docRecords Retention Schedule Adult Social Care
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Records Retention Schedule Adult Social Care
Records Retention Schedule for Adult Social Care JANUARY 2014 Version 3.8 18/05/2015 Author: Peter Bode ICT Security & Standards Team Consultation Lead: Laura Scott-Smith This retention schedule was developed in consultation with Laura Scott-Smith and Kit Bryce of the Social Care Archiving Project. It has been devised in the first instance to assist the project team with clearing the backlog of adult social care records. However, the schedule is to be incorporated into procedures for all Adult Social Care Teams following approval. Signature:_______________________________ Name: Peter Bode Title: Records Manager Date: 27/10/2014 Version 3.8 18/05/2015 Signature:__ ____________________________ Name: Denise D’Souza Title: Director of Adult Social Care Services Date: 27/10/2014 Retention and Destruction of Records Record Type – Service User 1. Introduction Adult Social Care is dependent on its records (in whatever format) to operate efficiently and to account for its actions. Records are kept for as long as they are required for legal and administrative purposes and are then destroyed or retained as archives to ensure a permanent record of the activities of the department. Version 3.8 18/05/2015 The Data Protection Act 1998 requires that personal data shall be: adequate, relevant and not excessive for the purpose(s) for which they are held (the third principle); accurate and where necessary kept up to date (sixth principle); and not kept for longer than is necessary for its purpose(s) (fifth principle). This guidance relates to all service user and carer records and associated records (e.g. complaints, financial) created, received or maintained by staff in the course of carrying out their functions. 2. Definition of a Service User Record and Carer Record A Service User Record and Carer Record is information created, received and maintained as evidence and information which has been stored as a record in either paper file or electronic file. This includes the following information Assessment and Review Case notes/Diary Sheets Correspondence Complaints Financial Contract documentation relating to a specific service user/carer Service modules e.g. residential, respite, home care and day services Safeguarding modules Registrations 3. Case Closure The decision to close a case record and apply the retention and destruction schedule is the responsibility of the Team in which the case record was held. 4. Retention, Archiving and Destruction Version 3.8 18/05/2015 The retention period is applied to the person’s record after the case is closed (usually following the last contact made with the department). Generally personal information should not be held for longer than that specified in the attached retention schedule and should be destroyed, unless it is felt it should be retained permanently because it is of historical significance or a high profile record. There must be legitimate reasons for extending the retention/archive period in order to comply with the Data Protection Act 1998. This applies in the following circumstances Records relating to cases where legal action is pending or that are being used in investigations for example by the police or internal audit. These must not be destroyed until the threat of litigation has passed. Information that has been requested under the Data Protection Act 1998 and Freedom of Information Act 2000. It is an offence to alter, deface, erase, destroy or conceal such information. Records that were due for destruction but were subject to a Freedom of Information request should be retained for six months after the last correspondence on the matter in accordance with The National Archives Retention and Disposal Guidelines. Where work has triggered major criticisms of the service The retention/archiving period needs to comply with the retention period of a partner agency because the record has been integrated e.g. Mental Health or Learning Disability. Version 3.8 18/05/2015 5. Permanently Archive: Please note that permanent archive arrangements with East Sussex are under review and further information regarding this will follow. In the interim please retain or store any records that fall into the following categories: The work is of historical significance High Profile cases e.g. serious case reviews If you have records that are not covered by this Retention Schedule, please do not assume they can automatically be destroyed. Please contact Peter Bode, Corporate Records Manager - Tel: 296634 6. Destruction To prevent unauthorised or accidental disclosure of personal information, it is important to exercise care in its disposal. 