In the last of this series of articles, Chris Payne rounds up with retention requirements in relation to record keeping.
Bringing Prompt 21A of the Care Quality Commission’s (CQC) Essential Standards of Quality and Safety to a close is a long list of items together with the amount of time that they should be kept to meet legal requirements.
This list does not include retention time for care records; these are covered separately in Prompt 23C, which is for specific service types. However, there are some requirements in this list that could be easily overlooked.
For example, care managers should keep both previous and current policies and procedures for three years. This means that after a policy and procedure has changed, the original document should be kept for three years from its start date. When the current one is revised that, too, should be subject to the three-year rule, and so on.
Similarly, records that account for the treatment of service users must be kept for at least three years, including records of any restraints applied, deprivation of liberty authorisations, keeping of money and valuables, and incidents that have been notified to the CQC. Staff records must be kept for three years.
There is also a requirement to keep risk assessments only until replaced by new ones. The guidance does not state what kinds of risk assessment it is referring to, but there is a good case for keeping service users’ risk assessments as part of their main records so that they can be used to review, over time, the progress being made with any risk assessment and management plans.
Records relating to health and safety issues — electrical testing, fire safety, water safety, maintenance of equipment and premises — are all subject to three-year requirements.
Staff rotas must be kept for four years after the year to which they relate, eg the one for year ending 2013 will need to be kept to the end of 2017. Records relating to the purchasing of medical equipment and devices should be kept for 11 years, though this requirement will apply mainly to health services and care homes that provide nursing. Care services’ annual accounts should be kept for 30 years. It will be useful for care service managers to draw up a retention and disposal schedule under headings of document type, start date, and minimum disposal date, with space for guidance notes.
Most record keeping in care services today takes place through a combination of manual and electronic methods. Whether electronic or manual, all record keeping must follow common rules to be legally compliant.
Electronic recording, which is promoted as being efficient and environmentally friendly, is on the increase, and comprehensive systems are available for care services that seek to become completely paperless. However, electronic methods must address the same issues as manual recording in relation to use, access and security, and require contingency measures for whenever the system goes wrong. Electronic recording, like manual recording, must also be seen as human activity, not the product of a machine.
The aim of a care service should be to develop person-centred care, which means that recording of the care must be equally person-centred, and carried out with the involvement of the person. This should be a key consideration in choosing a method for care recording.
The record-keeping system of any care service should be well planned, managed and organised, and kept under review as a whole.
Policies contributing to the maintenance of the system (all included in the Record Keeping topic, which should be used for further information), include:
Applications for Access to a Deceased Service User’s Care Records
CQC Outcome 21: Records
Service Users’ Access to Records.
Last reviewed 18 April 2014