Health & Social NVQ Level 2 Diploma Unit 9 Unit code: HSC 028 Technical Certificate Unit 9 Unit code: Y/602/3118 Unit Information Handle Information in Health and Social Care Setting & Understand how to Handle Information in Social Care Settings Vision Training North East 12 Yarm Road, Stockton-on-Tees,TS18 3NA T 01642 673255 W: visiontrainingnortheast.com 1 P age
Introduction About this qualification Level 2 This unit is aimed at those who work in health and social care settings. It provides the learner with the knowledge and skills required for good practice in recording, storing and sharing information. This unit has 3 learning outcomes 1 Understand the need for secure handling of information in health and social care settings 2 Know how to access support for handling information 3 Be able to handle information in accordance with agreed ways of working. About this workbook This book is split into two sections; the information about the learning outcomes which make up this particular unit, followed by a section of questions and opportunities for reflection and case studies that relate to that information. You will decide with your assessor how you want to prove your competency for this unit, you can use this work book, provide witness testimonies, have a professional discussion with your assessor. Table of Contents About this qualification... 2 Legislation... 3 Data Protection Act... 3 Freedom of Information Act... 3 Health & Social Care Act 2008 - Essential standards... 4 Safeguarding of vulnerable people... 4 General Social Care Council (G.S.C.C.) Code of Practice... 5 Security and support... 5 Training & Supervision... 6 Completing records... 6 Good practice guidance in confidentiality... 7 2 P age
Legislation Legislation about records includes: Data Protection Act 1998 Freedom of Information Act 2000 Health & Social Care Act 2008 - Essential standards Safeguarding Vulnerable People Data Protection Act The Data Protection Act 1998 came into force in March 2001, replacing the Data Protection Act 1984. It states that data must be: fairly and lawfully obtained used for the purpose for which it was obtained adequate, relevant and not excessive accurate kept no longer than is necessary processed in accordance with the data subject s rights kept secure not transferred to countries without adequate protection. Peoples rights under the act: To know what information about them is held To see and correct their information To refuse to provide information To confirm data is up to date To confirm data is correct Maintain confidentiality Data is not kept longer than required A Caldicott guardian is a senior person who is responsible for protecting the confidentiality of a person s information and enabling appropriate information sharing. This is normally a senior person within the organisation. Freedom of Information Act Is the right to request information held by public authorities, known as the right to know, information must be disclosed unless it is deemed to be against public interest The Act and the Environmental Information Regulations (EIR) allow you to access recorded information (such as e-mails, meeting minutes, research or reports) held by public authorities in England, Northern Ireland and Wales. Under the Act, a public authority includes: Central government and government departments Local authorities Hospitals, doctors surgeries, dentists, pharmacists and opticians 3 P age
State schools, colleges and universities Police forces and prison services The role of the Information Commissioner s Office (ICO) is to enforce and promote the Act and the EIR. It has responsibility for ensuring that information is disclosed promptly and that exemptions from disclosure are applied lawfully. Health & Social Care Act 2008 - Essential standards Regulation 20 Outcome 21 covers records People who use services can be confident that: Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential. Other records required to be kept to protect their safety and wellbeing are maintained and held securely where required. This is because providers who comply with the regulations will: Keep accurate personalised care, treatment and support records secure and confidential for each person who uses the service. Keep those records for the correct amount of time. Keep any other records the Care Quality Commission asks them to in relation to the management of the regulated activity. Store records in a secure, accessible way that allows them to be located quickly. Securely destroy records taking into account any relevant retention schedules. Safeguarding of vulnerable people Safeguarding and promoting the welfare of vulnerable adults requires information to be brought together from a number of sources and careful professional judgements to be made on the basis of this information. To this purpose records should be clear, accessible and comprehensive, with judgements made and decisions and interventions carefully recorded. Front-line staff that regularly come into contact with vulnerable adults must ensure that they record full information about the adult at the first point of contact. This information must be kept up to date. Records should also be accurate not only in fact, but also should indicate whether they are opinion, judgement and hypothesis. It is good practice to write in black ink, records should be dated, timed and signed, with the person s name legibly written at the end of the record entry. As records are an essential source of evidence for investigations and inquiries, and may also be required to be disclosed in court proceedings, it is essential that records are stored safely and can be retrieved promptly and efficiently. 4 P age