7. Retention Schedule (Preliminary Retention Classes for Adult Social Care) – see attached 8. Guidance for Recording information about Paper Files in CareFirst – please contact Sue Smith for a copy on Tel: 295852 or visit http://brightonadults.proceduresonline.com 9. Completion of Records Disposal Guidance/Template – please contact Laura Scott-Smith (Tel: 295049) or Peter Bode (Tel: 296634) for a copy or visit http://brightonadults.proceduresonline.com Version 3.8 18/05/2015 10. Transferring Records to Storage – please follow guidance on transferring record consignments to Modern Records File Storage available at http://wave.brightonhove.gov.uk/supportingyou/ict/servicecatalogue/Pages/Modern-records.aspx Version 3.8 18/05/2015 BHCC1.- – Community Support Case Management The activities involved in providing and recording the provision of, care services to adults in need, with the aim of enabling them to live independently in the community. Includes: DISABILITY SUPPORT Use: SAFEGUARDING categories where safeguarding is not associated with mental health 1.0001 Integrated Mental Health Temporary - Retain NHS Guidance to Trusts, Case Records – where 20 Years from date 2009 service user was sectioned of last contact. Y Adult Care Services Y Adult Care Services under the Mental Health Act. See also: 1.0092 1.0002 Integrated Mental Health Temporary – Retain NHS Guidance to Trusts, Case Records – where 10 Years from date 2009 service user was not of last contact. Version 3.8 18/05/2015 sectioned under the Mental Health Act. See also: 1.0092 1.0003 Integrated Mental Health Temporary – Retain NHS Guidance to Trusts Case Records – where the 8 years following last 2009 subject is known to be action. Y Adult Care Services Y Adult Care Services deceased. Note: In cases where criminal proceedings eventuate, the file must be retained for eight years following finalisation of these. See Also 1.0092 1.0097 Non-Integrated Mental Temporary - Retain NHS Guidance to Trusts, Health Case Records – 20 Years from date 2009 where service user was of last contact. sectioned under the Mental Version 3.8 18/05/2015 Health Act. See also: 1.0092 1.0098 Non-Integrated Mental Temporary – Retain NHS Guidance to Trusts, Health Case Records – 10 Years from date 2009 where service user was not of last contact. Y Adult Care Services Y Adult Care Services sectioned under the Mental Health Act. See also: 1.0092 1.0099 Non-Integrated Mental Temporary – Retain NHS Guidance to Trusts Health Case Records – 8 years following last 2009 where the subject is known action. to be deceased. Note: In cases where criminal proceedings eventuate, the file must be retained for eight years following finalisation of these. Version 3.8 18/05/2015 See Also 1.0092 1.0100 Integrated Social Care Case Retain 100 Years Limitation Act 1980, Section Records involving a mental from Date of birth 28 Non-integrated social care Retain 100 Years Limitation Act 1980, Section case records involving a from Date of Birth 28 Retain Permanently East Sussex Records Office Y Adult Care Services Y Adult Care Services Y Adult Care Services capacity or deprivation of liberty assessment. See also: 1.0092 1.0101 mental capacity or deprivation of liberty assessment. 1.0092 Social Care Case Records which meet the following Collections Policy criteria National public interest Version 3.8 18/05/2015 A change to policy or procedures for delivery of care Regulatory action Sustained media attention 1.0004 Integrated Learning Disability Temporary – Retain NHS Guidance to Trusts, Client Case Records. 10 years following 2009 Y Adult Care Services Y Adult Care Services death See also: 1.0092 1.0108 Non-Integrated Learning Temporary – Retain Limitation Act 1980 (Section Disability Client Case for 100 years from 28) Records. date of birth Where service user is known Version 3.8 18/05/2015 to be deceased see 1.0102 See also 1.0092 1.0102 Non-Integrated Learning Temporary – Retain NHS Guidance to Trusts Disability Client Case 10 years following 2009 Records where service user death N Adult Care Services Y Adult Care Services Y Adult Care Services known to be deceased. See also: 1.0092 296 Non-Integrated Learning Temporary – Retain Limitation Act 1980, Section Disability Client Case 7 Years following 5 Records where service user last contact known to be deceased. See also: 1.0092 and 1.0101 1.0005 Short Term Services formerly Temporary – Retain NHS Guidance to Trusts, Intermediate Care Records 2009 for 8 years after last contact Version 3.8 18/05/2015 1.0008 Informal Carer Case Files Temporary – Retain Limitation Act 1980 (Section 7 Years from date of 2) Y Adult Care Services Y Adult Care Services last contact with carer or other social care staff member. 