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Records and Record Keeping — People in Care Homes (England) Policy

Policy Statement

This policy sets out the values, principles and procedures underpinning this care service’s approach to the keeping of people’s records, the handling of their information, recording practices and access to records.

There are separate policies on general information governance, including for staff records, data protection and data security that comply with the Data Protection Act 2018 and the General Data Protection Regulation (GDPR).

Every care service is required to have systems and methods for keeping records that comply with Regulation 17: Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation states that the registered person must:

• Records required for the protection of people using services and for the effective and efficient running of {{org_field_name}} are maintained, are up to date and are accurate.
• People using services:
a) are involved wherever possible in the recording of their care and support
b) have access to their records and information about them held by {{org_field_name}}
c) have opportunities to help maintain their personal records.
• People’s records and other records that contain private, confidential personal data are kept securely, are up to date and in good order, and are constructed, maintained and used in line with data protection requirements.

Record Keeping Procedures

Care home staff must do the following.

1. Ensure that all files or written information of a confidential nature are stored securely in a locked filing cabinet or are kept in a safe place in a person’s room where practical.
2. Care records should only be accessed by people who have a need and a right to them.
3. Be aware that the relatives of a person receiving care do not have any automatic right of access to that person’s files and need to have their specific permission to see any information on that person.
4. If the person lacks the mental capacity to give their permission, a “best interests” procedure would then need to be followed in line with the Mental Capacity Act 2005. (See also related record-keeping policies.)
5. Ensure that all files or written information of a confidential nature are not left where they can be read by unauthorised people.
6. Wherever practical or reasonable, fill in all care records and people receiving care’s notes in the presence of and with the co-operation of the person concerned.
7. Ensure that all care records and people receiving care’s notes, including care plans, are signed and dated.
8. Check regularly on the accuracy of data being entered into computers.
9. Always use the passwords provided to access the computer system or devices and not abuse them by passing them on to people who should not have them.
10. Use screen locking to ensure that personal data is not left on screen when not in use.
11. Personal data relating to individuals or staff should not be kept or transported on laptops, USB sticks or similar devices, unless authorised by {{org_field_name}} manager. Where personal data is recorded on any such device, it should be protected by:
    a. ensuring that data is recorded on such devices only where absolutely necessary
    b. using an encrypted system — a folder should be created to store the files that need extra protection and all files created or moved to this folder should be automatically encrypted
    c. ensuring that laptops or USB drives are not left lying around where they can be stolen.

Procedures for Borrowing and Transfer of Files and Records

Staff will always check:

• that only authorised people have access to and use files
• the security of files
• the files’ whereabouts at all times.

The following information is recorded and regularly monitored.

• Name of person borrowing and in possession of the file.
• Signature of borrower.
• Purpose in removing the file.
• Name or signature of person authorising removal of file.
• Date and time of removal.
• Date and time of replacement in the cabinet.
• Signature of person returning the file.

Retention of Records

All records are kept in line with the requirements of the current legislation and guidance. Personal records of people receiving care that have been kept independently by the service are always kept for a minimum of three years from the date of the last entry after they leave the service or after their death.

Access to the records during the retention period for people who have died will follow the Applications for Access to a Deceased Person’s Care Records policy.

Related Policies

The policy should be read and used in relation to policies on:

• Applications for Access to a Deceased Person’s Care Records Policy
• Confidentiality of People Receiving Care’s Information (England) Policy
• Information Governance under the General Data Protection Regulation (England) Policy
• Data Protection and Compliance with the General Data Protection Regulation Policy
• Access to Records — People Receiving Care (England) Policy.

Training

All new staff receive training on {{org_field_name}}’s approach to record keeping as part of their induction and Care Certificate training.

All staff receive up-to-date training on data protection principles, access to records procedures, confidentiality and good practice in entering information on records of people receiving care.

The nominated data controller and staff responsible for data protection and information governance receive appropriate specialised training to equip them for their respective roles and responsibilities.

All staff who use {{org_field_name}}’s computers receive training to develop the required skills and to know how to keep electronic data safe and secure.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

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