Version: 1.0.42 | Published: 9 Jun 2026 | Updated: 3 days ago
Summary
Type:
Information standards
Effective From:
01 April 2025
Applies To:
CQC registered adult social care providers and their suppliers
Impacts On:
The Minimum Operational Data Standard impacts CQC registered adult social care
providers and the suppliers of their respective Digital Social Care Records.
Conformance Date:
01 July 2026
Topics:
- Access to records
- Accessibility
- Adult
- Age
- Appointment / scheduling
- Architecture, Models and Frameworks
- Artificial intelligence
- Authentication
- British Standards Institute (BSI)
- Care
- Care records
- Child
- Clinical decision support
- Clinical safety
- Coding
- Continuity of care
- Cyber security
- Data
- Data definitions and terminologies
- Data governance
- Date and Time
- Demographics
- Design
- Digital Imaging
- Dispensing
- Electronic Health Record
- Equality
- European
- Financial management
- Form
- GS1
- Genetic and Genomic
- Good practice
- Government
- Health
- Health Level 7 (HL7)
- Holistic and Traditional
- ISO Technical Committee 215 (ISO/TC 215)
- Information Technology (IT) Infrastructure
- Information codes of practice
- Information governance
- International Standardization Organisation (ISO)
- International Standards
- Interoperability
- Interoperability - Knowledge
- Interoperability - Organisation / Service
- Interoperability - Semantic
- Interoperability - Skills
- Interoperability - Structural
- Interoperability - Syntactic
- Interoperability - Technical
- Key care information
- Learning Health Systems
- Local
- Location
- Medical devices
- Medical products
- Messaging
- Metadata
- Naming and Number
- Open
- Orchestration
- Organisation
- Patient communication
- Personalised Digital Health
- Pharmacy, Medicines and Prescribing
- Product management
- Professional
- Provider
- Public health
- Publicly Available Specification
- Race and Ethnicity
- Record
- Reference data
- Referrals
- Requests, Orders and Observation
- Security, Safety and Privacy
- Service
- Sex and Gender
- Sexual orientation
- Technical Report
- Technical Specification
- Telehealth and Virtual Care
- Tests and diagnostics
- Vaccination
- Web
- Women's health
- Workforce
- Worldwide Web Consortium (W3C)
Care Settings:
- Care home
- Social care
Publication Date:
31 March 2025
Contact Point
Contact Point:
Documentation
Associated Media:
Is Part Of:
Name:The Digital Social Care Records Capabilities and Standards Roadmap
Document 1
Title:
Implementation Guidance
Abstract:
Guidance for CQC registered adult social care providers and their associated
suppliers implementing the Adult Social Care Record (MODS) which represents the
minimum operational data standard for direct care data in England.
Associated Media:
Paragraph 1
Description:
## Purpose
This document is designed to serve as a comprehensive guide for the implementation of the Adult Social Care Record - Minimum Operational Data Standard (MODS). It aims to detail the updates and modifications in the latest release, ensuring that stakeholders are informed about the essential classes of data encompassed within this standard and the dependencies between it and other standards. The primary intent is to facilitate a smooth adoption and practical application of a standardised data specification across organisations involved in adult social care.
The guidance provided here should be considered in conjunction with the [specific data dictionary for MODS](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification) and the overarching [Conceptual Model for Adult Social Care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=18). These resources collectively form a robust framework for understanding and applying the data standard effectively.
### Aims and objectives of the Adult Social Care Record (MODS)
The primary objective of the Adult Social Care Record (MODS) was to establish a minimum data requirement for recording direct care data by CQC registered adult social care providers and the suppliers in England. Establishment of the Adult Social Care Record (MODS) has been created to support and enable:
**Consistent Data Collection:** Establish a uniform baseline for data gathering by CQC registered adult social care providers in England, aiming to enhance the quality of care delivered.
**Standardised Data Formats:** Promote the use of consistent data structures, acting as a 'common glue' to enable safe data sharing and more cohesive care delivery across different entities.
**Regulatory Compliance and Best Practices:** Reflect regulatory demands and disseminate best practices for data management within the sector.
**Reduction of Administrative Burden:** Minimise repetitive data entry and overlapping reporting obligations, thereby streamlining operational processes.
**Alignment with Broader Standards:** Synchronise with existing standards in the wider health and adult social care systems to avoid inefficiency and redundant efforts ‘reinventing the wheel’.
**Specialised Data Model:** Develop a data model that integrates with current healthcare frameworks but is specifically tailored to the needs of adult social care.
**Support for Technological Advancements:** Foster innovation and the integration of assistive technology within the adult social care sector.
### Target Audience
The MODS is primarily developed for adult social care providers and suppliers of information systems in the adult social care sector. This guidance is particularly beneficial for those involved in implementing digital systems in all registered CQC adult social care settings, including integration across various providers. It also serves as a vital resource for care professionals responsible for recording and submitting data into systems using the MODS framework.
Furthermore, MODS is relevant to a diverse range of stakeholders, as outlined in the identified
[Personas](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=13), ensuring a comprehensive understanding and application of the data standard across the sector.
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## Background
The Adult Social Care Record: Minimum Operational Data Standard (MODS) has been designed to establish a suite of interoperable components that, when combined, create a comprehensive digital record for adult social care. These components, or "building blocks," are versatile and can be assembled into specific configurations or included within particular forms, yet they are all unified under an extensive conceptual framework. For instance, an identified need—a fundamental element of the digital social care record—is always connected to an individual. This need might be recognised during various interactions, such as in the process of assessment, within care planning, or through the actual delivery of direct care services.
**Latest Version:**
The Adult Social Care DSCR Minimum Operational Data Standard (MODS V1.0) was formally published 1 April 2025. This iteration is the culmination of an initial discovery phase and the creation of alpha and beta version of MODS. The ongoing development is dedicated to refining the functionality of MODS to ensure optimal performance. The development team is actively engaged in soliciting and incorporating user feedback, with the goal of continuously enhancing MODS in alignment with the insights gained from practical use and research.
All Assured Suppliers to the NHS must conform to the MODS standard by July 2026.
### Our Approach
**Related Standards and Programmes of Work:**
- Digital Social Care Record (DSCR)
- ISO 13606
- Contsys
- Core Information Standard
- HL7 FHIR UK CORE
- SNOMED CT (UK Edition)
- NHS Data Dictionary
- ISN Approved Collections
- Open Referral
- LGA inform
- SAVVI
- OpenEHR Social Determinants of Health
- OpenEHR Social Context Project
- The Gravity Project - Gravity Project - Confluence
- SNOMED International Social Care Project
///mermaid graph TD accTitle: Classes of information about the person within the MODS will fall into one of the following categories accDescr: Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find. subgraph EHR_EXTRACT DEMOGRAPHIC_DATA[DEMOGRAPHIC DATA] FOLDER[FOLDER] -->|sub_folders| FOLDER FOLDER -.->|compositions| COMPOSITION[COMPOSITION] COMPOSITION -->|content| SECTION[SECTION] COMPOSITION -->|content| ENTRY[ENTRY] SECTION -->|members| SECTION SECTION -->|members| ENTRY ENTRY -->|items| CLUSTER[CLUSTER] ENTRY -->|items| ELEMENT[ELEMENT] CLUSTER -->|parts| CLUSTER CLUSTER -->|parts| ELEMENT ELEMENT -->|value| DATA_VALUE[DATA_VALUE] end
- Explain the Classes of information about the person within the MODS diagram
Imagine a giant digital folder that holds all of a person’s health information in one place. Inside this folder, information is organized a bit like a nesting doll: big folders contain individual records (like a doctor's visit note), and those notes are broken down into smaller sections and specific entries. Each entry then points to the tiny details, such as a specific test result or a single measurement. The system is designed to handle general details about who the person is alongside these specific health stories, making sure that every piece of information—from a broad summary to a single data point—stays connected and easy for healthcare staff to find.
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## Requirements and use Cases
The NHS Transformation Directorate's Digitising Social Care (DiSC) Programme has introduced an Assured Supplier List to support Adult Social Care providers in England in selecting from a verified roster of Digital Social Care Records (DSCR) Solutions. These solutions have been integrated through the Dynamic Purchasing System (DPS), with its specifications transformed into Capabilities and Standards to align with the Digital Care Services (DCS) Framework.
The Adult Social Care Record (MODS) is a critical component of these data standards. It encompasses data classes and data elements that outline the requirements for how information should be recorded from individuals receiving care from a CQC regulated social care service.
In the process of establishing the MODS, a series of use cases and requirements were identified:
* [Use case 1: Consistency of care to an individual when a temporary worker needs to step in](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=5#)
* [Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=6#)
* [Use case 3: Consistency of care and recording across a multi-disciplinary team](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=7#)
* [Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=8#)
* [Use case 5: Implementing a new social care system](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=9#)
* [Use case 6: Care provider moving to a digital system](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=10#)
* [Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=11#)
* [Use case 8: DHSC receiving information from local authorities and care providers](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=12#)
* [Personas](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=13#)
* [Additional use cases](/adult-social-care/published-standards/adult-social-care-record-mods/implementation-guidance?page=14#)
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### Use case 1: Consistency of care to an individual when a temporary worker needs to step in
####Scenario:
Mr. Green ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) has been living in a care home ([Care Organisation](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+organisation&search=true&elementId=465255)) for several years. He is a very social person ([About me](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=about+me&search=true&elementId=463962#), [Strengths](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464142&q=strength&search=true), [Need](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=need&search=true&elementId=465037)) and is often in the communal rooms such as the dining room ([Preferences](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464123)). Also, he likes to participate in activities such as singing and painting ([Preferences](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464123), [Service](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057&q=service&search=true)). Mr. Green is somebody who likes to have a lot of structure in his life ([Preferences](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464123)).
He is normally assisted by Nurse Assistant Emily ([Care worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+worker&search=true&elementId=465857) who [provides care](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=provides+care&search=true&elementId=465819#) for Mr. Green and is flagged as a [key worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=key+worker&search=true&elementId=463619)), but she is on leave for a week and her shifts are being covered by an agency worker, Eliza ([Care worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+worker&search=true&elementId=465857)). Eliza is an experienced care worker but has never worked in this care home or met any of the residents. Before starting work this morning she spent a few minutes going over the residents' records (Adult Social Care Record) to find out a little about them.
Today, Mr. Green ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) woke up at 8 o’clock. Nurse assistant Eliza reviewed her tasks ([Task](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mod)) and assisted Mr. Green with a shower ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) and helped him to go to the toilet ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)).
By himself, he walked to the dining room where he ate two eggs and a roll and drank a cup of coffee. He was sitting next to Mr. Brown where he normally sits. After that, he read the daily newspaper.
At 9 o’clock nurse Eva ([Care worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+worker&search=true&elementId=465857)) gave him his medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), [Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)), which he took with a glass of water.
At 10 o’clock Mr. Green ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) was picked up ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) by the activity well-being facilitator Mahsa ([Care worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+worker&search=true&elementId=465857)) so that Mr. Green could participate in the choir group ([Service](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057&search=true&q=service)). He was in a good mood and looked as if he was having a good time with the other residents ([Outcome](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?search=true&elementId=465118&q=outcome#)). At 12 o’clock he went for lunch in the dining room where he ate some soup and a sandwich. After that he went for an afternoon nap in his room.
#### Goal:
Monitoring the assistance of Mr. Green with his daily life in a care home. Take care of him and help him with washing himself, ensuring he gets his daily medication, food and drinks and that he goes to the activities that he enjoys provided by the care home.
