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LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting

LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting

LO2 Explore the internal and external recording requirements in a care setting


Assignment Brief and Guidance


Purpose of this assignment:

The purpose of the assignment is to assess the learner firstly in relation to both the legal and regulatory aspects of reporting and record keeping in a care setting through producing an internal evaluative review of record keeping in their own care setting. Secondly, the learner will be assessed on the internal and external recording requirements in a care setting. Thirdly, the learner will be assessed on Review the use of technology in reporting and recording service user care in a care setting and fourthly the learner will demonstrate how to keep and maintain records in own care setting in line with national and local policies.



Breakdown of assignment:

Assignment:

You need to produce one written piece of work of 2,500 words (+/- 10%) covering all the assessment criterion in LO1-LO4 as one document.

Unit Learning Outcomes

LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting
LO2 Explore the internal and external recording requirements in a care setting
Assignment Brief and Guidance


Scenario:

You are a manager in a local authority setting providing residential and non-residential care services to individuals with specific needs. There have been several recent articles in the news regarding the ‘unnecessary’ death of a patient in a local hospital. The media reports that there was a catalogue of procedural errors in record-keeping in the hospital that led to the patient’s death. These included incorrect medicine dosage, missed patient observations due to inaccuracies in shift records, and an incident with the patient’s family reporting the patient’s chest pains not being recorded. In addition, the patient’s family was refused access to their health records, despite the family member requesting the records being authorised by the patient through a lasting power of attorney. Lastly, the personal details of the patient were leaked to the media by someone who journalists report worked at the local hospital.

As a result of this, and several other breaches in protocol and practice, the Secretary of State for Health has ordered the national regulator to conduct a review of the data management processes and procedures across all health and social care provision in their remit.

To facilitate this, your Director has tasked you with conducting a Self-Assessment Review of the reporting and record-keeping requirements and processes in an area of service provision in your setting, to be used in a series of training sessions to be given to all the care workers that are new to your organisation




Activity 1:
For this activity, you will produce an evaluative internal Review of the reporting and recordkeeping processes in an area of service provision in your setting. Your Review will be confidential, and evaluate how effective your work setting’s arrangements and processes for storing and sharing information are, in terms of efficacy and compliance. Your Review will put forward recommendations for how your setting can improve its processes, with reference to the consequences of ineffective systems for service user safety, the setting’s effectiveness and credibility and with reference to the media.


LO2 Explore the internal and external recording requirements in a care setting

Scenario

You have been asked by your Manager to produce some induction material for new staff. They are concerned with introducing new staff to material related to Compliance in Health and Social Care settings. The theme that they want you to focus on is relevant legislation and protocols to refer to as a new team member.

Activity 2

They have requested that you submit information in report format covering key legislation, guidelines and you will include an evaluation of the consequences of non-compliance with legal and regulatory aspects of reporting and record keeping in the setting. protocols that relate to Effective Reporting and Record Keeping in Health and Social Care.




Unit Learning Outcomes
LO3 Review the use of technology in reporting and recording service user care in a care setting

Scenario
With the increasing use of technology in the workplace, an inspirational manager needs to examine the uses of technology in a healthcare setting and be able to guide their team through both the procedural use of and the ethical issues surrounding recording and reporting using technology. This assignment will provide you with the opportunity to not only demonstrate your knowledge of record-keeping and reporting in a variety of situations, but also to produce a relevant, accurate set of documents to evidence your skills.
:
As a result of your review, your Director has asked that you run one of the training sessions for new staff. The session will train new staff on the use of technology for reporting and recording service user care in your setting, providing the staff with a demonstration of how specific records are completed, processed and stored in your setting. As part of the training session, you are to provide the staff with a range of anonymised examples of the records you have kept in the
setting, explaining how you completed, processed and stored these records in line with the setting’s policy, local and national policies and guidelines.

Activity 3:
Produce a set of training materials on record-keeping for new staff. These materials will include an electronic presentation using Powerpoint or Prezi that evaluates the effectiveness of the use of technology in the setting in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality. You need to include anonymised examples of how records are completed from your own practice.


LO 4: Apply law and policy in line with regulatory and ethical requirements in a relevant practice setting.

Scenario

You have been approached by a care provider as an independent Consultant to provide a briefing to a Care Home staff team that has recently received a Poor CQC report. Part of the reason for this was that record keeping was found to be requiring improvement. The care provider wants you to submit your briefing in the form of a report and include examples of your own record keeping practice.

Activity 4
In your report, you firstly need to explain the ethical and regulatory context of record keeping in relation to Health and Social Care, giving attention to the role of the CQC and the connection between different Ethical Principles and good record keeping.


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