Devon County Council, Adult and Community Services
Recording Policy

Agreed by SMG 14^th June 2006
Subject to finalising details of Implementation and Monitoring Plan

Policy Lead Officer – Paul Grimsey - Policy Manager - DCC  ACS,  Strategic Planning and Commissioning

Part One – Scope Context and Policy Statement

“Information is a fundamental and crucial element in the delivery of quality social care services … information drives services and sometimes actually is the service” (Department of Health 2001)

Scope

This policy applies to all Devon County Council (DCC) Adult and Community Services (ACS) Social Care Staff and Managers and those contributing to ACS Social Care Record on behalf of ACS.  It covers all information held, whether manual or electronic, about the users of our services and their carers.  It applies to records held by organisations and individuals acting for or on behalf of ACS.

National and Local Policy and Legal Context

Data Protection Act 1998
www.opsi.gov.uk/acts/acts1998/19980029.htm

Recording With Care – SSI National Inspection Report 1997  
www.csci.org.uk

Social Services Recording Inspection Standards  - SSI 1977  
www.csci.org.uk

Record Management and Retention Policy – Devon Social Services 2005
www.devon.gov.uk/index/socialcare/social_services/policies-procedures-guidance/organisational-processes/record-handling,-management-and-retention.htm

Single Assessment Process Policy
www.devon.gov.uk/index/socialcare/social_services/assessment-and-eligibility/sap.htm

Child Protection Procedures
www.devon.gov.uk/index/socialcare/children-and-families/child-protection/child- protection-procedures.htm

Adult Protection Procedures
www.devon.gov.uk/adult-protection

Management Information Procedures
http://www4.devon.gov.uk/private/socserve/miu

Electronic Social Care Record Procedures
http://www4.devon.gov.uk/private/socserve/escr

Any other DCC specialist guidance relating to social care recording  

N.B. This policy must be implemented in a way that is consistent with Devon County Council’s Equalities Policy.

www.devon.gov.uk/index/socialcare/social_services/policies-procedures-guidance/equalities-inclusion-partner/equalities-policy.htm

Policy Statement

Good quality recording will;

• Reinforce and provide evidence of good practice, equal opportunities and social inclusion
• Ensure that DCC remains accountable to service users, National Government and the local community, for the way in which it provides social care services.
• Reflect and reinforce DCC’s Policies Procedures and Guidance in relation to social care
• Evidence compliance with relevant social care legislation
• Enable us to communicate with service users, carers

Enable us to communicate with sanctioned Organisations can be sanctioned by law or by service users and carers, through consent being given, for personal information to be shared with them. organisations involved in promoting the welfare of service users and carers.Enable electronic information management systems to be used by staff and Managers to improve work management.

PART 2 – Protocols Guidance and Guidelines

Practice Requirements

Staff and Managers will ensure that:

• Decisions and plans, and the reasons for them, are recorded clearly
• Records are made accessible to the service users concerned and their carers where applicable.
• Information is only shared with appropriate consent and used for the purpose for which it has been given
• Information recorded complies with Minimum Data Set Requirements
• All sources of information are identified
• Concise description analysis and professional judgment is included as appropriate.
• There is a clear distinction between fact and opinion.
• There must be a clear indication where information has come from a third party.
• Records are kept up to date and accurate.
• The timeliness of inputting information onto Electronic Social Care Record is consistent with standards to be included in the Minimum Data Set Requirements.
• All recording should include the name of the person making the record and the date the record was made.
• Records should be kept no longer than necessary in accordance with the Record Management and Retention Policy

Front Line Managers will ensure that staff comply with the above requirements through;

• Monitoring management reports
• Monitoring case recording and to addressing any performance issues in supervision.
• Operating quality systems designed to provide management information on the implantation of this policy.

Senior Managers will ensure that;

1. Core Information requirements are identified throughout the care planning process.
2. Effective quality management systems are in place, as part of overall Management Information and Quality Strategies, to provide management information on the quality and accuracy of information recording.
3. Quality systems are used to monitor compliance with the policy
4. The effectiveness of these quality systems are periodically reviewed
5. Recording, and information management using electronic information recording and management systems, is part of all job descriptions unless it is clear that this will not be a requirement of the job.

PART 3  Implementation Plan

This Policy will be published on ACS’s Policy Procedures and Guidance web pages.  

It will be publicised through Stella and an email to all staff.

It will be implemented through the implementation of ACS’s Practice Quality Audit Process and the Electronic Data Quality Assurance Process including the Core Data Set. - details to be provided when available; contact Management Information and Quality Team for details.

PART 4 Monitoring

This policy will be monitored through ACS’s Practice Quality Audit Process and the Electronic Data Quality Assurance Process including the Core Data Set.