#### Assumptions:
Retaining patient data roughly consists of three steps: Recording (1), sharing it with colleagues (2) and sharing it with the recipient of care (3). For this process to run smoothly, it is important that the data is understandable and reusable for everyone and can be monitored over time to see changes. In this use case, the focus is on a recipient of care in a care home, so it is information that carers and activity well-being facilitators capture in the daily life of Mr. Green. Every individual and each day are different so the information can be different, it totally depends on the recipient of care and the care needs somebody has at the time. Also, this sharing of information is between carers and activity providers, but it can also be that a transfer message has to be shared multidisciplinary for example between a carer and a doctor. In all situations the information needs to be easily comparable with days, weeks or months before to understand changes in the individual’s state.
#### Process breakdown
Note time when Mr. Green was awake and wanted to have a shower ([Daily Living](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369&search=true&q=daily+living#))
Note which food Mr. Green ate and what he was drinking ([Daily Living](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369&search=true&q=daily+living#))
Note if and which medication Mr. Green took ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), [Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
Note in which activities Mr. Green was active ([Activities](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods))
Note which care worker helped the recipient of care ([Care worker](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?q=care+worker&search=true&elementId=465857))
Note how his day schedule looked ([Activities](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods))
Note in which social (group) activities he was active ([Activities](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584589&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods))
Note how his mood and communication was ([Outcome](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?search=true&elementId=465118&q=outcome#))
Note how much sleep he had ([Daily Living](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=466369&search=true&q=daily+living#))
Note if any markable changes occurred compared with the situation before ([Outcome](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?search=true&elementId=465118&q=outcome#))
These data points are the core information about Mr. Green's daily life. MODS contributes to Eliza's ability to care for him and the data she has access to and populates could be recorded using MODS.
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### Use case 2: Communicating an individual's care needs between local authority and care provider at the point of commissioning
#### Scenario:
Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) is a 73-year-old man ([Date of birth](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463585)), a widower ([Marital status](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464126)).
He was quite healthy until recently but is getting more and more health complaints ([Problems](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010&elementId=%22%22#), [Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and social care needs ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). He lives in a complex home situation (Accommodation status, Environment, Circumstances).
For a week, he cannot not really move due to recent foot problems - he lives on the third floor of an old apartment building with only steep stairs ([Problems](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464010&elementId=%22%22#), [Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). His days seem to become lonelier and lonelier, and neighbours from downstairs now rarely see him ([Social circumstances](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463989), [Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). One neighbour ([Personal contact](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463950)) talked to a social care youth worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) he met accidentally and mentioned the situation. The youth worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) offered to refer ([Referral](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464056&elementId=%22%22#)) Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) to Adult Social Care for an assessment of his needs ([Care needs assessment](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463713)).
#### Goal:
To assess Mr. Bodat’s eligible care and support needs, and to commission a package of care which will meet those needs and allow him to continue living independently in his own home.
#### Assumptions:
The system needs to reconcile Mr. Bodat's eligible outcomes, as assessed under the Care Act, with his desired outcomes in terms of his ability to live a fulfilling life. The assessment may identify non-eligible needs which Mr. Bodat nevertheless would like to have met. The care provider and Mr. Bodat may agree on a slightly different set of priorities and outcomes for the care to be provided versus the care funded by the local authority. However, since Mr. Bodat cannot contribute any first-party top-ups to the cost of his care, the costs need to remain within the authority's funding envelope.
#### Process breakdown
Youth care worker acknowledges he is not responsible for care, but makes referral to Social Care for assessment ([Referral](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464056&elementId=%22%22#))
Emma, a Social Worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)), visits Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) and carries out a Care Act needs assessment ([Care needs assessment](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463713))
Emma assesses Mr. Bodat's wellbeing, health, selfcare abilities and social situation, and determines that he is eligible for care to be provided by the local authority ([Care needs assessment](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463713))
Caroline, a finance officer, visits Mr. Bodat to carry out a financial assessment to determine what if anything he will need to pay towards the cost of his care. His income and savings are below the relevant thresholds and the local authority will fund the full cost of meeting his eligible care needs (Out of scope)
Caroline also makes an appointment for Mr. Bodat to speak to the Benefits Advice team at the council, as she believes he is eligible for more disability benefits than he is currently receiving due to his declining health (Out of scope)
In parallel, Emma ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) completes a care plan ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) covering Mr. Bodat's ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) eligible needs ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). This includes a base unit ([Device](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464570&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) providing medication reminders and a Lifeline alarm ([Device](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464570&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)), and two home visits a day ([Task](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mod)) to meet his personal care needs. Emma also puts Mr. Bodat in contact with a community group who offer a befriending service ([Service](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464057&search=true&elementId=%22%22&q=service)), can help him get online ([Task](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mod)), and can do a weekly shop for him ([Task](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464055&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mod)).
Once the care plan ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) has been agreed ([Agreed with person or legitimate representative](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464567)) with Mr Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)), Emma ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) passes it to the Brokerage team to procure the home care elements (Out of scope)
The package is picked up by a local provider ([Social Care Provider](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464567)), who sends Sue ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) to visit Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) to get to know him and see what his situation is really like. Sue confirms the information received from the local authority, captures further details of his day-to-day needs ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and completes the "About Me" record ([About me](https://standards.nhs.uk/adult-social-care/published-standards/about-me)).
Sue is able to gauge for herself, as she talks to Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)), that the information on the record is accurate in terms of his health, mobility, mental capacity and cognition ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702))(Review)
Mr. Bodat ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) tells Sue ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) about his regular medications ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052)) - although he can administer them himself, he worries about forgetting to take his medication and about getting his repeat prescriptions (Risk)
Sue ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) returns to the office and updates the records. She discusses Mr. Bodat's ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)) care needs ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) with her manager and they agree a more detailed care plan ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) showing how his needs will be met within the time funded by the local authority. The manager assigns another worker, Andi , to be Mr. Bodat's care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617))
New Chapter:
true
Paragraph 6
Description:
### Use case 3: Consistency of care and recording across a multi-disciplinary team
An individual's daily care involves a diverse group of healthcare and social care practitioners—including GPs, district nurses, social workers, care providers, care workers, social prescribers, local authority call handlers, among others. While these care workers do not function as a unified multi-disciplinary team, they require access to comprehensible and precise records. These records must be articulated in a vernacular that merges clinical precision with everyday language, enabling these varied practitioners to document and exchange information effectively. This collaborative approach is essential to inform continued care and support the individual in leading their desired lifestyle.
#### Scenario:
Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) lives alone ([Household composition](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464126)) but due to mobility issues ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) she is unable to leave her home without support ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and requires assistance with dressing ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and personal care ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). She has dementia ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) so can give inconsistent responses regarding her abilities and medication ([Risk](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)).
Jane ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)), an experienced care worker, visits (Tasks) Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) at 10am. When she arrives she wakes ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) and administers her medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), Action). Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) complains of a headache (Problem) so additional medication is given ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), Action). Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) is supported to get out of bed ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) , shower ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) and get dressed ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)). Jane cooks her breakfast ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590)) and then leaves.
At midday, Alan ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)), a new social worker, visits to review (Review) Mrs Smith's care plan ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)). Mrs Smith's son, Robert ([Personal contact](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463950)), also arrives to take part in this meeting. During the meeting Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) says that she has no mobility issues and can use the toilet independently. Robert ([Personal contact](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463950)), challenges this and explains that Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) has carers twice a day to help with this. Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) is confused about her care needs and insists that she does not need support ([Risk](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)). She also asks for additional medication for a headache. Robert gives her this medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), Action).
Sophie ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)), a new care worker who has recently joined the agency, arrives to visit (Tasks) Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) in the evening. When she arrives Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) advises that she does not need any help going to the toilet and has already taken her medication. Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) insists that she does not need support so attempts to get to the bathroom by herself and falls ([Incident](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463988)).
Sophie ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) calls an Ambulance as Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) hits her head when falling and she is taken to A&E ([Admission details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464147)). Sophie ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) is unsure what medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052)) Mrs Smith has taken today and the details of her support needs ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702), [Risk](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)). When Mrs Smith ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) arrives at A&E she tells the doctor and nurses that she lives independently and does not need support with personal care. She also tells them that she has not taken any medication today.
#### Goal:
Support Mrs Smith to continue to live in her own home by providing consistent care and support. Sharing information with all other professionals and family carers to safeguard and support her, including preventing falls and monitoring medication administered.
#### Assumptions:
In this use case, the recipient of care lives alone but has dementia so may give inconsistent responses about her care and support needs and medication. Providing clear and consistent information/records about medication administered, Mrs Smith's mobility and personal care needs and the likelihood of confusion due to dementia is essential. This information should be shared with all professionals and family members regularly so they can support Mrs Smith appropriately. If this information is not available to all professionals supporting Mrs Smith, then she may injure herself, receive duplicate medication or overstate her abilities.
#### Process breakdown
Record the time Mrs Smith was woken ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
Record the time Mrs Smith took routine medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), [Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
Record the additional medication administered ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), [Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
Record support required for personal care ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods))
Record food provided ([Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
Record Risks that Mrs Smith get’s confused and sometimes forgets that medication has been administered and overstates her abilities ([Risk](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463973&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods))
Record fall and procedure followed ([Incident](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463988)).
Record Hospital admission details ([Admission details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464147))
Record Hospital records of medication administered and support required ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052), [Action](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&search=true&elementId=584590))
New Chapter:
true
Paragraph 7
Description:
### Use case 4: Providing consistent support in hospital and at home for an individual with an existing care plan
Teams responsible for hospital admissions and discharges understand the existing care plans and ensure that they communicate the requisite care details to care providers upon a patient's discharge.
#### Scenario:
James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) has a learning disability ([Reasonable adjustment](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465648), Impairment, [Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and lives in supported living (Accommodation status).
James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) has not been well and was admitted to hospital for 48 hours ([Admission details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464147)).
When James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) arrived with his care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)), they explained to the nurse in A&E that he had a learning disability ([Reasonable adjustment](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=465648)) and would need information explained to him clearly ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and any documents would need to be in an easy read format ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). They did not bring along a copy of James' ([Care and support plan](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) which explains the support he needs with dressing and going to the bathroom etc.
When James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) was admitted to the ward, his care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) explained to the ward nurse ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) that he had a learning disability and would need additional support ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)). His care worker then had to leave.
During his stay at hospital James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) struggled to understand what the doctors and nurses were explaining to him and found it difficult to ask for help. When James was discharged ([Discharge details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=465031)), a different care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) came to collect him, James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) was very distressed ([Outcome](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=465118)). The nurse ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) gave James' care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) a copy of his discharge papers ([Discharge details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=465031)) and explained the extra support ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052)) James ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) would need over the next week.
When they arrived home, James' care worker ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) showed the manager ([Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617)) his discharge papers ([Discharge details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=465031)) and they were filed but the information about James' ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) additional support ([Need](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) and medication ([Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052)) this week were not shared with the rest of the team.
#### Goal:
Everyone who cares for James in hospital is able to access a digital copy of his care plan so they are aware of his needs and able to provide him with the correct level of support. When he is discharged from hospital, his after care is incorporated into his care plan and the necessary information from his hospital stay is shared with his family carers and care provider staff.
#### Assumptions:
As James has a learning disability, he may struggle to understand some of the information provided at the hospital, need extra support and a copy of his care plan should be shared with hospital staff. The Red Bag Scheme could be beneficial in this scenario.
Details of additional support needs noted by nurses - but unable to access a digital copy of care plan, no paper copy provided
Paper copy of the documents filed by the care provider but not shared with all staff who may support James over the next week
By having a clear digital shared care record with James's care and support needs available to all NHS staff would enable them to support James better. When he is discharged, the additional support needs from his hospital stay could be added to this digital record and then this could be accessed by all care staff at James' supported living accommodation. This would ensure consistent care and support in both settings.
