Assignment Brief (RQF)

Higher National Certificate/Diploma in Social &

Community Work (Integrated Health & Social Care)
Class: CP1

Unit 17 Effective Reporting & Record keeping in Health and

Unit Number and Title:
Social Care Services

Academic Year: Year One

Unit Assessor: Garett Evers

Assignment Title: Compliance with Requirements

Issue Date: 21st October 2022

Submission Date: 23rd December 2022

Internal Verifier Name: David Masterson

Date: October 2022

Submission Format:

The guidance provided for this assessment sets out the submission format for this work.Your
submission will be word processed, written work with clear indication of the unit title, and your
name. The appropriate assignment cover sheet should be used.
You are expected to use external sources, and clearly reference these in your work. References
should be added to the text (next to the quote or paraphrase), and also placed at the end in a
references list, using Harvard referencing style. The recommended word count for this
assignment is 1500-2000 words, but you will not be penalised for exceeding. The work must be
submitted on the date set out on this brief. No polypockets staple only. Late work may be
penalised.

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
The management of your care organisation has embarked upon an audit to determine
how compliant they are with the legal and regulatory aspects of reporting and record
keeping, as well as how the requirements of internal and external record keeping are
being met. You have been asked to participate in this audit by compiling information
 relevant to the following areas.

With regard to reporting and record keeping, describe the legal and regulatory bodies
requirements. (eg, Legal; GDPR, Regulatory Bodies ; HSE, HIQA, Coru.). Analyse and
evaluate the potential implications and consequences of non-compliance with the
requirements, (eg ; Service user safety, Media Reporting, personal and organisational
credibility).
You are also required to examine and evaluate how information/records are stored
and shared internally and externally, and to make recommendations for
improvement. This involves describing the process of storing records and explaining
the reasons for sharing information (internally and externally). You should also
accurately illustrate the requirements for recording information (internally and
externally).

Learning Outcomes and Assessment Criteria:

Learning Outcome Pass Merit Distinction
LO1Describe the P1 Describe the M1 Analyse the D1 Evaluate the
legal and statutory implications of consequences of
regulatory aspects requirements noncompliance noncompliance
of for reporting and with with
reporting and record legislation, reference to the
record keeping in a keeping in own regulating media,
care setting care and inspecting service user safety
setting bodies’ and
P2 Describe the requirements the credibility of the
regulatory and care
inspecting setting
bodies’
requirements for
reporting and
record
keeping in a care
setting
LO2 Explore the P3 Describe the M2 Examine the D2 Evaluate own
internal and process current work
external recording of storing of processes in own setting’s
requirements in a records in care arrangements
care setting own care setting setting related to and processes for
P4 Explain the storing storing
reasons and sharing records and sharing
for sharing information,
information making
within own setting recommendations
and for improvement
 with external
bodies
P5 Accurately
illustrate
the internal and
external
requirements for
recording
information in own
care setting

Introduction
This assignment is about Effective Reporting & Record keeping in Health and Social Care
Services. In the beginning of this assignment, I will define the statutory requirements for
reporting and record keeping in own care setting. Then I will describe all the regulatory and
inspecting bodies’ requirements for reporting and record keeping in a care setting. After that I
will tell the process of storing of records in own care setting and explain the reasons for
sharing information within own setting and with external bodies. Then I will have to
Accurately illustrate the internal and external requirements for recording information in own
care setting. The in my second I will Analyse the implications of noncompliance with
legislation, regulating, inspecting bodies’ requirements and examine the current processes in
own care setting related to storing and sharing records. At the end I will Evaluate the
consequences of noncompliance with reference to the media, service user safety and the
credibility of the care setting. I will also evaluate my own work setting’s arrangements and
processes for storing and sharing information, making recommendations for improvement.

