Your Care Record Guidance: Purpose, Scope and Procedure

1.1  The Care Record aims to:

 

1.2  Sharing of information is at the discretion of the assessed person who will allow access to their Care Record.

 

2.1  This guidance applies to all clinical and social care staff involved with the care of adults who are assessed using the Single Assessment Process (SAP).

 

2.2  This guidance should be used alongside the existing relevant policies and procedures (e.g. record keeping, consent, Mental Capacity Act implementation) of each partner organisation, and subsequent local guidance relating to the Care Record.

 

3.1.1  Every adult over the age of 18 years who is assessed using the Single Assessment Process (SAP) and who receives community support must be offered a folder.

 

3.1.2  The Care Record is not required for people going into, or already in, a permanent placement in a care home.

 

3.1.3  The folder will be issued at the first face-to-face assessment that takes place after the contact assessment has been completed, or at the point of review.

 

3.1.4  The SAP Coordinator or other practitioner who undertakes the face-to-face assessment or review will issue the folder, explain its purpose, and record that the folder has been issued. Further guidance on the role of the SAP Coordinator is attached as Appendix 1.

 

3.1.5  The folder will be issued when the assessed person consents to some level of information sharing between different professional groups or organisations that are party to the SAP Information Sharing Protocol, and their agreement is documented on the contact assessment form at the first face-to-face assessment opportunity.

 

3.1.6  The practitioner who undertakes the initial assessment will generally issue the folder. The initial or subsequent practitioners should ensure that consent to share information is discussed, and documented.

 

3.1.7  The assessed person is entitled to decline a folder. If the assessed person declines a folder, this must be recorded (7.2.1.j).

 

3.1.8  Where it appears that the assessed person may lack mental capacity, the SAP Coordinator or other practitioner should follow the Code of practice for the Mental Capacity Act to make a decision on the capacity of the person. If the practitioner decides that the person does lack capacity, a folder should not be issued unless it’s determined to be in the best interests of the assessed person to have one.

 

3.1.9  If the person has existing personal care records or information booklets e.g. people with a learning disability, acquired brain injury, independent living funds or direct payments, consideration should be made as to whether the addition of another folder is appropriate.

 

3.1.10  Where the assessed person is part of the self directed support approach, they may find the Care Record a useful addition to their support plan.

 

3.2.1  While a practitioner holds the role of SAP Coordinator, that person would be assumed to be the person primarily responsible for assisting with the maintenance of the folder.

 

3.2.2  All practitioners involved in the person’s care should take responsibility for inserting and updating information into the folder.

 

3.2.3  When documentation is completed, the practitioner may give or send the assessed person a copy to keep in their folder. Documents posted to the assessed person can be sent by Royal Mail, marked ‘private and confidential - for the addressee only’. A record should be made from the office sending the document detailing that this has been sent.

 

3.2.4  When any practitioners access the folder they should carefully check the current accuracy of the information. Any inaccurate information should be amended on the document contained in the folder and a note made in the Record of visits to alert other practitioners to the change in detail.

 

3.2.5  In any future episode of care, the folder should be updated with new, or clearly amended, documentation.

 

3.3.1  When delivery of all care or treatment ceases, the folder remains the property of the assessed person with the exception of some professional records (see 5.2).

 

3.3.2  If the assessed person’s mental or physical capacity deteriorates during the episode of care, the SAP Coordinator or other practitioner should follow the guidance in 6.5 and 6.6. In the event of an assessment of lack of mental capacity the SAP Coordinator should consult any advance care plan the person has completed to determine whether they should retain the folder.

 

3.3.3  Following the death of the assessed person, any remaining contents of the folder become part of that person’s estate. This should be explained to the person when the folder is issued (see 3.1.3).

 

3.3.4  In the event of a coroner’s inquiry, the coroner may request medical information from the folder if it is relevant and necessary to the investigation, or may require a person to attend an inquest to give information from the folder. If documents are received in evidence by the coroner in connection with an inquest or post mortem examination the length of time that the records will be retained and the return of any records should be discussed with the coroner at the time of the investigation.

 

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