This organisation believes that all records required for the protection of service users, and the effective and efficient running of the organisation, should be maintained accurately and 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 should be kept confidentially and securely. The organisation also adheres fully to data protection legislation.

This policy is intended to set out the values, principles and policies underpinning this organisation’s approach to record-keeping, data protection and access to records.

With the service user’s consent, care or support workers should write in the records kept in the homes of service users the time and date of every visit to the home, the service provided and any significant occurrences.

Where appropriate, records should include:

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 the effective and efficient running of the organisation should be maintained in an up-to-date and accurate fashion by all staff.

Service users have access to their records and information about them held by the organisation; they should also be given opportunities to help maintain their records.

Individual records and organisation records should be kept securely; should be up to date and in good order; and should be constructed, maintained and used following data protection legislation and other statutory requirements.
Records should be kept in the home for either 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 company and kept in a locked cupboard for safekeeping.

In this organisation staff should:

The organisation believes that access to information, alongside the security and privacy of data, is an absolute right of every service user and those service users are entitled to see a copy of all personal information held about them and to correct any error or omission therein.

Access to Records and Files
Adult Safeguarding
Care and Support Planning
Confidentiality
Cyber Security
Data Protection Legislative Framework (GDPR)
Record Keeping

ICO Guide to the GDPR:
https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/

NHS Record Management Code of Practice:
https://digital.nhs.uk/data-and-information/looking-after-information/data-security-and-information-governance/codes-of-practice-for-handling-information-in-health-and-care/records-management-code-of-practice-for-health-and-social-care-2016

All staff, during induction, are made aware of the organisation’s policies and procedures, all of which are used for training updates. All policies and procedures are reviewed and amended where necessary, and staff are made aware of any changes. Observations are undertaken to check skills and competencies. Various methods of training are used, including one to one, online, workbook, group meetings, and individual supervisions. External courses are sourced as required.

Date Reviewed: May 2021
Person responsible for updating this policy: Carly Fortune
Next Review Date: May 2022