General Social Care Council (G.S.C.C.) Code of Practice Records - Item 6 of the code of practice for Health and Social Care Workers states: As a social care worker, you must be accountable for the quality of your work and take responsibility for maintaining and improving your knowledge and skills. This includes: 6.2 Maintaining clear and accurate records as required by procedures established for your work; Confidentiality - Item 2 of the code of practice for Health and Social Care Workers states: As a social care worker, you must strive to establish and maintain the trust and confidence of service users and carers. This includes: 2.3 Respecting confidential information and clearly explaining agency policies about confidentiality to service users and carers; Security and support It is essential in care to maintain secure records this is to ensure we Maintain confidentiality Maintain the rights of individuals Promote trust Help prevent identity theft Maintain professionalism Prevent embarrassment Ensure information is accessible for those who need to know Meet legal requirements (see law section) Be also aware of The need to keep both paper and electronic records secure. Accuracy, retention, availability and disposal of information issues Access to secure information; Sharing information eg freedom of information Principles of confidentiality Sources of support with regards to records may include: Manager care professionals procedures Codes of practice colleagues policies Information Commissioners Office government organisations such as: www.dh.gov.uk www.directgov.co.uk It is important to share any concerns you have about data protection with an appropriate person. If you have any concerns at all you should access support and advice this could be via: Your manager A colleague A trade union representative A regulator Reading relevant policies and procedures 5 P age
Be aware of workplace policies and procedures for: recording information storing information sharing information. Check policies and procedures are up to date. Reporting and recording your concerns. Training & Supervision You should receive training on recording and reporting, this can either be in the form of a course, in-house induction training, in-formal training during buddying. Your employer should also ensure that your recording techniques are monitored during your supervisions and should be checked when client records are audited by senior members of the team. Be aware your company may have agreed ways of working in their policies and procedures that you should be following in regards to the recording, storing and destroying of information. If concerns are raised about your recording and reporting you should always be offered further training, if you are not - ASK. Completing records As discussed in the Law section is essential that records are kept up to date, you can ensure that you keep your records up to date by updating them after any care, support or treatment you supply and if any incidents occur, eg accidents, safeguarding issues or if an individual won t consent to you supporting them as per the plan of care. You will regularly complete records in your practice these may include: Care or Support plans Medication charts Assessment tools Investigative chart Sign-in book Accident and incident book Basic information sheet Time sheets Safeguarding reports We complete records for a variety of reasons they can include Accountability who did what, why, where and when Continuity keep other people involved in the care informed and up to date Review to assist in reviews of service and to record reviews Assess risk completing risk assessments Monitor monitor service provision & employees Share information with colleagues, managers and other professionals 6 P age
Before you complete records you should always consider: What is this record for? Is it relevant? Is the information factually accurate? Does it include the person s wishes and strengths? Is it already held elsewhere? Will the information be used to plan better services? Is it suitable for people who read it? Can you use information from other sources? Remember records should be accurate factual not opinion based legible clear and written in black ink complete, containing all important information. Eg For a medication call in domiciliary care, do not just write prompted meds or meds taken Instead a more accurate, complete report might be Administered lunch time medication as per the MARs sheet, waited with Mrs Q until she stated that all her medication had been taken, placed blister pack back into the safe once medication administration was complete Problems related to record keeping Remember Confidentiality: Information should only be given to people on a need to know basis. If they do not need to know, do not tell them! In domiciliary care encourage the individual you support to allow you to store their files safely and securely Good practice guidance in confidentiality Electronic records should have an appropriate password that should not be shared. People should not be discussed outside of the workplace. Workers should not talk among themselves in communal areas about people. 7 P age
People need to know that records and reports are kept, and who has access to this information. The process of sharing reports should be secure. Personal information should not be left unattended on a computer screen; always log out. Information on people should only be passed to other agencies on a need-to-know basis. Confidential information should be marked as such and kept in secure places eg locked cabinets, locked drawers, locked rooms. Daily records should be concise and factual, and shared only with people who need to know. 8 P age