Essential standards Of quality and safety
What providers should do to comply with the sections of
170 Care Quality Commission: Guidance about compliance Essential standards of quality and safety March 2010
What do the regulations say?
20.—(1) The registered person must ensure that service users are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them by means of the maintenance of—
(a) an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care and treatment provided to each service user; and (b) such other records as are appropriate in relation to—
(i) persons employed for the purposes of carrying on the regulated activity, and (ii) the management of the regulated activity.
(2) The registered person must ensure that the records referred to inparagraph (1) (which may be in paper or electronic form) are—
(a) kept securely and can be located promptly when required; (b) retained for an appropriate period of time; and
(c) securely destroyed when it is appropriate to do so.
Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010
➜ What should people who use services experience?
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.
Prompts for all providers to consider
Manage risk through effective procedures about records
21A People who use services can be confident that their personal records for their care, treatment and support are properly managed because: ●● The service has clear procedures that are followed in practice, monitored and reviewed, to ensure personalised records and medical records are kept and maintained for each person who uses the service. ●● Records about the care, treatment and support of people who use services are updated as soon as practical. ●● Verbal communications about care, treatment and support are documented within personal records as soon as is practical. ●● Records about care, treatment and support are clear, factual and accurate and maintain the dignity and confidentiality of the people who use services. ●● Records are securely stored and transferred internally between departments and externally to other organisations, when required. ●● Protocols exist with other organisations for secure information sharing. ●● Records about people who use services are used to plan appropriate care, treatment and support to ensure their rights and best interests are protected and their needs are met. ●● The record of the current interaction is linked with any previous records that exist for that person, whenever the service is able to reliably identify the person. ●● They, or others acting on their behalf, and relevant staff, are aware of and can access, and where appropriate, contribute to the record. ●● They are assured that safe and secure records management arrangements will continue to be in place for the legally required period should the registered provider close operations. ●● Where a request for access to a record is made, all legislation and guidance in respect of Freedom of Information Act 2000...
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