#### Process breakdown
Hospital admission ([Admission details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464147))
Additional support needs noted by nurses ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702), Care and support plan)
Hospital records maintained and shared ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702), [Medication](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464052))
Discharge papers provided to care worker ([Discharge details](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=465031))
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### Use case 5: Implementing a new social care system
Enabling easier implementation of new adult social care IT systems.
#### Scenario:
A London council are in the process of implementing a new social care IT (DSCR) system.
They need to be confident that all potential suppliers have the same understanding of the requirements set out in the tender documentation, so that the tenders they receive are directly comparable and are fit for purpose.
Each [Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) (person’s) record needs to capture their [demographic information](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463586), [alerts](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464180), [care and support needs](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464165), family support network, [professionals involved](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&q=professional&search=true&elementId=464564) etc.
Then they need to tailor the workflow to meet the needs of their staff for accurate and efficient recording, whilst also capturing all the essential information for statutory returns and future CQC regulatory requirements.
They also need to consider integrations like connected care health systems to ensure they are sharing data securely, in the correct format and regularly to maintain an accurate DSCR
To ensure they have captured all this information, are using the most up to date datasets and terminology, they refer to the Adult Social Care (ASC) Data Catalogue and MODS.
#### Goal:
Implement an effective, accurate and efficient adult social care IT (DSCR) solution which meets the needs of their staff, captures all statutory information and promotes effective support and safeguarding of vulnerable adults.
Implementing a system with standardised datasets and terminology will lead to more effective interoperability between health, adult social care and care providers.
Having agreed a MODS, it will make it easier to switch between systems and given agreed areas that should be covered by the MODS should enable system suppliers to have more consistent processes across systems as they all need to meet the same requirements. This should reduce the training overhead for staff and will improve safeguarding as recording standards should be easier to maintain.
#### Assumptions:
The LA will have legacy data from whatever system was in use previously. It should be possible for this data to be able to be incorporated into the new system so that there is one case history for each service user. Any previous documents/attachments should be able to be transferred across so that they give the appropriate context to the service user's information. This is not in scope for this programme of work.
It should be possible for information fields to be mapped so that the legacy data can be straightforwardly imported into the new system and will sit under the appropriate headings/sections of that system (e.g. involvements, contact numbers, hazards etc). LA Case Management systems (CMS) out of scope.
#### Process breakdown
Procure a adult social care system that meets the needs of the organisation and supports efficient recording of regulatory requirements
Tailor the system to meet the needs of the staff using the system and the people receiving care
Consider which data tables are in the system and to which of the MODS do these link
Import legacy data into the new system and be able to access it (view, edit, update) in the correct screens/areas of that system
Import any associated documentation or plans into the new system and be able to access them in the appropriate areas of that system
Work with health and care providers to ensure the systems can integrate for future sustainability
Provide training to all staff to ensure they can use the system to maintain accurate records for direct care
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### Use case 6: Care provider moving to a digital system
As care providers move to digital systems by 2025, this will enable easier transfer of routine info to local authorities.
#### Scenario:
A CQC registered care adult social care provider ([Social Care Provider](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464567)) is in the process of implementing digital social care records to improve the support they can provider for their recipients of care ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463685&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)) and their joined up working with other services.
Utilising the [MODS](https://standards.nhs.uk/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) on the ASC Data Catalogue has provided them with guidance around the minimum operational data standard so they are confident that they will meet all regulatory requirements and the data they will be sharing will be fully aligned with other services. They have then been able to work with the Digitising Social Care Programme to tailor this to their needs and use this opportunity to improve their recording practices.
By having access to up to date health and adult social care information, they can create better packages of support for their recipients of care ([Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)). As a care provider ([Social Care Provider](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464567)), they have valuable insight into the recipient of care's day to day activities and support needs ([Needs](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463702)) so they can also share this valuable data with the other services to provide more consistent support in all settings.
#### Goal:
The Digitising Social Care Records Programme is aiming for 80% all CQC-registered adult social care providers to have access to a digital social care record that can interoperate with a local Shared Care Record by March 2025.
These records will play a vital role in joining up health and adult social care, freeing up time spent for the workforce across health and adult social care on administrative tasks whilst equipping them with the information they need to deliver care. They are the platform on which other remote care tools can integrate and can enable the greater personalisation of care planning that focuses on the individual.
Assumptions:
The care provider will have enough networked equipment available (e.g. tablets, pads, laptops etc) for their staff to be able to capture and access key information once that information has been put into a digital system.
The workforce will be sufficiently trained and IT-capable to be able to access the relevant system(s) to be able to view, edit and update key information on their service users.
#### Process breakdown
Procure a digital system that meets the needs of the organisation and supports efficient recording of statutory and regulatory requirements
Tailor the system to meet the needs of the care provider and people receiving care.
Work with health and adult social care suppliers and providers to ensure the systems can integrate.
Provide training to all staff to ensure they can use the system to maintain accurate records
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### Use case 7: Sharing elements of care planning information across many systems – components or "building blocks" of care plan
This use case does not follow the structure of the others, as there are multiple scenarios involved. Instead we have identified a range of user needs which combine to describe the benefits of a properly structured record.
| As a… | I need… | So that… | MODS data sources | Other data sources |
|---|---|---|---|---|
| Person receiving care | To tell people about my care and support needs (including any changes to what I need) once and once only |
(a) I don't have to keep repeating myself to all the different professionals involved in my life (b) my care and support can adapt to meet my changing needs |
About Me Observations including but not limited to Needs, Risks, Wishes, Preferences, Strengths | |
| Person receiving care | Everyone involved in my care and support to have access to comprehensive and up-to-date information about my care and support needs | I get the right level and type of care and support at the right time |
About Me Observations such as Needs, Risks, Wishes, Preferences, Strengths Problems Medication management Allergies and adverse reactions | |
| Care actor | My involvement as a carer to be included in the Digital Social Care Record | Professionals are aware of the role I play in caring for/supporting the individual, and are able to involve me appropriately throughout the individual's care journey | Carers | |
| Data SME | I need to understand the definitions, formats and processes used to collect data from various organisations and people and ensure that is consistent | I can provide aggregate data that is statistically valid, consistent over time, and fit for a wide range of purposes | ||
| Data SME | Client/person level data to align with existing data sources about individuals, eg PDS, GP Connect | To avoid duplication of records, so that aggregate data gives a more accurate picture across the whole population | MODS |
PDS GP Connect |
| Operational SME (care provider) | My records to be populated with accurate, up-to-date data about health conditions, allergies and adverse reactions, prescriptions, etc from the GP's records; and this data to be updated in real time if it changes |
(a) I can ensure the person receiving care’s day-to-day health needs are being met correctly (b) I don't need to re-create/re-enter data that is already held digitally |
About Me Observations including but not limited to Needs, Risks, Wishes, Preferences, Strengths | GP Connect |
| Operational SME (care provider) | Confidence that I have a legitimate reason to hold/access all the data held within the DSCR/MODS | I am fully compliant with the GDPR | ||
| Operational SME (care provider) | New care and support packages arriving from the local authority to contain as much detail as possible about the individual's care and support needs, health conditions (including cognitive and sensory impairments) and desired outcomes | I don't need to repeat any aspects of the needs assessment process which others have already undertaken |
Observations including but not limited to Needs, Risks, Wishes, Preferences, Strengths |
Care Act eligibility assessment LA care and support plan GP Connect |
| Operational SME (care provider) | New care and support packages arriving from the local authority to include a clear statement of the care and support being commissioned, including time and cost | I can ensure the care and support I provide is in line with the funding available for it |
LA care and support plan LA funding – time and budget | |
| Operational SME (care provider) | To locate data sources about indicators/metrics | I can incorporate data collection needs into my internal working processes as efficiently as possible |
NHS Digital CQC Skills for Care | |
| Operational SME (care provider) | Confidence that the DSCR/MODS is fully aligned with statutory/regulatory requirements | I can be certain that by adopting MODS I am meeting all these requirements | MODS |
Primary and secondary legislation CQC guidance NICE guidance |
| Operational SME (care provider) | To be consulted/informed about changes to statutory requirements, data standards, data gathering requirements, registration requirements etc | I can be fully prepared for changes which will impact on the way I provide care and support and/or capture data | ||
| Operational SME (care provider) | Access to standard national datasets and data standards | I can review/compare them against the data I capture in my own systems | ||
| Operational SME (care provider) | To be notified when someone I provide domiciliary care for is admitted to hospital | I do not have to make unnecessary visits | Hospital systems | |
| Operational SME (health) | Clear and accurate information about the care and support needs of a person with sensory or cognitive impairment, learning disabilities and/or mental health needs when they are admitted to hospital | We can communicate with them effectively and take account of their needs in the way we care for them in hospital |
About Me Observations including but not limited to Needs, Risks, Wishes, Preferences, Strengths Care and support plan Carers | About Me |
| Operational SME (health) | Clear and accurate information about the care and support arrangements available at home when someone is discharged from hospital | We know if it is safe and appropriate to discharge the individual back home |
Care and support plan Carers | |
| Operational SME (social work) | Data from care providers and TEC systems at an appropriate level of detail about the day-to-day care and support provided to an individual and the outcomes being achieved |
(a) Contribute to the annual review of the individual's care and support plan (b) Flag any significant changes in care and support needs (c) Ensure commissioning meets current and future demand |
Instructions Actions Alert Outcome |
TEC data Day-to-day care record Hospital admissions/discharges Changes in care and support needs |
|
Operational SME (social work) Operational SME (care provider) | To record data once in the system, ensure it is complete and accurate, and be confident that it will reach everyone else who needs to see it | To reduce the time pressure of constantly re-entering data and responding to requests for routine information | MODS | |
| System SME (system administrator) | To be consulted/informed about changes to statutory requirements, data standards, data gathering requirements, registration requirements etc | I can be fully prepared for changes which will impact on the way I capture data | ||
| System SME (system supplier) | To locate data sources about indicators/metrics | I can ensure that data is captured correctly to auto-populate the statutory returns required of my clients | MODS | |
| System SME (system supplier) | To locate person-specific data sources | I can create the functionality to import person-specific data from reliable and trustworthy sources to save double-entry and data quality issues |
Data Catalogue PDS GP Connect |
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### Use case 8: DHSC receiving information from local authorities and care providers
#### Use case:
DHSC able to receive management information from all local authorities and adult social care providers which uses agreed, understood and shared terminology
#### Scenario:
* The Department of Health and Social Care (DHSC) are working to improve the way they collect management information from local authorities and adult social care providers. They have noticed that the information they are receiving is often inconsistent and during sessions to analyse the data with local authorities and adult social care providers they discussed the data discrepancies. This highlighted different understanding of the terms being used differently by local authorities and adult social care providers, for example 'carer' and other terms like 'personal budget' and ‘needs assessment’ had varying definitions.
* A glossary of adult social care terminology with agreed definitions would help to resolve this issue and provide more consistent data for both health and adult social care, supporting improved secure information sharing available at the right time for the right person in the right place for direct care.
#### Goal:
DHSC receive management information in a consistent format with agreed and understood terminology to ensure information is reported consistently. To do this, an agreed glossary of terms and definitions should be created in partnership with health, care providers and local authorities.
#### Assumptions:
Throughout the discovery phase of this project we have identified a number of words/terms that are used inconsistently by different services or have multiple meanings. Finding consistent definitions can be difficult and often each authority has a slightly different definitions for a term, a good example is personal budget. Having a defined and consistent terminology that all local authorities and care providers use would reduce the confusion and inconsistency.
