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Records Kept in the Homes of People Who Use Care at Home Services (Scotland) Policy

Policy Statement

This policy sets out the values, principles and policies underpinning this domiciliary care provider’s approach to record keeping, data protection and access to records, which are kept in the home of the person who uses care at home.

It is written in line with the national health and social care standards set out in My Support, My Life, particularly statements made under Standard 4: “I have confidence in the organisation providing my care and support”.

The policy should also be read and used in relation to other policies on record keeping, data protection and confidentiality of information.

{{org_field_name}} considers that all records required for the protection of people and for the effective and efficient running of the service should be maintained accurately and should be up to date, that people should have access to their records and information about them and that all individual records and agency records are kept in a confidential and secure fashion.

Record Keeping Policy

1. With the person who uses the service’s consent, care or support workers should record, in records kept in the person’s home, the time and date of every visit of to the home, the service provided and any significant occurrence.
2. Where appropriate, records should include:
   a. assistance with medication — including time and dosage
   b. financial transactions undertaken on behalf of the person receiving care
   c. details of any changes in the person’s or carer’s circumstances, health, physical condition or care needs
   d. any accident, however minor, to the individual and/or care or support worker
   e. any other untoward incidents
   f. any other information that would assist the next health or social care worker to ensure consistency in the provision of care.
3. All records required for the protection of people who use the services, and for the effective and efficient running of {{org_field_name}} should be maintained in an up-to-date and accurate fashion by all staff.
4. People should have access to their records and information about them held by {{org_field_name}}; they should also be given opportunities to help maintain their personal records.
5. 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.
6. 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 person receiving care, to the provider agency or other suitable body (eg local authority or health trust, or other purchaser of the service), for safe keeping.

In {{org_field_name}}, staff should:

1. wherever practical or reasonable, fill in all care records and notes on the person who uses the service in the presence of and with the co-operation of the individual concerned
2. ensure that all care records and notes, including plans for people who use the services, are signed and dated
3. ensure that all files or written information of a confidential nature are stored in a secure manner wherever possible.

Access to Records Policy

{{org_field_name}} considers that access to information and security and privacy of data is a right of every person, and everyone is entitled to see a copy of all personal information held about them and to correct any error or omission in it. {{org_field_name}} has a separate policy which describes the procedures involved. (See Access to Social Care Records — People Using the Service Policy.)

Training

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

All staff receive up-to-date training on data protection principles, access to records procedures, confidentiality and good practice in entering information on individual’s records.

All staff who use {{org_field_name}}’s computers receive training to develop the required skills.

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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: this policy is reviewed annually (every 12 months). When needed, this policy is also updated in response to changes in legislation, regulation, best practices, or organisational changes.

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