Records
19.—(1) A provider shall keep a record of the following matters in respect of each service user:–
(a)the service user’s name, address and date of birth;
(b)the name, address and telephone number of the service user’s next of kin or of any person authorised to act on behalf of the service user;
(c)the name, address and telephone number of the service user’s general practitioner; and
(d)the date on which the service was first provided to the service user.
(2) A provider shall keep a record of all persons employed in the provision of the service, specifying in each case–
(a)their full name, address, date of birth, qualifications, training and experience;
(b)the date of commencement and, where applicable, the termination of the employment;
(c)positions held;
(d)any registration which the person is required by or under any enactment to hold in order to perform the duties for which the person is employed; and
(e)any disciplinary action which the employer has taken against the person, including the outcome of any such action.
(3) A provider shall keep a record of–
(a)any occasion on which restraint or control has been applied to a user, with details of the form of restraint or control, the reason why it was necessary and the name of the person authorising it;
(b)the procedure which is to be followed in the event of a fire or other emergency;
(c)all fire drills and alarm tests which have been conducted;
(d)any incident which is detrimental to the health or welfare of a service user;
(e)any maintenance of equipment which is used in the provision of the service;
(f)any complaint made by a service user or a representative or relative of a service user or a person employed in the care service about the operation of the care service, the outcome of such complaint and the action taken;
(g)the persons who were employed in the provision of the service each day;
(h)all money or other valuables deposited by a service user for safekeeping or received on the service user’s behalf, which–
(i)shall state the date on which the money or valuables were deposited or received, the date on which any money or valuables were returned to a service user or used, at the request of the service user, on the service user’s behalf and, where applicable, the purpose for which the money or valuables were used; and
(ii)shall include the written acknowledgement of the return of the money or valuables;
(i)the date, time and cause of death of any service user who has died while the care service was being provided to the service user and the name of the doctor certifying death;
(j)medicines for the use of service users which are kept on the premises from which the care service is provided; and
(k)details of any instance in which medication has been administered to a service user without the consent of that service user or of a person duly authorised to consent on the service user’s behalf.