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### Personas
During development of the minimum operational data standard the following stakeholder groups were identified:
Health and adult social care professional bodies
Local Government Association - Adult Social Care
Adult Social Care CQC registered and non-registered providers
NHS - primary, secondary and community care
NHS England/Improvement, NHS Digital, DHSC
Local Government - other
Other central government departments/agencies/NDPBs
System suppliers
Individuals and their representative bodies (inc voluntary sector)
Academia, research, statistics
Other professional stakeholders
Technology Enabled Care
Professional Bodies e.g. PRSB
CQC Registered Manager
Deputy Home Manager/Care Manager /Deputy Care Manager/Senior Carer/Team Leader
Pharmacist/ Pharmacy technician
Nurses (currently can access full record if needed)
Social workers
Care workers - paid or unpaid
195 organisations were engaged, either through webinars or meetings. A diverse mix or roles were identified across the attendees from each organisations and several themes emerged. Personas were developed where the people engaged had similar roles and a similar set requirements.
The focus of the development of the personas for the MODS was to identify end-users of the minimum operational dataset product as a standard i.e. the people who would understand the data specifications, rather than the ultimate end users of the data. These include:
Performance Manager
Data Architect
Business Intelligence Manager
Software Developer
Business Analyst
Business Lead
Systems Integrator
Individuals and care workers who will be end-users of the data have been represented during the development of the MODS by DSCR assured solution suppliers, professional bodies and many others listed. However, these users, whilst they do consume and collect data through digital systems build to a specification consistent with the MODS, may not be the users who will be reading the detail of and be configuring systems to capture the MODS formats as part of of their core role, therefore they have not been included in this set of personas.
The following personas and uses of the MODS standard as a product have been identified below:
#### Sarah - Performance Manager
##### Background
Sarah is a Performance Manager responsible for data management, system management and professional performance monitoring. Her primary interest is the consistency and quality of data, monitoring performance and interoperability.
Sarah receives data from a variety of sources in a range of formats, and needs to combine this information to produce unified reports.
##### Common titles
* Data Officer
* Performance Analyst
* Reporting Manager
* Data Scientist
##### Why would they use the product?
Reviewing existing datasets, data standards and preferred definitions to support accurate recording and reporting, resulting in better data quality across health and adult social care.
“Having data standards of terminology, would allow us to translate activity into more consistent reporting and interpretations of guidance.”
##### What are the challenges or barriers in their role?
“From a reporting perspective, the lack of data standards means making comparisons across different provider organisations for the same activity can be inconsistent and misleading.”
#### Claire - Data Architect
##### Background
Claire is a Data Architect who is developing national data specifications and requirements. Her primary interest is creating effective data specifications to support compliance and data quality.
##### Common titles
* Data Architect
* Data Modeller
* Knowledge Manager
##### Why would they use the product?
Access to consistent versions of the latest datasets and data standards, with preferred definitions, to support the data specifications being created.
##### What are the challenges or barriers in their role?
Inconsistent definitions or ambiguous terms.
"There is a lack of consistency when it comes to reporting different activities at different organisations, this makes comparisons more difficult. Having data standards of terminology, would allow us to translate that into more consistent reporting and interpretations of guidance"
#### Steve - Business Intelligence Manager
##### Background
Steve is a Business Intelligence Manager responsible for reporting at a regional and national level. His primary interest is in data quality and consistency to support more robust reporting.
##### Common titles
* Business Intelligence Manager
* Reporting Manager
* Data Manager
##### Why would they use the product?
Access to consistent versions of the latest datasets and data standards, with preferred definitions, to support the production of consistent and credible reports.
##### What are the challenges or barriers in their role?
Inconsistent definitions or ambiguous terms.
"There are areas of data standards and guidance that are still open to organisational interpretation... When you apply it to a real-life example, it becomes more difficult, and members of my team – and even some data providers – look to me to decide how to interpret the data we receive."
#### Owen - Software Developer
##### Background
Owen is a Software Developer for a system supplier. His primary interest is developing a system that provides a clear data structure, meets the needs of customers and is interoperable with other systems.
##### Common titles and/or roles
* Software Developer
* Systems Architect
* System Manager
* System Supplier
* Systems Analyst
* Data Architect
* Enterprise Architect
* Product Owner
* Product Manager
##### Why would they use the product?
Accessing datasets, data standards and terminology to ensure they are using the latest datasets, preferred definitions and capturing the required data to meet statutory requirements.
"From a supplier perspective, a standardised terminology would make development and procurement a lot easier."
##### What are the challenges or barriers in their role?
Inconsistent use of language in health and adult social care, this becomes challenging in procurement.
Changing reporting requirements which mean that data needs to be collected/held differently.
#### Jordan - Business Analyst
##### Background
Jordan is a Business Analyst working to implement a new software solution. Jordan’s primary interest is identifying the organisation’s requirements and ensuring the system meets these needs.
##### Common titles
* Business Analyst
* Systems Analyst
##### Why would they use the product?
Accessing a catalogue of datasets, data standards and terminology to ensure the system being implemented meets the organisation’s needs and also captures all statutory information in the correct format to support interoperability and reporting requirements.
##### What are the challenges or barriers in their role?
Gathering the full range of requirements around the data and fields required.
Changes within the sector that create new language and reporting requirements which need to be factored into system implementation.
“Sometimes new terms are introduced via new legislation, and they become part of the standardised vocabulary, e.g. needs assessment. Others come in through custom and practice or the evolving relationship between care providers and care recipients. Terminology is always evolving”
#### Raj - Business Lead
##### Background
Raj is leading the procurement of a new software solution for his organisation.
He is responsible for evaluating suppliers to find systems that meets the service and statutory requirements and provides the most cost-effective solution for the organisation.
##### Common titles
* Procurement Officer
* Procurement Manager
* Business Lead
##### Why would they use the product?
Using the catalogue of datasets and data standards to check which standards are mandated to ensure the systems he is procuring meet the statutory requirements.
##### What are the challenges or barriers in their role?
A variety of systems available that use different data specifications and terminology to capture information.
Lack of clarity around which standards are mandated and need to be included in the procurement process.
Different understanding of terms like ‘carer’ which can cause confusion when explaining requirements to system suppliers.
#### Adam - Systems Integrator
##### Background
Adam is a Systems Integrator and his primary interest is enabling interoperability between health and adult social care systems. Adam improves the ways systems can interact and information can be shared to create digital shared care records.
##### Common titles
* Data Engineer
* Systems Architect
* ETL (Extract, Transform, Load) Developer
##### Why would they use the product?
Using a data catalogue of consistent datasets, data standards and terminology will support the development of system integrations. These integrations will be more effective if system developers and data officers are using the same terminology and data specifications.
##### What are the challenges or barriers in their role?
A variety of systems that use different data specifications and terminology to capture information.
Organisations understanding how two or more systems can work together to create an effective integration.
Security, data protection and cultural implications for sharing data between organisations.
| As a performance manager I need... | So that... | And ultimately... |
|---|---|---|
| To be able to signpost data providers to a central repository with standardised data definitions and collection methodologies | All the people in my own organisation and external organisations who submit their data to me have consistent definitions and consistent data collection methodologies | I can provide aggregate data that is statistically valid, consistent over time, and fit for a wide range of purposes |
| Access to new data/reporting requirements | I can ensure that our data and recording practices fully reflect the requirements of statutory returns, including the design of new forms/workflow to support new reporting requirements | We can keep better, clearer and more consistent case records, supporting direct care provision, service management and forward planning. |
| Access to agreed definitions | I can provide a meaningful analytical narrative | My organisation's management team can make sense of complex data |
| Access to an agreed information governance and data security framework | I can ensure that the sensitive data I receive is being processed and shared appropriately | My organisation has a holistic and accurate picture of people's health, care and support needs |
| As a data architect I need... | So that... | And ultimately... |
|---|---|---|
| Access to past and present data standards, preferred definitions, collection methodologies and terminology hierarchies | I can understand the capabilities and limitations of existing data collections | I can develop new data standards and specifications which overcome any problems identified within existing approaches |
| A comprehensive glossary of terms used across health and adult social care | I can identify inconsistencies in the definition of terms which may lead to inconsistency in data gathering and/or its interpretation | I can provide a clear set of preferred definitions as part of new data standards and specifications |
| Access to the level of granularity of current datasets | I can identify areas where too little (or too much) detail is currently being recorded | New data specifications can strike the right balance in terms of the granularity of data capture vs the resource required to capture/analyse it and the value which that analysis will offer |
| A publishing platform to share draft and final data standards I develop | I can receive feedback from users | New standards can be widely adopted |
| An agreed conceptual data model | New data standards and specifications can draw on and build on existing standardised approaches | New standards and specifications can be readily implemented |
| Access to an agreed information governance and data security framework | I can be confident that data suppliers will contribute sensitive data to new data models | New data standards and specifications will give a holistic and accurate picture of individuals' health, care and support needs |
| As a business intelligence manager I need... | So that... | And ultimately... |
|---|---|---|
| To be able to signpost data providers to a central repository with standardised data definitions and collection methodologies | All the people/organisations who submit their data to me have consistent definitions and consistent data collection methodologies | I can provide aggregate data that is statistically valid, consistent over time, and fit for a wide range of purposes |
| Visibility of data standards and their relationship to statutory/regulatory requirements (eg Care Act, Equality Act, Mental Health Act, Mental Capacity Act, CASSG, CQC registration requirements, NICE/SCIE/RCOT guidance, etc) | I have confidence that DSCR/MODS data is fully aligned with statutory and regulatory requirements | I can be confident that the data I receive gives evidence that organisations are compliant with their statutory obligations |
| To see details of the data standards in use by providers, local authorities and NHS bodies | I can understand whether data is being provided in a standardised digital format, and if not, what the different data formats comprise | I can quickly and efficiently import data from multiple sources into my modelling tools without the need for extensive manual processing |
| To see details of the personal identifiers used in different data standards/systems | Client/person level data can be aligned with existing data sources about individuals, eg PDS, GP Connect | To avoid duplication of records, so that aggregate data gives a more accurate picture across the whole population |
| Access to an agreed information governance and data security framework | I can be confident that data suppliers will contribute sensitive data to inform integrated reports | My reports will give a holistic and accurate picture of people’s health, care and support needs at both an individual and an aggregated level |
| As a software developer I need... | So that... | And ultimately... |
|---|---|---|
| To be consulted/informed about changes to statutory requirements, data standards, data gathering requirements, registration requirements etc | I can be fully prepared for changes which will impact on the way our system captures and analyses data | We are able to maintain and deliver an efficient roadmap for our product |
| To locate data sources about indicators/metrics | I can ensure that data is captured correctly to auto-populate the indicators and metrics our customers need | Our system provides better business value to our customers |
| To locate person-specific data sources and the data structures they utilise | I can create the functionality to import person-specific data from reliable and trustworthy sources | System users can avoid double-entry and the data quality issues it causes |
| To access the data standards used across the health and adult social care sectors | Our system can be designed for maximum interoperability | Our system can be an effective tool to support a shared care record |
| Access to an agreed information governance and data security framework | I can be confident that our system will handle sensitive data appropriately | Our system will give a holistic and accurate picture of people's health, care and support needs |
| As a business analyst I need... | So that... | And ultimately... |
|---|---|---|
| To identify all the potential functional and non-functional requirements of the new system | The information collected in and generated from the system will be unambiguous, consistent and comprehensive | The system will meet business needs |
| To be aware of all statutory and mandatory data standards, both current and forthcoming | The system can be implemented to meet current and future reporting needs as far as possible | Future development and implementation costs can be reduced and/or delayed |