The statutory requirements for reporting and record keeping in own care
Report and keeping records are subject to a number of statutory requirements, in order to
execute record keeping and reporting in a proper manner, care setting Group must follow the
law and the statutory instructions. A number of rules exist that has been planned for the
efficient execution of operational tasks by the experts (EU). The EU has worked to secure
the preservation of this right thru legislation because it's a part of the 1950 European
Convention on Human Rights, which stipulates that "Everyone has the right to respect for his
private and family life, his home and his correspondence." The EU saw the necessity of new
protections as technology advanced and the Internet was created. The European Data
Protection Directive was thus passed in 1995, setting basic requirements for privacy and data
security. Every member country then developed its own adopting law on this directive. the
General Data Protection Regulation GDPR after being approved by the EU Parliament in
2016, then in may 25, 2018 came into effect and all enterprises had to comply. The world's
strictest security and privacy law is the General Data Protection Regulation (GDPR). Despite
being created and adopted by the European Union (EU), it sets requirements on organizations
worldwide that target or gather information about individuals living in the Europe. Those that
break the GDPR's security and privacy regulations will face severe fines that could total
hundreds of millions of dollars.
Data protection principles
The seven protection and accountability standards listed in Article 5.1-2 must be followed
when processing data:

1. Lawfulness, fairness and transparency: A legitimate legal basis must be

shown before handling personal information. You must obtain it honestly and
disclose clearly how you intend to utilize the information belonging to the
individual whose information it is.
2. Purpose Limitation: You may only use someone's personal information for
the purpose(s) you have disclosed to them.
3. Minimisation: You can only ask a person for as much personal information as
is absolutely necessary.
4. Accuracy: Any personal information you possess must be correct and, if
required, up to date.
5. Storage Limitation: You could only keep personally identifiable information
for as long as is required to fulfil the intended purpose.
6. Integrity and Confidentiality: You must maintain personal information
secure to prevent inadvertent deletion, modification, or access by unauthorized
parties.
7. Accountability: It is up to the data controller to be able to show that they have
complied with all of the General Data Protection Regulation (GDPR) guiding
principles.

Data breaches
Data breaches could cost companies, Government, individual have a long-term detrimental
impact. Some of the impacts are  financial cost, losing trust on the company or government,
loss of customer, brand damages and also the company can be dismissed.
The HSE
the Health Service Executive (HSE) is a sizable organization tasked with overseeing all of
Ireland's public health services. The HSE organizes services using a framework that is
intended to place customers and patients at the centre of the care. The HSE Code of
Governance gives a general overview of the principles, regulations, processes, and guidelines
that the HSE uses to direct, control, and handle its operations. It is meant to serve as a manual
for the Directorate, leadership team, and all other employees of the HSE as well as the
agencies it funds to ensure that they carry out their responsibilities to the highest levels of
accountability, integrity, and propriety.
The HSE has a strict record keeping policy, All the records created by HSE must be accurate
and comprehensive. They will offer proof of the action or function they were designed to
record. The Records need to be true, dependable, honest, and usable in order to be considered
evidence. Some of the HSE record covers are Service user healthcare records, Computerised
Records Scanned Records. The HSE suggest the Service user confidentiality is maintained at
all times and
The HSE always suggests when any organisation making a record keeping All Client
information is kept private at all times. All locations utilized for record keeping should be
clear of any immediate dangers, secure, shielded from fire and flooding, have constant
temperatures and humidity levels, and be kept neat and orderly. Any new information,
whether it comes from internal or external sources, is linked to the appropriate medical
record. No new information should be added to a record after it has been closed. 

The HIQA
The Health Information Quality Authority or HIQA was established under health act 2007
and it is An independent authority. In order to promote high-quality and secure care for those
accessing the health- and social-care services in Ireland, the Health Information and Quality
Authority was founded as an independent body. The scope of HIQA's mandate currently
encompasses a particular set of services provided by the private, public, and non-profit
sectors. The mission of HIQA, which reports to the Minister of Health and collaborates with
the Ministers of Children, Equality, Disability, Integration, and Youth Services, is to develop
standards, evaluate, and investigate health and social care in order to help policymakers make
well-informed choices about how to provide services.

The purpose of HIQA

The hiqa is only curious about the following information on clients:

o their safety
o having their rights upheld
o participate in choices relating to their care
o if they are getting the care that satisfies their unique social and health needs
o live a life of good quality
HIQA has a good repetition when we mention record keeping, HIQA creates guidelines and
resources and collects evidence on best practices from throughout the nation and the world in
collaboration with key major people. HIQA also consults with specialists, interested parties,
service givers, and clients.

