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3.2b Use this template to consider the effectiveness of the systems you have identified above.

What is/are the main reasons for having systems?

To ensure adherence to legislation and good practice, that confidential information is secure and correct records are kept.

Who is the information and data for?

The information is for staff, clients and the business.

Who owns the data and information?

The company owns the data

how do the systems in place meet legal and ethical requirements?

Confidential and personal information is secured and only accessible on a need-to-know basis.

reflect on the links to respect and privacy issues for the data and information in your systems

The online system only allows access on a need-to-know basis. Similarly, paper records are locked away and secured to ensure that only the relevant individuals can obtain access to them. This is covered by GDRP.

3.2a Reflect on your own information management system. For each piece of information stored complete the following grid.

 

InformationWho completes/stores?Who monitors?How is it stored/secured?Who has access?
Support/care plansManagers and seniorsManagers/seniorsOnline systemClient, support staff
Personal information of people who access care and supportManagers and seniorsManagers and seniorsOnline systemClient and support staff
Personal staff filesHRHRLocked filing cabinet in locked officeHR

Staff can ask to access their own files

Supervision/appraisal documentsManagers, seniors and HRManagers and seniorsLocked filing cabinet in locked officeHR, managers and seniors
Statutory information, advice, guidanceRegistered manager, managersRegistered managers, managersOnline systemAll staff
Other

3.1b Reporting and Recording Systems

Explain the difference between subjective and objective recording

Objective recording only contains the facts, whereas subjective recording also contains the individual’s own personal thoughts, feelings and views.

From your experience, identify three consequences of inaccurate or incomplete records
  1. An appointment is missed
  2. Time is spent doing something that has already been completed by someone else
  3. Medication overdose (given twice as first administration was not recorded)
Consider why and how you might share records with people who access care and support, carers and relatives

Personal information about a client should only be shared with their consent unless not doing so would result in harm or injury to themselves or others or result in the law being broken.

Information should then only be shared in a private setting and on a need-to-know basis and should also be in the client’s best interests.

What difference might this make to the format and storage of any records?

Records should be kept and archived until no longer needed.

Provide specific examples of how you might use accurate records to support positive outcomes for people who access care and support

Showing records of a clients meals and snacks to their dietitian so that they can offer the best health advice for the individual.

Informing a pharmacist of the conditions and current medications of a client  before supporting them to buy over-the-counter medication.

 

3.1a Think of a case study of someone that you have communicated with – a staff member or someone who accesses your service. Write a brief summary of the situation/circumstances and then answer the following questions.

Brief Description of situation

A member of staff called to say that she couldn’t do her shift because she had had some major personal issues that had put her in a precarious mental state.

how did you demonstrate empathy?

I told her that I was sorry to hear about her situation and expressed that I would not know what to do myself if it had happened to me. I told her not to worry about work as family is more important and I would arrange to get her shift covered.

What difference did it make to the person?

It gave her an opportunity to offload her personal issues, made her feel like she had a sympathetic ear and made her feel less guilty about taking time off work.

how did you demonstrate active listening?

She was very upset but just having someone to listen to her seemed to help a lot. I demonstrated I was listening by repeating back to her what she had said in my own words for confirmation that I had I understood.

How did that enhance effective communication?

She became less frantic and more relaxed.

2.2b KLOEs: Outline what each question might mean for your setting. Think about areas where this might apply and what evidence you may be able to provide for that. You may want to work with other members of your team or your line manager to review this plan and consider what evidence might be helpful.

 

Key lines of enquiry
AreaApplication in own settingEvidence
SafeClients are protected from avoidable harm and injury? Clients are safeguarded from abuse.   Accident book, property maintenance log, recorded smoke alarm, carbon monoxide and electrical safety tests, safeguarding policy, staff safeguarding training
EffectiveClients have a good quality of life and achieve good outcomes.      Speaking with clients, daily records, activity planner, meal planner, MAR sheets, support plans, well-trained staff
CaringClients are treated with compassion, kindness, dignity and respect.     Speaking to clients, observations, well-trained staff, policies and procedures, risk assessments, support plans  
ResponsiveClients needs are met and support is well-organised and flexible.Shifts based on client needs and wishes, client is able to go on regular holidays and other activities they wish to do, dialogue between staff and clients on their requirements, shifts can be changed when required, procedures and policies that provide support to staff for emergencies or unforeseen circumstances
Well ledGood leadership and management. A learning culture.   Staff training and personal development, organisational charts (hierarchy), regular supervision, appraisal, observations and professional discussions, honesty and transparency, company policies and procedures.
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