| To access good practice in data management as evidenced by the data catalogue | The new system can incorporate non-mandatory elements which reflect good practice across the health and adult social care sectors | Ensure there is flexibility for the system to meet specific local information needs |
| To access existing data standards | I can ensure that the new system will be interoperable with others | Reducing the need for manual intervention, double-entry and potential data quality issues |
| Access to an agreed information governance and data security framework | I can ensure that the new system specification will reflect the need to handle sensitive data appropriately | The new system will give a holistic and accurate picture of people's health, care and support needs |
| As a procurement officer I need... | So that... | And ultimately... |
|---|---|---|
| Standardised terminology which I can reference when writing our system specification | I can ensure that both my organisation and all system suppliers have the same understanding of terms used in our procurement documentation | My organisation is exposed to reduced risk in respect of procuring a system that is fully fit for purpose |
| To verify which standards are mandated | I can ensure the systems I am procuring meet statutory reporting requirements | The organisation is exposed to reduced risk in respect of meeting its statutory and regulatory requirements |
| To identify existing data collections and data sources, and the structures/data standards to which they operate | I can identify opportunities for system integration and interoperability | My organisation can secure value for money through streamlined and integrated systems and processes |
| Access to an agreed information governance and data security framework | I can ensure that the new system specification will reflect the need to handle sensitive data appropriately | My organisation is exposed to reduced risk in respect of information governance and data security |
| As a systems integrator I need... | So that... | And ultimately... |
|---|---|---|
| To understand the content and format of different data sources | I can extract the required information from the most appropriate source | I can create a standardised master record |
| To transform data extracted from different sources into a consistent format | Heterogeneous data can be shared across multiple systems | Front line professionals can have a single view of all the information held about an individual |
| Design a target data model into which to load different data sources | I can provide data analysts/data scientists with a common data model | To allow them to interrogate multiple sources |
| To understand the quality and provenance of all my data sources | I can offer data analysts/data scientist, within the common data model, the context of the source data as well as the data itself | Users of the common data model can be clear about the limitations of the data they are accessing |
| Access to an agreed information governance and data security framework | I can ensure that the new system specification reflects the need to handle sensitive data appropriately | The new system will give a holistic and accurate picture of people's health, care and support needs |
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### Additional use cases
Additional use cases, prioritised and mapped to care actors:
| Category | Use case | Priority (derived from stakeholder survey) | LA ASC | Care recipients | Carers | Care providers | NHS | PH | C&F | DHSC | Software suppliers |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Individual | Multiple clinicians/professionals/carers involved in an individual's day-to-day life (GP, District Nurse, social worker, care provider, care worker, social prescriber, local authority call handler, others), not operating as part of a multi-disciplinary team, but needing to access clear and accurate records - in a language that bridges the gap between clinical and everyday terminology - and capture/share information to inform ongoing care delivery and to help the person live the life they want to. | 3.97 | Y | Y | Y | Y | Y | ||||
| Individual | Communicating an individual's care needs between local authority and care provider at the point of commissioning | 3.86 | Y | Y | Y | ||||||
| Individual | Hospital admissions/discharge teams understand the care plan already in place and are able to provide the necessary care information to care providers on discharge | 3.86 | Y | Y | Y | Y | Y | ||||
| Individual | Consistency of care to an individual when a temporary worker needs to step in | 3.79 | Y | Y | Y | ||||||
| Individual | Care Home sending information to GP system | 3.21 | Y | Y | Y | ||||||
| Service | Enabling easier implementation of new social care IT systems | 4.00 | Y | Y | Y | ||||||
| Service | Sharing elements of care planning information across many systems – componentisation of care plan | 3.90 | Y | Y | Y | Y | |||||
| Service | As care providers move to digital systems (by 2024?), enable easier transfer of routine info to local authorities | 3.79 | Y | Y | Y | ||||||
| Service | DHSC able to receive management information from all local authorities and care providers which uses agreed, understood and shared terminology | 3.76 | Y | Y | Y | ||||||
| Service | Population Health Management – greater ability to share health and care datasets to gain insights across a place | 3.41 | Y | Y | Y | Y | Y | ||||
| Service | Care providers can interrogate the data they are capturing, rather than just recording it | 3.41 | Y | ||||||||
| Service | Local authorities receiving information from care providers that enables activity (review of needs etc) to be stratified through artificial intelligence | 3.17 | Y | Y |
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## Information Governance
Information Governance is a key aspect of the Authority's requirements for all assured solution systems suppliers under the DiSC Framework and contract agreements for the standards and capabilities who record considerable amounts of sensitive, personally identifiable information, this Standard intends to provide controls over the processing and use of that data. They must comply with these principles. For more information please visit [Information Governance (DSCR)](https://gpitbjss.atlassian.net/wiki/spaces/DSCR/pages/12238684246/Information+Governance+DSCR)
Care actors recording the MODS data in digital systems, must comply with the following principles specific to adult social care in the [Care Quality Commission Regulation: 17 Good governance](https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance) and the [Care Quality Commission Code of practice on confidential personal information](https://www.cqc.org.uk/sites/default/files/20180419%20Code%20of%20practice%20on%20CPI%20with%20GDPR%20and%20IRMER%20updates.pdf)
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## Accessible Information Standard
From 1 August 2016 onwards, all organisations that provide NHS care and/or publicly-funded adult social care are legally required to follow the **Accessible Information Standard**:
“The Accessible Information Standard aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need from health and adult social care services.”
Adult social care providers and assured solution suppliers implementing the MODS should allow “patients, service users, carers and parents with a disability, impairment or sensory loss to:
Be able to contact, and be contacted by, services in accessible ways, for example via email or text message.
Receive information and correspondence in formats they can read and understand, for example in audio, braille, easy or large print.
Be supported by a communication professional at appointments if this is needed to support conversation, for example a British Sign Language interpreter.
Get support from health and care staff and organisations to communicate, for example to lip-read or use a hearing aid.”
[More information on the standard is available here](https://standards.nhs.uk/adult-social-care/published-standards/accessible-information)
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## Audit and provenance information
All information recorded must include audit information about when a record was created, modified, completed and authorised and by whom. This may also include proof of an attestation i.e. authorisation and the source system where the information was recorded.
Audit information is about the provenance of information record itself rather than information about who performed an activity.
[For more information about audit and provenance see the audit and provenance conceptual model.](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=26)
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## Conceptual Model: Adult Social Care Record
**Version:** 0.2.1 Beta
**Release date:** 12.02.2024
**Abstract:** A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019
**Keywords:** Adult Social Care, Care Actor, Assessment, Care Plan, Instruction, Activity, Action, Administrative, Consent, Legal, Audit, Provenance, Conceptual Model, Adult Social Care Record, MODS, Minimum Operational Dataset, Data Standard
**Contact Point:**
[Jira Service Management](https://metadata.atlassian.net/servicedesk/customer/portal/16)
Overview:
///mermaid
graph TD
accTitle: A visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019
accDescr: This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.
subgraph AuditCol [" "]
Audit[Audit
Info.]
end
subgraph Main Model [" "]
subgraph TopActors [" "]
Org[Organisation]
Team[Team]
Person[Person]
end
CareActors[Care Actors]
Subject[Subject of Care]
Obs[Observations]
subgraph LeftInfo [" "]
Legal[Legal Information]
Admin[Administrative Information]
Consent[Consent Information]
end
subgraph RightActions [" "]
Assessments[Assessments]
Plans[Care Plans]
Actions[Instructions
Actions
Activities]
end
Org & Team & Person --> CareActors
CareActors --> |"Supports
Provides Care for
Takes Decisions on Behalf of"| Subject
Subject --> |Refers to| Obs
Legal & Admin & Consent --> |Concerns| Subject
Subject --> |Performed for| Assessments & Plans & Actions
Obs --> |Recorded| Assessments & Plans & Actions
Obs --> |Influences| Assessments & Plans & Actions
end
- Explain the visualisation of a conceptual data model for adult social care based on the International Standard EN ISO 13940:2016 and Contsys:2019
This diagram shows how different people and groups work together to support someone who needs care. At the heart of it all is the person being looked after, surrounded by the important details that keep them safe, such as their legal rights and their permission for care. A team of professionals—which could be an individual, a small team, or a large organization—uses this information to provide support and make decisions on the person's behalf. By carefully watching and recording what they see (observations), these helpers can figure out the best way to plan the person's care and daily activities. These observations act as a guide: they tell the team what is happening right now and help them decide which actions or plans are needed to help the person live their best life.
Care actors include People, Teams and Organisations who can have multiple roles where they Support, Provide Care for and/or Take decisions on behalf of the Subject of Care
Assessments & Care plans are performed for the Subject of Care and can be influenced by Observations about the Subject of Care. These result in Instruction, activity & actions which may result in further Observations being recorded which in turn may trigger ReAssessments & Care plan reviews.
Consent and legal information concerning the subject of care must be captured to inform the provision of care, as well as Administrative Information that will inform operational delivery of care.
All adult social care records must include Audit Information.
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### Care actor
Organisation, team or person participating in health and adult social care.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Care Actor - Organisation, team or person participating in health and adult social care. accDescr: When someone needs support with their health or daily life, they are the "Subject of Care" at the heart of a big team. This team includes family and friends (like personal contacts or unpaid carers) and professional care workers who all work together to provide the right help. To make sure everything runs smoothly, organizations like the NHS or local councils (the commissioners and service providers) organize and fund the care, while voluntary groups offer extra support to the person and their family. Most importantly, the person receiving care is involved in every step, but if they ever need help making a choice, a trusted "proxy" can step in to make decisions on their behalf to ensure they always get the best possible support. subgraph Taxonomy ["Left Diagram: Taxonomy & Inheritance Structure"] direction TB CareTeam_T[Care Team] -->|part of| Person_T[Person] Organisation_T[Organisation] -->|is a| CareActor_T[Care Actor] Person_T -->|is a| CareActor_T CareActor_T -->|has role 1..*| Role_T[Role] subgraph Providers [" "] direction LR LocalAuthority_T[Local Authority] --> Commissioner_T[Commissioner] HealthcareProvider_T[Healthcare Provider] --> ServiceProvider_T[Service Provider] SocialCareProvider_T[Social Care Provider] --> ServiceProvider_T VoluntaryOrganisation_T[Voluntary Organisation] --> ServiceProvider_T end subgraph GeneralRoles [" "] direction LR UnpaidCarer_T[Unpaid Carer] PersonalContact_T[Personal Contact] SubjectOfCare_T[Subject of Care] Proxy_T[Proxy for Subject of Care] end subgraph CareWorkers [" "] direction LR LocalAuthorityProfessional_T[Local Authority Professional] --> CareWorker_T[Care Worker] Volunteer_T[Volunteer] --> CareWorker_T CareProfessional_T[Care Professional] --> CareWorker_T HealthProfessional_T[Health Professional] --> CareWorker_T end Commissioner_T -->|is a| Role_T ServiceProvider_T -->|is a| Role_T UnpaidCarer_T -->|is a| Role_T PersonalContact_T -->|is a| Role_T SubjectOfCare_T -->|is a| Role_T Proxy_T -->|is a| Role_T CareWorker_T -->|is a| Role_T end subgraph ER_Model ["Right Diagram: Functional Relationship Model"] direction TB ServiceProvider_R[Service Provider] --- Commissioner_R[Commissioner] CareTeam_R[Care Team] CareWorker_R[Care Worker] --- SubjectOfCare_R[Subject of Care] --- UnpaidCarer_R[Unpaid Carer] VoluntaryOrganisation_R[Voluntary Organisation] Proxy_R[Proxy for Subject of Care] PersonalContact_R[Personal Contact] ServiceProvider_R -->|0..1| Commissioner_R ServiceProvider_R -->|0..* supports| SubjectOfCare_R Commissioner_R -->|0..1 supports| SubjectOfCare_R CareWorker_R -->|1..* part of| CareTeam_R CareTeam_R -->|0..* provides care for 1..*| SubjectOfCare_R UnpaidCarer_R -->|1..* part of| CareTeam_R CareWorker_R -->|* employed by 0..1| ServiceProvider_R CareWorker_R -->|0..* provides care for 1..*| SubjectOfCare_R UnpaidCarer_R -->|0..* provides care for 1..*| SubjectOfCare_R CareWorker_R -->|* employed by 0..1| VoluntaryOrganisation_R VoluntaryOrganisation_R -->|0..* supports| SubjectOfCare_R VoluntaryOrganisation_R -->|0..* supports| UnpaidCarer_R Proxy_R -->|0..* takes decisions on behalf of 1| SubjectOfCare_R SubjectOfCare_R -->|1 has 0..*| PersonalContact_R SubjectOfCare_R -->|1..* ordinarily resident in 0..1| Commissioner_R SubjectOfCare_R -->|1..* ordinarily resident in 0..1| ServiceProvider_R end
- Explain the visualisation of a conceptual data model for Care Actor
When someone needs support with their health or daily life, they are the "Subject of Care" at the heart of a big team. This team includes family and friends (like personal contacts or unpaid carers) and professional care workers who all work together to provide the right help. To make sure everything runs smoothly, organizations like the NHS or local councils (the commissioners and service providers) organize and fund the care, while voluntary groups offer extra support to the person and their family. Most importantly, the person receiving care is involved in every step, but if they ever need help making a choice, a trusted "proxy" can step in to make decisions on their behalf to ensure they always get the best possible support.