“HIQA, as a Data Controller must meet our obligations under the Data Protection Act 2018
as outlined below:
 o obtain and process information fairly
o keep it only for one or more specified, explicit and lawful purposes
o use and disclose it only in ways compatible with these purposes
o keep it safe and secure
o keep it accurate, complete and up-to-date
o ensure that it is adequate, relevant and not excessive
o retain it for no longer than is necessary for the purpose
o provide an individual with a copy of his/her personal data on request”

CORU

The multidisciplinary Irish health regulator is called CORU, and it controls the people who
work in Ireland's health and social care systems.. Coru’s responsibility is to safeguard the
public by encouraging high standards of professional behaviour, instruction, training, and
competency through the statutory registration of health and social care professionals. The
Health and Social Care Professionals Act of 2005 led to the establishment of CORU as
amended. Social workers, physiotherapists, and speech and language therapists are among
the professions regulated by CORU. Soon, Psychologists, Psychotherapists, Social Care
Workers will be governed by it.

Anyone practicing one of the titles that CORU regulates (ex. Physiotherapists, Podiatrists,
Radiographers, Radiation Therapists, Social Workers) must register with CORU in order to
use the CORU services. This enables Coru to confirm that they comply with the necessary
educational levels, adhere to a Code of Professional Conduct and Ethics, and go through
Garda vetting.

CORU in record keeping

In Coru, every document must be entirely Complete, Readable if handwritten, Identifiable as
being prepared by you, Dated, prepared as quickly as feasible following the intervention,
Straightforward, and Fact based. Additionally, Coru has rigorous guidelines for the security
of data. Every effort is required to safeguard information against loss or damage, and it must
be secure and accessible to authorized persons only. If the business does not adhere to
requirements, it may result in Monetary Penalty Notices, Enforcement Notices, Damage to
personal professional credibility, harm to organizational believability, and audit cancellation
of the contract, Unfavourable media exposure and reaction.

Analyse and evaluate the potential implications and consequences of non-compliance with
the requirements, (eg ; Service user safety, Media Reporting, personal and organisational
credibility).
the GDPR and the other regulatory bodies has a harsh penalty when its about data keeping,
The GDPR has very steep penalties for violations. The two categories of penalty have a
combined maximum of €20 million or 4% of global revenue (whatever is higher), or The
maximum penalties for infractions in the lower tier is €10 million, or two percent of yearly
revenue, which is half as much as the maximum fine in the top tier and data users also have
the option of pursuing damages compensation and also the company may get negative media
coverage, the user safety, negative publicity, ineligible to participate in work sector. In past
Ireland had same incidents we can talk about the Sunbeam House service (“Independent
inquiry after woman choked to death in disability care home
Woman with intellectual disabilities choked on piece of toast, inquest heard”) this was in the
Irish times news Wroten by Jack Power Thursday November 10, 2022 - 05:00. This kind of
things we led to negative publicity and bad media coverage. Also the people will not put their
beloved in the same care house because of the bad publicity in brand or care place and
scaring for the safety. the government could shut down the care place if they don’t follow
with the GDPR and HSE, CORU, HIQA regulations. In that case we can see the Ashbrooke
Care Home in Enniskillen is operated by runwood Homes. The BBC headline it “Ashbrooke
Care Home closed over 'serious risk to life'.” When the inspection happened, they found
dirty facilities and a "strong odour of faeces and urine", posed a serious risk to life and they
had to shut it down.

another exmaple I will mentions is the Phoenix Park Community Nursing Units (also known
as St Mary's Hospital). The St Mary’s hostital was was inspected by HIQA (Health
Information and Quality Authority) earlier in 2022 following death of 20 service users in
2020. the Inspectors unexpectedly visited the facility and discovered that the system of record
keeping, employee development, and training did not comply with rules. Health Information
and Quality Authority found poor record keeping on the staff record or the qualification of
working in the nursing home.
“Over the course of the two-day inspection, staff training records were requested on six
occasions, but these were not supplied.”
None decision was made Early in May was when it planned to release the final report.

