Policy on Record Keeping



Records Kept in the Home

Policy Statement

Westminster Homecare believes in the following:

1. Records required for the protection of service users and for the effective and efficient running of the Company are maintained, are up to date and are accurate.

2. Service users have access to their records and information about them held by the Company, as well as opportunities to help maintain their personal records.

3. Individual records and Company records are kept in a secure fashion, are up to date and in good order; and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements.

The home adheres fully to Standard 16 – Records kept in the home and Standard 24 – Record Keeping of the National Minimum Standards for Domiciliary Care.

Aim of the Policy

This policy is intended to set out the values, principles and policies underpinning Westminster Homecare’s approach to records kept in the home.

Records kept in the Home

Westminster Homecare believes that maintaining a record of key events and activities in the service user’s home safeguards the best interests and rights of the service user. At the beginning of a service contract, the service user should receive a file containing their personal profile, assessments and care plan.

• Care workers should record on records kept in the home of service users, the time and date of every visit to the home, the service provided and any significant occurrence.

• Any assistance with medication should be recorded on the ‘Assistance with Medication’ Chart, including the time and dosage.

• Financial Assistance should be recorded on the appropriate chart.

• Details of any changes in the service user’s condition, circumstances, health or care needs should be recorded on the daily record.

• Changes in care plans should be recorded in the file.

• Accidents involving the service user or care worker, no matter how minor, should be recorded on an accident form located in the client’s file.

• Care workers should record any other information that would assist the next health or social care worker to ensure consistency in the provision of care.

Procedures

Staff should do the following:

1. Records kept in the home are kept in a safe place as agreed with the service user.

2. Ensure that all files or written information of a confidential nature are not left out where they can be read by visitors to the client’s home.

3. Wherever practical or reasonable fill in all care records and notes in the presence of and with the co-operation of the service user concerned.

4. Ensure that all care records and notes including care plans are signed and dated.

5. All entries into the file should be legible and factual.

6. Always use the passwords provided to access the computer system and not abuse them by passing them on to people who should not have them.

7. Records are kept in the home for a minimum of three months after which they are transferred to Westminster Homecare for safekeeping.

8. Any service user refusing to have records kept in their home are requested to sign and date a statement confirming the refusal. This is kept on the service user file at the branch office.

Training

All new staff should be encouraged to read the policies on data protection and on confidentiality as part of their induction process. Existing staff will be offered training to National Training Organisation standards covering the basic information about confidentiality, data protection and access to records. Training in the correct method of entering information in service user’s records should be given to all care staff. The nominated data controller/registered manager should be trained appropriately in the Data Protection Act 1998.

Signed: ________________________________________________________

Date: ________________________________________________________

Policy review date: ________________________________________________________

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