A [Person](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=584770), [Organisation](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=464197) or **Care Team** can be a [Care Actor](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&elementId=58691). Each [Care Actor](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=""&elementId=58691) will have a **Role** in a particular context. For example the same [Person](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=584770) may have one or more roles in various different contexts: [Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685) [Unpaid carer](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463690) [Personal contact](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463950) [Care worker](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463617) [Proxy for subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463949) **Service Providers** are all [Organisations](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464197&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) that provide a [type of service](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463710) and include: [Social Care Providers](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464567) **Healthcare providers including** [General practices](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=464566) **Voluntary Organisations** and in some cases **Local Authorities**. Service Providers are [Organisations](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=464197&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods) that *support* the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)** and employ **[Care workers](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463617&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)** who *[provide care for](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=465636)* the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)**, sometimes as *part of* a **[Care Team](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&q=care+team&search=true&elementId=463701)**. Unpaid carers *[provide care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&q=provide+care&search=true&elementId=465636)* for the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)** and can be *part of* the **[Care Team](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&q=care+team&search=true&elementId=463701)**. **[Personal contacts](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463950)** and their *relationship* with the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)** is captured as part the record. If the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)** does not have capacity, a **[Proxy for subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463949)** may be appointed to take *decisions* on their behalf and the *relationship* between them and the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)**, alongside **[Legal information](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=463609&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods)** is recorded. **[Care Actors](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=584644)** can also be a *Commissioner* of services i.e the [source of care funding](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=465036). This may be determined by the **Local Authority** that the **[Subject of care](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463685)** and/or **[Unpaid carer](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&classId=463690)** is *[ordinarily resident in](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/data-specification/data-browser?classId=""&id=adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods&elementId=463700)*.
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### Assessment
The process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Assessment - the process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them. accDescr: When a person needs support, their care team carries out a formal check, called an assessment, to understand their unique situation and how best to help them. This process involves looking at the person’s strengths, what they are good at, and what they want for their own life, while also identifying any risks or specific needs they have. Professional care workers lead these checks, but they always listen to the person or a trusted friend acting on their behalf to make sure the final plan reflects their true wishes and preferences. Because lives change, these assessments are regularly reviewed and updated to ensure the support stays right for the person, making sure they stay safe, healthy, and in control of their future. subgraph ContextLayer [" "] direction LR Observation[Observation] Review[Review] end subgraph PrimaryActors [" "] direction LR CareActor[Care Actor] Proxy[Subject of Care Proxy] SubjectOfCare[Subject of Care] end subgraph CoreHub [" "] Assessment[Assessment] end Observation -->|1 influences| Assessment Review -->|0..* reviews 1| Assessment CareActor -->|1..* performs| Assessment CareActor -->|1..* completes| Assessment CareActor -->|1 authorises| Assessment Proxy -->|1 expressed by 1| Assessment SubjectOfCare -->|1 performed for 0..*| Assessment subgraph Subtypes [" "] direction LR NeedsAssessment[Needs Assessment] MentalCapacityAssessment[Mental Capacity Assessment] FinancialAssessment[Financial Assessment] RiskAssessment[Risk Assessment] end Assessment -->|is a| NeedsAssessment Assessment -->|is a| MentalCapacityAssessment Assessment -->|is a| FinancialAssessment Assessment -->|is a| RiskAssessment MentalCapacityAssessment --- DoLS[DoLS] FinancialCircumstance[Financial circumstance] FinancialAssessment -->|1| FinancialCircumstance SubjectOfCare -->|1 ... 0..*| FinancialCircumstance subgraph RiskDetails [" "] direction LR SafeguardingConcern[Safeguarding Concern] Risk[Risk] end RiskAssessment -->|1 identifies 0..*| SafeguardingConcern RiskAssessment -->|1 identifies 0..*| Risk SubjectOfCare -->|1 has 0..*| SafeguardingConcern SubjectOfCare -->|1 has 0..*| Risk subgraph NeedsDetails [" "] direction LR Need[Need] Wishes[Wishes] Strength[Strength] Preferences[Preferences] end NeedsAssessment -->|1 evaluates 0..*| Need NeedsAssessment -->|1 evaluates 0..*| Wishes NeedsAssessment -->|1 evaluates| Strength NeedsAssessment -->|1 evaluates 0..*| Preferences SubjectOfCare -->|1 has| Need SubjectOfCare -->|1 expresses 0..*| Wishes
- Explain the visualisation of a conceptual data model for Assessment
When a person needs support, their care team carries out a formal check, called an assessment, to understand their unique situation and how best to help them. This process involves looking at the person’s strengths, what they are good at, and what they want for their own life, while also identifying any risks or specific needs they have. Professional care workers lead these checks, but they always listen to the person or a trusted friend acting on their behalf to make sure the final plan reflects their true wishes and preferences. Because lives change, these assessments are regularly reviewed and updated to ensure the support stays right for the person, making sure they stay safe, healthy, and in control of their future.
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### Care plan
A written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. The person receiving care should have the opportunity to be fully involved in the plan and to say what their priorities are. If the person receiving care is in a care home, home care (domiciliary care), or attends a day service, the plan for their daily care may also be called a care plan.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Care plan - a written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. accDescr: A care plan is like a helpful roadmap designed specifically for you to ensure you get the right support. It is built by listening to your personal wishes and preferences, looking at what you are already good at, and identifying the areas where you might need a hand to stay safe. For any of these plans to start, you—or someone you trust to speak for you—must understand the plan and agree to it, which is known as giving consent. Professional care workers then use this agreement to set clear goals and write down simple instructions for the team to follow. This process makes sure that every action taken is centered on what matters most to you, helping you stay in control of your life while receiving the help you need. subgraph UpperContext [" "] direction LR Consent[Consent] CareActor[Care Actor] end subgraph CoreActors [" "] direction LR Proxy[Subject of Care Proxy] SubjectOfCare[Subject of Care] end subgraph Hub [" "] CarePlan[Care Plan] end subgraph ExternalInfluences [" "] direction LR Observation[Observation] Wishes[Wishes] Preferences[Preferences] end subgraph PlanComponents [" "] direction LR Need[Need] Risk[Risk] Strength[Strength] Goal[Goal] Instruction[Instruction] end CareActor -->|1..* performs| CarePlan CareActor -->|1..* completes| CarePlan CareActor -->|1 authorises| CarePlan Proxy -->|1 expressed by| CarePlan SubjectOfCare -->|1 performed for 0..*| CarePlan CarePlan -->|1 requires 1| Consent SubjectOfCare -->|1 gives 1| Consent Proxy -->|1 states 1| Consent Observation -->|0..* influences 1| CarePlan Wishes -->|0..* influences 1| CarePlan Preferences -->|0..* influences 1| CarePlan CarePlan -->|1 addresses 0..*| Need CarePlan -->|1 addresses 0..*| Risk CarePlan -->|1 evaluates 0..*| Strength CarePlan -->|1 targets 1..*| Goal CarePlan -->|1 determines 0..*| Instruction Instruction -->|0..* targets 0..*| Goal Instruction -->|0..* is performed for 1| SubjectOfCare SubjectOfCare -->|1 has 0..*| Need SubjectOfCare -->|1 has 0..*| Risk
- Explain the visualisation of a conceptual data model for Care plan - a written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive.
A care plan is like a helpful roadmap designed specifically for you to ensure you get the right support. It is built by listening to your personal wishes and preferences, looking at what you are already good at, and identifying the areas where you might need a hand to stay safe. For any of these plans to start, you—or someone you trust to speak for you—must understand the plan and agree to it, which is known as giving consent. Professional care workers then use this agreement to set clear goals and write down simple instructions for the team to follow. This process makes sure that every action taken is centered on what matters most to you, helping you stay in control of your life while receiving the help you need.
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### Instruction, activity action
Records of instructions, activities and actions detail how care should be, and how care has been, provided. Instructions target goals from the care plan and determine a set of planned Activities. Actions log that a planned (or unplanned) activity has been completed and any associated outcomes or observations.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Instruction, activity action accDescr: When you have a health goal, your care team writes down clear instructions on exactly what needs to happen to help you reach it. These instructions are turned into specific activities, like a nurse giving a vaccination, a doctor performing a check-up, or a care worker helping with daily tasks. Every time one of these tasks is finished, it is recorded as an "action" so there is a clear history of what was done, who did it, and when it happened. This careful tracking makes sure everyone on your team knows exactly how you are being supported and ensures that every step taken is helping you stay healthy and safe %% Top Level Activity Grid subgraph Activities ["Types of Activity"] direction LR Vaccination ~~~ Device ~~~ ToC[Transfer of Care] ~~~ Comm[Communication] Medication ~~~ Procedure ~~~ Task ~~~ Referral ~~~ Service end %% Main Logic Flow with Cardinality Goal -- "0..* targets 0..1" --> Instruction Instruction -- "1 determines 0..*" --> Activity Activity -- "0..* performed in 0..1" --> Location %% Connecting Subtypes to Parent Activity --- Activities %% Operational Links Activity -- "0..* performed for 1" --> SubjectOfCare Activity -- "0..* responsible for 0..*" --> CareActor Action -- "0..* recorded 0..*" --> Activity Action -- "0..* performed by 1..*" --> CareActor Action -- "0..* during 0..1" --> Visit Action -- "1..* recorded 0..1" --> Observation Action -- "0..* performed for 1" --> SubjectOfCare Location -- "1 contains 0..*" --> Visit
- Explain the visualisation of a conceptual data model for Instruction, activity & action
When you have a health goal, your care team writes down clear instructions on exactly what needs to happen to help you reach it. These instructions are turned into specific activities, like a nurse giving a vaccination, a doctor performing a check-up, or a care worker helping with daily tasks. Every time one of these tasks is finished, it is recorded as an "action" so there is a clear history of what was done, who did it, and when it happened. This careful tracking makes sure everyone on your team knows exactly how you are being supported and ensures that every step taken is helping you stay healthy and safe.