(Ashbrooke Care Home closed over 'serious risk to life' - BBC News )
( Independent inquiry after woman choked to death in disability care home – The
Irish Times )
( HIQA finds record keeping issues at nursing home (rte.ie) )

Examine and evaluate how information/records are stored

Data storage involves gathering, arranging, and putting data in Digital storage and Physical
storage into database.  Information management throughout time can be either easier or
harder depending on how it is stored. All the information should be stored according to the
the security requirements, whether they be digital or physical, how long must information be
retained, the frequency of information access, he worth of the data in relation to the price of
storage options all those has to be in mind.

Any type of digital data can be stored using digital storage. Any data that has been stored as
an electronic file is referred to as digital data. The one and only way to produce a file is in
digital format. Physical data can be efficiently stored by putting it in vault and facilities with
the right access, temperature, and humidity control. First of all the data that has been
gathered, processed, has to be stored in manual and electronic formats. We need to keep this
inmind It is important to keep thorough and accurate records of all choices and actions as
soon as possible following the incident. the contains information about the service user's
demographics, distinctive identification, clinical data, photographs, investigations, samples,
correspondence, and communications regarding the service user's care. These ensure security
, confidentiality and to make it possible to quickly retrieve information if needed, these
should be simple to understand, All documentation must be clearly readable, and writing
when prescribing is done in legible capital letters or lowercase type. The day, month, and
year on which an entry was made are always readily apparent from the record. Every medical
entry must include the time. All entries are signed when writing records with a legible
signature, printed name, job title, and ID number. In this way It might be taken up by a
colleague if the person has to take over the patient's care on their own.

By sharing information internally that the quality of care user can be improved by exchanging
service user data. Healthcare records serve a variety of purposes, making record keeping
important for healthcare organizations. keeps track of decisions made regarding a service
user's treatment plan and records them. It also supports the clinical and administrative
workflow of the organization for healthcare providers and other related workers.
Additionally, it facilitates the exchange of medical information with outside sources
including radiology and laboratory units, as well as with colleagues for consultations and
recommendations.  It also help you to identify the service users Complaints, Incidents and
exprince for improvement. Externally, To evaluate the service users total benefit, you might
need to disclose personal information to the service users family, friends. however, They do
not have a broad right to view the service users records or to receive unrelated information
about them. Also Any person who has been chosen to support and represent a service
user  who lacks the capacity to give consent, or who is authorized to make choices on their
health and welfare on their behalf, must have access to the pertinent information. A welfare
lawyer, a deputy or guardian appointed by a court, or a private mental capacity advocate
could be in this position.

The results a poor record keeping and lack of information exchange across providers can
occasionally be disastrous. A poorly maintained, inaccurate, or disjointed medical record is
evidence of the healthcare provider's negligence. Some of the reason are Insufficient
infrastructure, a lack of system integration, and complexity; anxiety over legal and regulatory
complexity; worries about confidentiality breaches; professional and organizational culture; a
lack of instruction, training, and direction; worries about forward sharing of confidential
information.

On the result of that, the health care workers who fail to maintain accurate records may be
subject to legal action, and could have serious personal and professional repercussions. Also
your colleague may find it hard to give effective care if the record is poor and its also risky
for the service user treatment. It's critical to understand that there are many different ways in
which healthcare providers can be held accountable for their conduct and negligence. In the
event that they are ever required to answer for their deeds or omissions, pertinent records may
be cited as proof to support or refute the claim. also it can lead to a detrimental for both
residents and healthcare professionals. The service user can also claim compension but if the
profetionals is sharing the service users information those should be the first to share for
thegood treatment of the service user Information about your allergies, current or past
medical issues, prescriptions they have used, and any adverse drug responses they've had in
the past, as well as personal information like your age, name, and residence.

Healthcare professionals are required to maintain correct records and pertinent paperwork
regarding the patient they are providing treatment for. To deliver the greatest and most
pertinent treatment for you based on the most recent facts, healthcare workers require access
to this data.
Any document, whether it be written on paper or stored electronically, must be kept safely
while still being easily accessible when needed. After keeping a record for the "proper"
amount of time, it should be safely deleted. Government officials are aware of this fact.