1.00061 Non-Integrated Adult Service Temporary – Retain User Case Records for 7 years following last contact Limitation Act 1980 VAT Act 1994 Includes cases for: Older People Vulnerable adults Guardianship Occupational Therapy Asylum seekers Version 3.8 18/05/2015 Day and home care Short Term Disabilities Physical Disability Sensory Disability Note: This class not to be used for mental disability cases. 1.00062 THIS CLASS HAS BEEN Temporary – Retain Limitation Act 1980 Y Adult Care Services RETIRED FROM FURTHER for seven years [Retired] USE: following death Non-Integrated Adult Service User Case Records Permanent Disabilities Includes: Physical Disability Sensory Disabilities Version 3.8 18/05/2015 Mental Disabilities Learning Disability Note: for Integrated Learning Difficulty Case Records, use 1.0004. 1.0063 Non-integrated Adult Service Temporary – Retain User Case Records – where for 100 years date of death is unknown following Date of and it has been at least 7 Birth Limitation Act 1980 Y Adult Care Services East Sussex Records Office Y Adult Care Services years since last contact. See Also: 1.0092 1.0093 THIS CLASS HAS BEEN RETIRED FROM FURTHER [Retired: See Retain Permanently Collection Policy USE: 1.0092] USE: 1.0092 Version 3.8 18/05/2015 Non-integrated Adult Service User Case Records to which the following criteria apply: National public interest A change to policy or procedures for delivery of care Regulatory action Sustained media attention 1.0007 Disability Registration Temporary – Retain DH guidance for CVI, LVL and Y Documents for 3 years following RVI: Explanatory notes for transfer to a new SSDs & optometrists (Last local authority or updated: September 2007) Includes: CV1 and BD8 Adult Care Services following death. Data Protection Act 1998 Version 3.8 18/05/2015 1.0009 Clients of Concern – Care Temporary – Review BHCC - Clients of Concern First Indicators status on a six Procedures Y Adult Care Services Y Adult Care Services Y Adult Care Services monthly basis and remove flag when appropriate to do so. 1.0010 1.0011 Records documenting one off Temporary – Retain 1 contacts to Adult Care year following Teams. contact. Reports and investigations of Temporary – Retain incidents on Council 6 years following premises involving adult care date of incident. Limitation Act 1980 service users. Version 3.8 18/05/2015 BHCC1. – Complaints Management The activities involved in receiving and responding to complaints concerned with the provision of adult care services. 1.0012 Adult Care Complaints – Temporary – Retain Partially Upheld 7 Years following Limitation Act 1980 Y Adult Care Services Limitation Act 1980 Y Adult Care Services Limitation Act 1980 Y Adult Care Services resolution of complaint. 1.0013 Adult Care complaints Temporary – Retain upheld – where investigation 7 years after last resulted in a form letter action apology 1.0014 Adult Care complaints – Temporary – Retain investigated and dismissed. 7 years after last action Version 3.8 18/05/2015 1.0096 Adult Care Complaints – Temporary – Retain Resulting in a payout 7 years after last Limitation Act 1980 Y Adult Care Services East Sussex Records Office Y Adult Care Services N Adult Care Services action Note: for complaints of national interest or other significance use 1.0088 1.0088 Adult Care complaints Retain permanently resulting in: National public interest A change to policy or collection policy procedures Regulatory action Sustained media attention 1.0095 Independent Complaints Temporary – Retain Investigator Registration 7 Years Following Files signing of contract Limitation Act 1980 Version 3.8 18/05/2015 305 Complaints by or on behalf Temporary – Retain of carers 7 Years following Limitation Act 1980, Section 2 Y Adult Care Services Y Adult Care Services Y Adult Care Services resolution of complaint. BHCC1 – Hospital Admissions The activities involved in delivering social care interventions to people admitted to hospital 1.0103 1.0104 Hospital Social Work Temporary - Retain 1 East Sussex Social Care Referrals – Out of Area East Year following Requirement Sussex Service Users intervention Hospital Social Work Temporary Retain 1 West Sussex Social Care Referrals – Out of Area month following Requirement West Sussex Service Users intervention BHCC1. Operational Planning The activities involved in formulating and implementing plans of action Version 3.8 18/05/2015 1.0118 Team Plans (Annual) Temporary – retain 3 Common Administrative N Adult Care Services years following end of Practice financial year for which the plan was formulated BHCC1. Personnel Management The activities associated with recruitment and management of staff 1.0106 CRB Check documentation Temporary – Destroy CRB Code of Practice 6 months after Guidance Y finalisation of recruitment 1.0107 Documents recording Temporary – Destroy decision making as to 6 Years following whether to employ someone finalisation of with a criminal record recruitment Limitation Act, Section 5 Y Version 3.8 18/05/2015 1.0117 Team Meetings – Minutes Temporary – Retain Common Administrative and Papers 3 years following Practice N date of meeting BHCC1 – Reporting The activities involved in compiling and reports to senior management and external regulators. 1.0105 Department for Health Temporary – Destroy Funding Returns 6 Years following Limitation Act, Section 5 Adult Care Services end of year in which the return was submitted BHCC1. Residential Care Case Management The activities involved in case administration of adults residing in care homes. 1.0015 Residents Case Files – Temporary – Retain where resident has been for 20 years following sectioned under the Mental last contact Mental Health Act 1983 Adult Care Services Care Homes Regulations Version 3.8 18/05/2015 Health Act. 2001, Schedule 3 See also: 1.0092 1.0016 Residents Case Files Temporary – Retain Care Homes Regulations 6 years following 2001, Schedule 3 Y Adult Care Services Y Adult Care Services departure from the home. See also: 1.0092 1.0017 Residents Case files – Temporary – Retain Care Homes Regulations cases where resident dies 8 years following last 2001, Schedule 3 whilst in care. action. Note: In cases where death results in legal action, “last action” is taken from the Version 3.8 18/05/2015 conclusion of the case. See also: 1.0092 1.0018 Care Home Residents - Temporary – Retain Care Homes Regulations Informal Carer’s Case Files 6 years following 2001, Schedule 3 Y Adult Care Services Y Adult Care Services Y Adult Care Services departure from home. 1.0115 Learning Disability Service – Temporary – Retain Common Administrative Non case file service user 12 months following Practice information: date of recording Includes: Meals Bowel Charts Participation Indexes Task Analysis Documentation 1.0116 Learning Disability – Weekly Temporary – Retain Care Homes Regulations Service User Meetings – 3 years following 2001 Version 3.8 18/05/2015 Minutes and Papers date of meeting BHCC1. Residential Care Establishments The activities involved in operating a Residential Care Establishment 1.0066 Statement of Purpose – `Temporary – Retain Care Homes Regulations under Schedule 1 of the 3 years after the date 2001, Regulation 17 regulations the statement N Adult Care Services N Adult Care Services N Adult Care Services N Adult Care Services amended or superseded 1.0067 1.0068 Service User’s Guide - Temporary – Retain Care Homes Regulations under Section 5 of the 3 years after the date 2001, Regulation 17 regulations of the last entry Annual Accounts - under Temporary – Retain Section 25 of the regulations 3 years after the date Care Homes Regulations 2001, Regulation 17 of the last entry 1.0069 Registered Provider’s Temporary – Retain Care Homes Regulations monthly Inspection Reports 3 years after the date 2001, Regulation 17 & of the last entry Regulation 26 Version 3.8 18/05/2015 1.0070 Record of Persons Temporary – Retain Care Homes Regulations Employed 3 years after the date 2001, Regulation 17 Y Adult Care Services N Adult Care Services Y Adult Care Services N Adult Care Services N Adult Care Services Y Adult Care Services of the last entry 1.0071 Staff Rosters Temporary – Retain Care Homes Regulations 3 years after the date 2001, Regulation 17 of the last entry 1.0072 1.0073 Records of charges levied Temporary – Retain Care Homes Regulations on individual Service Users 3 years after the date 2001, Regulation 17 & of the last entry Section 25 (3) (a) Records documenting Temporary – Retain Care Homes Regulations deposits of money or 3 years after the date 2001, Regulation 17 property with the of the last entry establishment by service users 1.0074 Records serving as an Temporary – Retain Care Homes Regulations inventory of furniture brought 3 years after the date 2001, Regulation 17 & into the establishment by of the last entry Schedule 4 Temporary – Retain Care Homes Regulations Service Users 1.0075 Records documenting Version 3.8 18/05/2015 reporting and investigation of 3 years after the date Complaints by service users 2001, Regulation 17 of the last entry or their representatives 1.0076 Records documenting the Temporary – Retain reporting and investigation of 3 years after the date Incidents in relation to Care Homes Regulations Y Adult Care Services N Adult Care Services N Adult Care Services N Adult Care Services 2001, Regulation 17 of the last entry service users 1.0077 1.0078 Records documenting the Temporary – Retain Care Homes Regulations menus in relation to food 3 years after the date 2001, Regulation 17 provided to service users of the last entry Records documenting Fire Temporary – Retain Care Homes Regulations Safety procedures, drills and 3 years after the date 2001, Regulation 17 & checking of safety of the last entry Regulation 23 (4) (e) Records documenting the Temporary – Retain