Regulation 19(1)(a)
SCHEDULE 4RECORDS TO BE KEPT IN A DAY CARE SETTING IN RESPECT OF EACH SERVICE USER
1. The following documents in respect of each service user—
(a)the assessment of needs referred to in regulation 15(1)(a);
(b)the service user’s plan referred to in regulation 16(1).
2. A recent photograph of the service user.
3. A record of the following matters in respect of each service user—
(a)the name, address, date of birth and marital status of each service user;
(b)the name, address and telephone number of the service user’s next of kin or of any person authorised to act on his behalf;
(c)the name, address and telephone number of the service user’s general medical practitioner and of any officer of a HSS trust whose duty it is to supervise the welfare of the service user;
(d)the date on which the service user commenced attendance at the day care setting;
(e)the date on which the service user ceased to attend the day care setting;
(f)if the service user transfers to another day care setting, the name of the day care setting and the date on which the service user transfers;
(g)if the service user died in the day care setting, the date and time of death;
(h)the name and address of any HSS trust, organisation or other body which arranged the service user’s attendance in the day care setting;
(i)a record of all medicines brought into the day care setting for the service user, and the date on which they were administered to the service user;
(j)a record of any accident affecting the service user in the day care setting and of any other incident in the day care setting which is detrimental to the health or welfare of the service user including the nature, date and time of the accident or incident, whether medical treatment was required and the name of the persons who were respectively in charge of the day care setting and supervising the service user;
(k)details of any specialist communications needs of the service user and methods of communication that may be appropriate to the service user;
(l)details of any healthcare plan relating to the service user in respect of medication, specialist health care provision or nutrition;
(m)a record of falls and of treatment provided to the service user;
(n)a record of any restraint used in relation to the service user;
(o)a record of any limitations agreed with the service user or his representative as to the service user’s freedom of choice, liberty of movement and power to make decisions.
4. A copy of correspondence relating to each service user.