LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting
LO2 Explore the internal and external recording requirements in a care setting
Assignment Brief and Guidance:
Working in any health or care setting, every staff member is responsible for maintaining records and reporting outcomes to supervisors. As a supervisor or manager, you will likely also have the added responsibility of monitoring the records kept by the team for accuracy, reliability and validity. It is essential that you are confident discussing arrangements made to complete records designed for use both internally and with partner organisations or inspecting bodies, as well as the need to store and retrieve records effectively, either manually or electronically. You will also need to recognise the correct procedures when sharing and disposing of records in the setting, following legislation and guidelines.

Scenario:
You are a manager in a care home managed by your local council, looking after service users with specific care needs. There have been several recent articles in the local news regarding the ‘unnecessary’ death of a patient in a local care home. The local media reports state that there was a catalogue of procedural errors in record-keeping in the care home which led to a service user’s death. The report stated that an incorrect dosage of a prescribed medication had been given which had eventually resulted in the patient’s death, they found that accurate records hadn’t been kept and that the service users relative had highlighted a deterioration in their relatives condition but this hadn’t been acted on or documented in addition, the service users family was refused access to their health records, despite the family member requesting the records being authorised by the service user through a lasting power of attorney. The patient was named in the media following a leak on face book through a member of staff discussing concerns online.

As a result of this, and several other breaches in protocol and practice, the Secretary of State for Health has ordered the national regulator to conduct a review of the data management processes and procedures across all health and social care provision in their remit.

To facilitate this, the local council has asked you to conduct a Self-Assessment Review of the reporting and record-keeping requirements and processes in an area of service provision in your care setting, to be used in a series of training sessions to be given to all the care workers that are new to your organisation.

Activity 1:
For this activity, you will produce an evaluative internal Review of the reporting and record-keeping processes in an area of service provision in your setting. Your Review will be confidential and evaluate how effective your work setting’s arrangements and processes for storing and sharing information are, in terms of efficacy and compliance. You will include an evaluation of the consequences of non-compliance with legal and regulatory aspects of reporting and record keeping in the setting. Your Review will put forward recommendations for how your setting can improve its processes, with reference to the consequences of ineffective systems for service user safety, the setting’s effectiveness and credibility and with reference to the media.

Learning Outcomes and Assessment Criteria

Learning Outcome
Pass
Merit
Distinction
LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting P1 Describe the statutory requirements for reporting and record keeping in own care setting
P2 Describe the regulatory and inspecting bodies’ requirements for reporting and record keeping in a care setting M1 Analyse the implications of non-compliance with legislation, regulating and inspecting bodies’ requirements
D1 Evaluate the consequences of non-compliance with reference to the media, service user safety and the credibility of the care setting

LO2 Explore the internal and external recording requirements in a care setting P3 Describe the process of storing of records in own care setting
P4 Explain the reasons for sharing information within own setting and with external bodies
P5 Accurately illustrate the internal and external requirements for recording information in own care setting M2 Examine the current processes in own care setting related to storing and sharing records D2 Evaluate own work setting’s arrangements and processes for storing and sharing information, making recommendations for improvement