///mermaid graph LR Instruction --- Activity1[ACTIVITY] Instruction --- Activity2[ACTIVITY] Instruction --- Activity3[ACTIVITY] Activity1 --- Action1_1["ACTION 2aug2008 12:00"] Activity1 --- Action1_2["ACTION 6aug2008 15:45"] Activity2 --- Action2_1["ACTION 4aug2008 10:30"] Activity3 --- Action3_1["ACTION 1aug2008 10:30"] Activity3 --- Action3_2["ACTION 3sep2008 10:40"] Activity3 --- Action3_3["ACTION 1oct2008 10:30"] StandaloneAction["ACTION 13sep2008 11:23"]
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### Observation
A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of the Subject of care. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Observation accDescr: An "observation" is simply a way for your care team to write down important information about your health and daily life, covering everything from your personal wishes and strengths to medical facts like allergies or test results. When a professional notices something or you share how you are feeling, they record it to create a clear picture of your situation, noting where it happened and who was involved. These gathered details are vital because they help your team make the right decisions about your future support. By looking at these observations, your team can update your care plan, check your progress in reviews, and give specific instructions to make sure the help you receive always matches what matters most to you. %% Top Level Observation Types (Inheritance) subgraph ObservationTypes [Types of Observation] direction LR Problem ~~~ Allergies ~~~ Alert ~~~ InvRes[Investigation Result] ~~~ Outcome Incident ~~~ SafCon[Safeguarding Concern] ~~~ Need ~~~ Strength ~~~ Risk Circumstance ~~~ DailyLiving[Daily Living] ~~~ Preferences ~~~ Wishes ~~~ Environment end %% Core Entity Observation((Observation)) %% Central Relationships with Cardinality Observation -- "is a" --> ObservationTypes SubjectOfCare -- "1 refers to 0..*" --> Observation CareActor -- "1 records 0..*" --> Observation Observation -- "0..* involves 0..*" --> CareActor Observation -- "1..* performed in 1" --> Location %% Downstream Influences Observation -- "influences 0..*" --> Review Observation -- "influences 0..*" --> CarePlan[Care Plan] Observation -- "influences 0..*" --> Assessment Observation -- "influences 0..*" --> Instruction
- Explain the visualisation of a conceptual data model for Observation
An "observation" is simply a way for your care team to write down important information about your health and daily life, covering everything from your personal wishes and strengths to medical facts like allergies or test results. When a professional notices something or you share how you are feeling, they record it to create a clear picture of your situation, noting where it happened and who was involved. These gathered details are vital because they help your team make the right decisions about your future support. By looking at these observations, your team can update your care plan, check your progress in reviews, and give specific instructions to make sure the help you receive always matches what matters most to you.
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### Administrative Information
Information recorded when a person interacts with health and adult social care actors and concerning the management of a person's care and those responsible for caring for them.
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Administrative Information accDescr: To help your care run smoothly, there is a lot of behind-the-scenes work focused on keeping everyone connected through clear communication and organized records. This includes sharing documents and important details about when you start or finish using a care service. Your care worker will regularly schedule a "review" to check in on how things are going. This review is the main place where big decisions happen; your team looks at your assessments, daily activities, and specific instructions to decide if your overall care plan needs to be updated. This process ensures that the support you receive is always current and based on what is actually happening in your life. %% Main People and Entities Sub[Subject of Care] CA[Care Actor] SP[Service Provider] %% Central Administrative Items Comm[Communication] Doc[Document] Adm[Admission details] Dis[Discharge Details] Occ[Occupancy] Rev[Review] %% Supporting Concepts (Side boxes) subgraph Context Location Address Event end %% Administrative Flow Comm -- sends/receives --> CA Comm -- concerns --> Sub Doc -- records/concerns --> CA Doc -- concerns --> Sub Adm -- provides/concerns --> SP Adm -- concerns --> Sub Dis -- provides/concerns --> SP Dis -- concerns --> Sub Occ -- concerns --> SP CA -- Schedules --> Rev %% Review Fan-out Rev -- concerns --> Assessment Rev -- concerns --> Instruction Rev -- concerns --> Action Rev -- concerns --> Activity Rev -- concerns --> CarePlan
- Explain the visualisation of a conceptual data model for Administrative information
To help your care run smoothly, there is a lot of behind-the-scenes work focused on keeping everyone connected through clear communication and organized records. This includes sharing documents and important details about when you start or finish using a care service. Your care worker will regularly schedule a "review" to check in on how things are going. This review is the main place where big decisions happen; your team looks at your assessments, daily activities, and specific instructions to decide if your overall care plan needs to be updated. This process ensures that the support you receive is always current and based on what is actually happening in your life.
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### Consent and legal information
Records of informed consent and legal information for a person’s care.
///mermaid graph TD accTitle: visualisation of a conceptual data model for Consent and legal information accDescr: Everything in your care starts with your permission, which is often called giving informed consent. You are at the heart of every decision, but you can also have a trusted person—like a legal proxy or someone with power of attorney—help make choices for you if you are ever unable to do so yourself. There are also special documents used to record your specific wishes ahead of time, such as how you want to be treated in an emergency or if you want to refuse certain medical treatments. The most important rule shown here is that your clear agreement is required before your care team can start a new care plan, carry out health tests, or follow specific instructions. This process ensures you stay in control of your health and that your personal choices are always respected. %% Top Level Legal/Professional Entities CA[Care Actor] Sub[Subject of Care] Proxy[Subject of Care Proxy] LPA[Lasting Power of Attorney] IC[Informed Consent] %% Legal Documents (Left and Right) DoLS[DoLS] ADRT[Advanced Decision to Refuse Treatment] CPR[CPR Decision] AS[Advanced Statement] MHA[Mental Health Act or Equivalent] %% Organizational Logic CA -- "1 assigns 0..*" --> LPA LPA -- "0..* is assigned to 1" --> Sub LPA --- Proxy Sub -- "1 has 0..*" --> DoLS Sub -- "1 concerns 0..*" --> ADRT Sub -- "1 concerns 0..*" --> CPR Sub -- "1 concerns 0..*" --> AS Sub -- "1 concerns 0..*" --> MHA Sub -- "1 states 0..*" --> IC Proxy -- "1 states 0..*" --> IC %% Consented Processes subgraph Processes [Processes Requiring Consent] direction LR Ass[Assessment] ~~~ Inst[Instruction] ~~~ Actn[Action] ~~~ Actv[Activity] ~~~ CP[Care Plan] end IC -- "0..1 requires 0..*" --> Ass IC -- "0..1 requires 0..*" --> Inst IC -- "0..1 requires 0..*" --> Actn IC -- "0..1 requires 0..*" --> Actv IC -- "0..1 requires 0..*" --> CP
- Explain the visualisation of a conceptual data model for Consent and legal information
Everything in your care starts with your permission, which is often called giving "informed consent". You are at the heart of every decision, but you can also have a trusted person—like a legal proxy or someone with power of attorney—help make choices for you if you are ever unable to do so yourself. There are also special documents used to record your specific wishes ahead of time, such as how you want to be treated in an emergency or if you want to refuse certain medical treatments. The most important rule shown here is that your clear agreement is required before your care team can start a new care plan, carry out health tests, or follow specific instructions. This process ensures you stay in control of your health and that your personal choices are always respected.
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### Audit Information
Information about the provenance of all information recorded and any changes to an information record for audit purposes:
///mermaid graph TD accTitle: Visualisation of a conceptual data model for Audit Information accDescr: To make sure your information is always handled safely, every time a professional—like a doctor or social worker—looks at or updates your records, a digital "diary" called a change log automatically takes a note of it. Whether they are writing a new document, changing an old one, or even deleting something, the system keeps track of exactly what happened, who did it, and when. This creates a permanent history of your information that acts as proof to show that everything is being done correctly and fairly. By having this clear record of every change made by a care worker, your team can always look back at previous versions of your files to see how your support has evolved, ensuring your details are accurate and your privacy is protected. %% Main Entities Doc[Document] Sys[System] CL[Change Log] VR[Versioned Record] CA[Care Actor] %% Relationships with Cardinality Doc -- "0..1 proves 1" --> CL Sys -- "1 recorded in 1" --> CL CL -- "1 relates to 1" --- VR CA -- "1 Creates, Modifies, Amends, Attests, Deletes 1" --> CL
- Explain the visualisation of a conceptual data model for Audit Information
To make sure your information is always handled safely, every time a professional—like a doctor or social worker—looks at or updates your records, a digital "diary" called a change log automatically takes a note of it. Whether they are writing a new document, changing an old one, or even deleting something, the system keeps track of exactly what happened, who did it, and when. This creates a permanent history of your information that acts as proof to show that everything is being done correctly and fairly. By having this clear record of every change made by a care worker, your team can always look back at previous versions of your files to see how your support has evolved, ensuring your details are accurate and your privacy is protected.
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## Data Dictionary: Overview
The Minimum Operational Data Set impacts CQC registered adult social care providers and the suppliers of their respective Digital Social Care Records.
MODS release 0.2.1 is a minimum viable product and as such, is an initial data specification that will form the basis of a national social care information standard that covers provider activity and the information needed to support the deliver of care. It provides a ‘blueprint’ for the classes of data and formats for data that a provider should support.
What it is not: MODS is not a national data collection and does not imply that a care provider must capture all of the content in the model.
The Minimum Operational Dataset includes the following classes of data:
Care actors are organisations or persons participating in health and adult social care. The following care actors are included in the MODS:
Care Organisation
Care Provider : information about a care provider supporting the subject of care. Includes Healthcare services, Community or Integrated healthcare, Residential Social Care, Community Social Care and Other Health and Adult Social Care Services.
GP Practice: information about the subject of care’s registered GP practice.
Local Authority: information about the local authority that a care actor is an ordinary resident in e.g. place where you live, or main home, which determines which council will assess your needs and potentially fund any care and support you need. If you have more than one home, councils follow guidance from the Government to help them decide which one is your main home, and which council should fund your care.
Care Worker:
Care Worker: details of the person’s professional contacts including other regulated care providers.
GP: details of the person’s general practitioner.
Local authority professional: details of professional working for the local authority to support the subject of care.
Subject of Care: A person who seeks to receive, is receiving, or has received care.
Proxy for Subject of Care: Health and adult social care third party having person role with the right to take decisions on behalf of the subject of care. One or more people can be given power (Lasting Power of Attorney) by the person when they had capacity to make decisions about their health and welfare should they lose capacity to make those decisions. To be valid, an LPA must have been registered with the Court of Protection. If life-sustaining treatment is being considered the LPA document must state specifically that the attorney has been given power to consent to or refuse life-sustaining treatment. Details of any person (deputy) appointed by the court to make decisions about the person’s health and welfare. A deputy does not have the power to refuse life-sustaining treatment.
Unpaid Carer: Information about somebody who provides support or who looks after a family member, partner or friend who needs help because of their age, physical or mental illness, or disability. This would not usually include someone paid or employed to carry out that role, or someone who is a volunteer.
Personal Contact: The details of the subject of care’s personal contacts and information about the relationship between the subject of care and the person.
See the [Care actor conceptual model](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=19) for a visualisation of care actors and the relationships between them.
Assessments include social care assessments of needs, risks, mental capacity, wishes, preferences, strengths and finances.
Care Needs Assessment: Local authorities must carry out an assessment of anyone who appears to require care and support. The aim of assessment is to understand the person's needs and goals. Providers additionally assess and review needs, risks and mental capacity, as well as collect background “about me” information. N.B. results from specific assessments i.e. Waterlow, would be recorded as an observation and be considered as part of the assessment and care planning process.
Risk Assessment: An assessment of your health, safety, wellbeing and ability to manage your essential daily routines. You might also hear the term risk enablement, which means finding a way of managing any risks effectively so that you can still do the things you want to do.
Mental Capacity Assessment [PRSB]: Mental capacity needs to be assessed at each decision point, for instance where decisions around treatment, discharge, support needs, living situation or other factors need to be made. Hence there should be provisions for more than one mental capacity assessment to be shared. If sharing the outcome of a mental capacity assessment it is important to record to which decision it relates. The mental capacity assessment is based on one of the following Acts, Mental Capacity Act 2005 (England and Wales) Adults with Incapacity Act 2000 (Scotland) Mental Capacity Act 2016 (Northern Ireland).
