I had cause this week to review the Bettal Quality Consultancy policy on records, as part of our updating service to our customers. As is my normal approach I started by carrying out research on the net to see what information is out there on the types of records that should be kept by managers of social care services and how long they should retain them.
Normally, some of my main ports of call are CQC, NICE, NHS, HSE and U-Gov among others. But to my consternation I was unable to find a definitive answer to these questions and thereby lies the dilemma faced by registered managers.
CQC and the regulatory position on records
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 states providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity.
Note, the Regulation is hardly specific. Defining records that come under the overall management of the regulated activity could be a nightmare. In terms of what to leave in and what to leave out. In addition, the regulation says nothing about how long a service should retain records before there destruction.
The problem here is the CQC do not definitely describe what a social care record is and does not include the important records relating to the management of the activity as required by Regulation 17.
What is a social care record?
There is some confusion about what constitutes a social care record but the following would be included:
Relevant contact details;
Means of identification, including a photograph;
Dates of entry and departure, eg when transferring to hospital, another care home or another domiciliary care service, or date and time of death with information about cause of death;
Healthcare provision;
Medication;
Accident and incident records;
Risk assessments;
Records of any restraints and restrictions imposed on a person with or without his or her consent;
Records of consent;
Terms and conditions of residency;
Assessment of needs;
Service User Care Plans.
Records relating to the overall management of the regulated activity
Deciding which records to keep in relation to the management of the regulated activity is much more problematical for the registered manager.
A retention of records schedule would include the following:
Maintenance of the premises
Maintenance of equipment
Electrical testing
Water safety
Fire safety
Medical gas safety, storage and transport
COSH Assessment Records
This is not an exhaustive list but the problem for the registered manager here is what do I include, and how long do I keep the record. Each of these activities may have retention periods embedded in legislation relating to the specific activity.
Importance of records in keeping on the right side of the law
I am sure that registered managers do not need reminding of the importance of having good tracible records available for regulators to inspect, but also as a means of avoiding any litigation or responding to complaints that may be faced by a social care service.
Summary
The research for this blog has shown there exists confusion and a lack of clarity in what is expected of registered managers in relation to records that they should keep and how long they should keep them. One of the esential values of inspection is transparency, and regulators should be charged to make clear their expectations of registered managers in relation to records. My research has found that we have still some way to go in this regard, and in the meantime, registered managers will continue to struggle with their dilemma.
Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy