Digital record systems: achieving good outcomes for people using adult social care services

Here, we identify 4 guiding principles that support good outcomes for people when you use digital record systems.

Each principle describes what people should be able to expect and how you can achieve this.

1. Person-centred

Your digital record system supports staff to put people at the centre of their care and treatment, promoting and enabling good outcomes for them.

People using services should be able to expect:

• to be as involved as much as possible in making decisions and planning their care and support
• care and support that is personalised and responsive to their needs
• their care records to reflect their needs, choices, preferences, interests and aspirations.

This is because:

• the information you record about people reflects what is important to them, including their preferences and choices, their needs and how these will be met
• people can access and contribute to information recorded about them in a way that meets their needs. This includes when someone is acting on their behalf
• you involve and support people to understand what the digital system means for them. This includes being aware of any devices that staff use when supporting them
• the system enables people to have access to the right care, support and treatment when they need it.

As a good provider, you can demonstrate:

• how the digital system meets the individual needs, preferences and choices of the people using your service and how it supports you to deliver their care, support or treatment
• how you involve people in planning their care and that care plans meet and reflect people’s individual needs, including their communication needs. This includes how the digital system enables you to meet the Accessible Information Standard
• how you have involved people using your service and the people who matter to them, so they know what to expect and what the digital system means for them
• you have involved your staff in setting up the system and they understand how the system enables and supports them to provide person-centred care.

2. Availability

The right people can access information when they need to. Your system does not create unnecessary barriers to recording, accessing or sharing information.

People using services should be able to expect:

• to have access to their care records in a way that meets their needs and preferences
• to be involved in the decision to share their personal information when needed
• to be supported by staff who have access to the information they need to fully understand their needs, preferences and choices
• continuity in their care and treatment from the different staff, teams and services involved.

This is because:

• people understand what information is recorded about them, who it is shared with and why, the importance of their consent to share information with others and their rights
• the right people have access to essential recorded information, which can be shared when needed so people don’t have to ‘keep repeating their story’
• everyone involved in a person’s care can access essential information about them to work well together to understand and meet their needs, preferences and choices
• someone legally acting on behalf of a person using a service can access the information they are entitled to see to support decision making
• staff know how to operate the digital systems they are working with to carry out their role effectively
• misunderstanding data protection legislation does not create a barrier to appropriate and legal data sharing.

As a good provider, you can demonstrate:

• a clear understanding of your role and responsibilities around providing appropriate access to the information you hold about the people you support or the service you provide. This includes where someone is legally acting on behalf of a person using the service, for example when they have power of attorney
• how you support people to understand the information that is recorded about them and to give their informed meaningful consent to share this with others, when needed
• your system does not create a barrier to working with essential partners as it enables people to access information and share it when needed
• you actively seek out and use other appropriate data sources to support people who use your service
• the information recorded about a person is clear and easy to understand for the people who access and use it
• your staff have the skills, support and confidence they need to use the system appropriately for their role
• your staff have the equipment and connectivity they need to access and use the system effectively.

3. Security

People who use services can trust that information about them is kept safe.

People using services should be able to expect:

• that information about them is stored securely
• to be treated with dignity and respect and their privacy and confidentiality are protected
• to be protected from avoidable harm.

This is because:

• information is shared appropriately and safely. Only the people who should be able to see a person’s information can see it
• if privacy or confidentiality has been breached and this puts people at risk, they are told what this means for them and what will happen next
• information about people is being used in their best interests and that of the wider population.

As a good provider, you can demonstrate:

• staff understand their roles and responsibilities around keeping people’s information safe, including when they need to share information about a person and how they can do this safely and legally
• records are kept, used and shared in line with Data Protection legislation, including UK General Data Protection Regulation (GDPR) requirements and the common law duty of confidentiality
• you understand the importance of appropriate data sharing with other health and care partners. This enables joined up care across the health and care system and minimises data collections for providers
• you comply with the Data Security and Protection Toolkit (DSPT) or equivalent, as a minimum. This also applies where you use a combination of digital and paper record systems

• you have a clear plan to deal with the risk of:

  • data breaches or loss
  • cyber-attacks

  This includes how you are assured that your digital system has appropriate protections to guard against this, your contingency plans, and what action you will take to respond.

• you have contingency plans to ensure essential information is available if the digital system is inaccessible. This is to ensure that if you cannot access the digital system it does not negatively affect the safety or standard of care a person receives.

4. Governance

The system supports the service to be well-led. It enables the provider to assess, monitor and minimise the risks to people and improve the quality of their care.

People who use services should be able to expect:

• people in charge of services are open, honest and act with integrity
• support from a service that understands and manages risks to their safety
• support from a service that improves the quality of care it provides.

This is because:

• the digital records system helps to keep them safe, experience good quality care and to have good outcomes
• the quality of information recorded about them is accurate, complete and up-to-date.

As a good provider, you can demonstrate:

• your system supports effective quality assurance, helping you to provide evidence of good outcomes, identify risks and quality issues and take action to improve the service
• your system supports information to be as accurate, complete and up-to-date as possible. Where you use digital and paper systems, the information in both systems aligns and is accurate
• you work with digital social care record suppliers to continuously improve how your system works. This includes maintaining devices and ensuring software is updated appropriately.