Care Homes Regulations procedures to be followed 3 years after the date 2001, Regulation 17 for incidents such as of the last entry equipment 1.0079 Version 3.8 18/05/2015 accidents and missing service users 1.0080 Daily visitors log Temporary – Retain Care Homes Regulations N Adult Care Services 3 years after the date 2001, Regulation 17 Limitation Act 1980 N Adult Care Services Y Adult Care Services N Adult Care Services N Adult Care Services of the last entry 1.0082 1.0109 Tunstall incident response Temporary – retain 7 logs years CB1 Physical Intervention Temporary – retain 3 Limitation Act 1980, Section Data Sheets years from date of 11 incident 1.0110 Food Hygiene Checks Temporary – retain 3 Care Homes Regulations, years after date of 2001 check 1.0111 Health and Safety Temporary – retain 3 Care Homes Regulations Version 3.8 18/05/2015 Inspections years after date of 2001 inspection 1.0112 House Diaries Temporary – retain 3 Care Homes Regulations Y Adult Care Services years after date last 2001 Care Standards Act 2000 Y Adult Care Services Y Adult Care Services entry 1.0113 E9 Staff Communication Temporary – retain 5 Sheets years after date of entry 1.0114 E8 Residents Temporary – retain 1 Common Administrative Summary/Handover Sheets month following date Practice of entry BHCC1. Carer Recruitment and Management The activities involved in carer recruitment, assessment, monitoring and support. Note: For informal carer case records, refer to the Community Support Case Management section. Version 3.8 18/05/2015 1.0019 Shared Lives Carers Case Temporary – Retain Limitation Act 1980 (Section Files 7 years from 2) Y Adult Care Services Y Adult Care Services termination of carer relationship. 1.0020 Applications to be a carer – Temporary – Retain Limitation Act 1980 (section refused or withdrawn 7 years from date of 2) decision. BHCC1. – Adult Safeguarding The activities involved in safeguarding vulnerable adults within the Authority Use: Mental Health categories where safeguarding is associated with a mental capacity or mental health assessment. 1.0064 Adult Safeguarding Case Temporary – Retain Limitation Act 1980, Section Records – no longer at risk 7 Years after last 2 Y Adult Care Services Version 3.8 18/05/2015 Includes: contact Investigation Medical Assessment Protection Plan Monitoring Case Reviews 1.0065 Safeguarding Case Records Temporary – Retain where subject assessed as 100 Years from date continuing to pose a risk to of birth of case file others in the community. subject. Data Protection Act 1998. Y Adult Care Services Y Adult Care Services Schedule 3, Section 3(a) See also: 1.0092 BHCC1. – Personnel Management The activities involved in departmental/unit level administration of staff 1.0084 Employee local supervision Temporary – retain 7 Limitation Act 1980 Version 3.8 18/05/2015 files years from date of departure from the team BHCC1. – Finance Processes The activities involved in administering financial incoming and outgoings 1.0085 Records supporting Temporary – retain Common administrative payments made (paper hard copies until practice originals) payments are N Adult Care Services N Adult Care Services approved electronically 1.0086 Records supporting Temporary – retain payments made (electronic for 7 years after system records) conclusion of VAT Act 1994 financial transaction Version 3.8 18/05/2015 BHCC1. – Committees & Meetings The activities involved in recording the details of staff meetings 1.0081 1.0087 Record of Senior Care Temporary – retain 7 Limitation Act 1980, Section 2 N Adult Care Services Officer Meetings years Record of Kitchen staff Temporary – retain 1 Common administrative Adult Care Services meetings year practice N BHCC1. – Serious Case Reviews The activities involved in conducting reviews of cases of death caused through abuse or neglect, identifying changes to policy and procedure on the basis of the investigation and implementing those recommendations. 1.0089 Records accumulated for the purpose of conducting Retain Permanently East Sussex Records Office Y Adult Care Services Collection Policy serious case reviews. Version 3.8 18/05/2015 1.0090 Serious Case Review – Retain Permanently Published Reports. 1.0091 Records created and East Sussex Records Office Y Adult Care Services Y Adult Care Services Y Adult Care Services Collection Policy Retain Permanently received in the course of East Sussex Records Office Collection Policy implementing recommendations of serious case reviews. BHCC1.- Enquiries Management 1.0094 Records accumulated in the Temporary – Retain course of handling external 3 months after last enquiries, requiring only a action form letter response or referral to another service. NON PREFERRED TERMS Intermediate Care Version 3.8 18/05/2015 NON PREFERRED TERM: Use SHORT TERM SERVICES Version 3.8 18/05/2015
