff who use Focus Care Link’s computers receive training to develop the required skills.
Management July 2021