About me [PRSB]: About Me information is the detail that a person wants to share with professionals in health and adult social care in a narrative form.
Note: Results from specific assessments e.g. Waterlow, MUST, Bedrail, Abbey Pain, would be recorded as Observations and the results would be considered as part of the Risk or Care Need Assessments.
See the [Assessment conceptual model ](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=20) for a visualisation of assessment entries and the relationships between them.
Care Plans are written plans, after you have had an assessment, setting out what your care and support needs are, how they will be met (including what you or anyone who cares for you will do) and what services you will receive. The subject of care should have the opportunity to be fully involved in the plan and to say what their priorities are. If they are in a care home or attend a day service, the plan for their daily care may also be called a care plan.
Care and support plan [PRSB]: This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.
Additional support plans [PRSB]: Additional care and support plan which the person and/or care professional consider should be shared with others providing care and support.
Contingency plan [PRSB]: These are the things to do and people to contact, should an individual’s health or other circumstances get worse.
End of life care plan: Details of a person's palliative and end of life care plans. Based on the PRSB end of life care plan.
See the [Care plan conceptual model](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=19) for a visualisation of care plan entries and the relationships between them.
Instructions, Activities & Actions. Instructions include a summary of how care should be provided. Instructions contain multiple activities. Activities are actionable records linked to an instruction that are planned or scheduled to take place. Actions are usually logged against each Activity but can also be ad-hoc to record that an action has been performed.
Note: The model is based on the EHR Information Model:
Instruction: Information, including a narrative summary, describing how care should be delivered based on a care plan(s). Usually linked to a set of specific activities.
Activity: Defines an actionable activity , such as a medication administration.
Medication [PRSB]: All medications and devices that can be prescribed to be entered via this Medication item entry. Handles details of continuation / addition / amendment of admission medications.
Vaccination [PRSB]: Details of vaccinations.
Procedure [PRSB]: The details of any procedures performed. Includes both psychological and medical therapies and procedures (e.g. cognitive behaviour therapy, hip replacement).
Communication: A record of a communication e.g. planned, completed, failed etc.
Task: A record of a specific actionable activity that can be preformed to support the subject of care (e.g. household task).
Referral [PRSB]: Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organisation.
Service: Used to record services delivered as part of a person’s care plan
Device: Used to record provision of assistive technology, equipment and medical devices
Transfer of care: When you move from one place of care to another, such as from hospital to your home, supported housing or residential care. Your transfer should be properly planned and coordinated, and health and social care services should work together. Transfers of care may be delayed for various reasons. For example, you may be ready to leave hospital but end up staying there longer than you need to, while you wait for community care services or a place in a care home to be available.
Action: Used to record an action that has been performed, which may have been ad hoc, or due to the execution of an Activity in an Instruction workflow. Note: actions may or may not be part of a single document and can be recorded and associated with an activity once the action has been completed.
See the [Instruction, activity & action conceptual model ](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=22) for a visualisation of entries and the relationships between them.
Observations:
Alerts [PRSB]: Details of an alert, which should be determined locally. They might, for example, include the fact that the person has a dangerous dog. It is important that alerts are managed and removed when they are no longer relevant - e.g. 'the dangerous dog' alert if the dog is no longer present. The alerts displayed to users viewing the core information may vary by use case and user's role.
Allergies and adverse reactions [PRSB]: Details about the Subject of care's allergies or adverse reactions.
Circumstances: Used to record observed circumstances that impact a person’s health and wellbeing.
Access requirements [PRSB]: Details of access for the person, such as special access requirements
Accommodation status [PRSB]: Details of the type of accommodation where the person lives.
Dependants: Details of any dependants
Education history [PRSB]: The current and/or previous relevant educational history of the person.
Household composition [PRSB]: Description of the household composition e.g. lives alone, lives with family, lives with partner, etc.
Household environment [PRSB]: Factors in the household which impact the person's health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Occupational history [PRSB]: The current and/or previous occupation(s) of the person
Social Circumstances [PRSB]: Details of the persons social circumstances
Environment: Factors in a persons environment that could impact the person's health and wellbeing or are relevant to actors providing care e.g. near a busy road or where a stopcock is located outside a property
Daily living: Observation of activities relating to personal care and mobility about the home that are basic to daily living.
Goal: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person.
Incident: An incident that occurred in relation to care services resulting in unexpected or avoidable death, harm or injury to patient, carer, staff or visitor.
Investigation results [PRSB]: Healthcare activity with the intention to clarify one or more health conditions of a subject of care. This can include a report which may have results for multiple tests.
Outcome: End result, change or benefit for an individual who uses social care and support services.
Need: All needs, including emotional, social, cultural, religious and spiritual needs, should be included in assessments about the care and treatment people receive.
Preferences: A description of what is most important to a person, the people who are important to a person and things a person wants someone supporting them to do or not to do.
Problem [PRSB]: Healthcare problems associated with the Subject of care.
Risk: Details about a risk to a person or others, this includes any risk the person might cause to them self or to others. e.g. suicide, self harm
Safeguarding concerns [PRSB]: Identified safeguarding concerns protecting vulnerable people from neglect or physical, financial, psychological, verbal or other forms of abuse. Implementation guidance: It is recognised that local authorities may not record the details of safeguarding concerns as a matter of policy. In such scenarios, health and social care organisations enquiring about a safeguarding flag may be directed to the local Multi-Agency Safeguarding Hub (MASH) team.
Strengths [PRSB]: A description of strengths and assets the person has relating to their goals and hopes about their health and well-being.
Wishes: A record of a person's aspirations and a description of things they want someone supporting them to do (or not to do)
See the [Observation conceptual model](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=23) for a visualisation of entries and the relationships between them
Administrative Information: Information recorded when a person interacts with health and adult social care services and concerning the management of a persons care and those responsible for caring for them.
Address: The identification of a place of relevance. This could be to a: PERSON ORGANISATION ORGANISATION_SITE or LOCATION. The ADDRESS may have COMMUNICATION_CONTACT_METHOD associated with it and may be the location for an ACTIVITY.
Admission Details [PRSB]: Details about a health and social care admission.
Communication: A record of a communication or correspondence, including the status such as preparation, completed, stopped etc.
Discharge details [PRSB]: Details about a health and social care setting discharge.
Document [PRSB]:Details about documents related to the person.
Events: Abstract class. Contains information that should be included as part of any event record e.g. plan, assessment, observation etc.
Location: A physical LOCATION. This could be: where a SUBJECT OF CARE is seen where SERVICES exist from which requests for ACTIVITIES are sent or any other place of interest to an ORGANISATION which is not recorded as an ORGANISATION or an ORGANISATION_SITE. For ACTIVITIES provided by staff groups, LOCATIONS are places where a face-to-face contact or a Group_Session occurs. For diagnostic ACTIVITIES, LOCATIONS either define the whereabouts of the ACTIVITY or the places from which requests are sent. Each LOCATION must be classified by one and only one type of LOCATION and the same classification must be used by all users.
Occupancy: Record of occupancy and availability for a given location.
Review [PRSB]: Details of a scheduled re-assessment of a person’s needs and/or review of a care plan, so that people can look at whether the services a person is receiving meet their needs and help them to achieve their goals.
See the [Administrative Information Conceptual Model ](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=24) for a visualisation of entries and the relationships between them.
Consent and Legal Information: Information recorded about a consent given by a person concerning the management of a persons care and those responsible for caring for them, as well as the legal records relating to a person.
Cardio-pulmonary resuscitation [PRSB]: Whether a decision has been made, the decision, who made the decision, the date of decision, date for review and location of documentation. Where the person or their family member/carer have not been informed of the clinical decision please state the reason why,
Informed consent: The voluntary and continuing permission of the person to receive particular treatment or care and support, based on an adequate knowledge of the purpose, nature, likely effects and risks including the likelihood of success, any alternatives to it and what will happen if the treatment does not go ahead. Permission given under any unfair or undue pressure is not consent. By definition, a person who lacks capacity to consent cannot consent to treatment or care and support, even if they cooperate with the treatment or actively seek it.
Lasting power of attorney [PRSB]: Details of the person's LPA record or equivalent. A legal instrument that allows a person (the 'donor') to appoint one or more people (known as 'attorneys') to make decisions on their behalf. There are 2 types: health and welfare, and property and financial affairs, and either one or both of these can be made. To have legal force, lasting powers of attorney must be created in accordance with section 9 and section 10 of the Mental Capacity Act 2005. The attorney must have regard to section 4 of the Mental Capacity Act 2005, the Mental Capacity Act Code of Practice, and must make decisions in the best interests of the person. (NG108) Lasting power of attorney is a legal document that lets someone appoint one or more people to make decisions on their behalf, should they be unable to. Lasting power of attorney can be made in relation to health and welfare, and property and financial affairs.(NG96).
Deprivation of Liberty Safeguards (DoLS) or equivalent [PRSB]: DoLS are a legal framework applying to individuals who lack the mental capacity to consent to the arrangements for their care. Where such care may amount to a "deprivation of liberty" the arrangements independently assessed to ensure they are in the best interests of the individual concerned.
Mental health act or equivalent [PRSB]: Details about a person diagnosed with a mental disorder, including where they are formally detained under the Mental health act or equivalent and the section number, or if a person is subject to Community Treatment Order or Conditional Discharge (or equivalent).
Advance decision to refuse treatment (ADRT) [PRSB]: Record of an advance decision to refuse one or more specific types of future treatment, made by a person who had capacity at the time of recording the decision. The decision only applies when the person no longer has the capacity to consent to or refuse the specific treatment being considered. An ADRT must be in writing, signed and witnessed. If the ADRT is refusing life-sustaining treatment it must state specifically that the treatment is refused even if the person's life is at risk.
Advance statement [PRSB]: Written requests and preferences made by a person with capacity conveying their wishes, beliefs and values for their future care should they lose capacity.
See the [Consent and legal information Conceptual Model](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=25) for a visualisation of entries and the relationships between them
Audit Information: Information about when a record was created, modified, completed and authorised and by whom. All records in the MODS are expected to include audit and provenance information. Every record must be versioned and a log created for every change to a record.
See the [Audit Information Conceptual Model ](/adult-social-care/published-standards/adult-social-care-digital-social-care-record-minimum-operational-data-standard-mods/implementation-guidance?page=26) for a visualisation of entries and the relationships between them.
MODS does not currently include :
Financial information & Financial Assessment
Carer Assessment
Compliance Information
New Chapter:
true
Paragraph 27
Description:
## Glossary
[A draft glossary and comparison of terms used across adult social care MODS data standards is available here:](https://data.digitisingsocialcare.co.uk/browser/dataset/110069/0)
A downloadable version can be found in the Resources section of the Glossary.
New Chapter:
false
Review & Status
Contributor:
- William Hemingway
- Alison Taylor
- Andrew Chiu
- Andrew Fenton
- Adam Milward
- Gavin Start
- Charlotte Reynolds
- Mervyn Olver
- Paul Marsden
- Natasha Neads
Sponsor:
Alice Ainsworth
Approval Date:
31 March 2025
Business Lead:
Alison Taylor
Scope:
The scope of the Minimum Operational Data Standard is to outline a baseline of
data to be collected by all CQC registered adult social care providers, to
enable interoperability and ensure data collected supports the delivery of
quality care.
SRO:
Peter Skinner
Technical Committee:
Adult Social Care Terminology Project Steering Board
Mandated:
No
Status:
active
Registration
Registration Status:
ISO - preferred standard
Registration Authority:
NHS England Data Alliance Partnership Board
Origin
Name:
NHSE-SD Data Catalogue