Effective Reporting and Record-keeping in Health and Social Care - ABC Home Care Case Study - Health Essay Writing Assessment Answer

Assessment Task:

Effective Reporting and Record-keeping in Health and Social Care Health Essay Writing Assessment Answer

Learning Outcomes

There are four learning outcomes (LOs) to this unit:

1. Describe the legal and regulatory aspects of reporting and record-keeping in a care setting.
2. Explore the internal and external recording requirements in a care setting.
3. Review the use of technology in reporting and recording service user care.
4. Demonstrate how to keep and maintain records in a care setting in line with national and local policies and appropriate legislation.

Task 1
Describe the legal and regulatory aspects of reporting and record-keeping in a care setting.

Case Scenario:

As a manager in ABC care home, you had a recent visit from the CQC and they reported that your relevant reports were up to date. However, a friend who happened to be a manager in another care home have had CQC visit and where found failings in areas of record-keeping and reporting in areas such as inaccurate medical records, fire safety records not updated, incidents not reported correctly in line with RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) or not reported at all. Also, service users data not properly secured in line with the Data Protection Act 2018.
As a result of these breaches, has approached you to share some good practice with him to ensure that they were able to put their records in order to avoid closure of the care home.

Activity:

To complete task 1 effectively, your report should describe the statutory requirements for reporting and record-keeping in own care setting as well as the requirements of regulatory and inspecting bodies for reporting and recording in a care setting. In order to achieve this, you need to analyse the implications of non-compliance with legislation, regulating and inspecting bodies’ requirements in addition to evaluating the consequences of non-compliance with reference to media, service user safety and the credibility of the care setting.

Task 2

This task is composed of three sub-tasks:
•    Explore the internal and external recording requirements in a care setting.
•    Review the use of technology in reporting and recording service user care.
•    Demonstrate how to keep and maintain records in a care setting in line with national and local policies and appropriate legislation. 

To satisfy the assessment requirements of task 2, you need to base your answers on the following case scenario.

Case Scenario:

The care home where you work as an operation manager has invited an external trainer to come and train your staff on the use of latest technology in reporting and recording information with the immediate development of emerging technology so they will continue to keep up to date with current trends in the business. 
After the training, your director has asked you to provide the same training to new staff members. In the training session, you will need to show some examples of some of the records you have kept in the organisation, how you completed, processed and preserve them in line with the organisational policy as well as local and national policies and guidelines

Activity:

Based on the above scenario, you need to describe the process of storing records in own care setting and explain the reasons for sharing information within own setting and with external bodies. To support your analysis you must accurately illustrate the internal and external requirements for recording information in own care setting. You may wish to examine the current processes in own care setting related to storing and sharing records and evaluate own work setting’s arrangements and processes for storing and sharing information, making recommendations for improvement. You should also describe how technology is used in recording and reporting in own care setting and explain the benefits of involving service users in record-keeping processes. You can support your analysis by reviewing the use of digital technology in relation to own medical management procedures or care plan and by evaluating the effectiveness of the use of technology in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality. In your report, you must produce accurate, legible, concise and coherent records regarding service user care for different service users following own setting’s guidelines and explain different aspects of own management of service user records with reference to compliance with national and local policies and guidelines. To enhance the quality of your arguments and discussions you may analyse the process of maintaining records in own setting, identifying any potential or actual difficulties along with evaluating the effectiveness of own completion of the documentation in terms of meeting service user needs, ensuring appropriate care is given and effective reporting is carried out.

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