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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Record-Keeping and Confidentiality

1. Introduction

{{org_field_name}} is committed to maintaining accurate, secure, and confidential records in compliance with the General Data Protection Regulation (GDPR), the Data Protection Act 2018, the Health and Social Care Standards, and the requirements of the Care Inspectorate. Proper record-keeping ensures high-quality service provision, legal compliance, and the safety and well-being of service users and staff.

2. Purpose of This Policy

The purpose of this policy is to outline the principles and procedures related to record-keeping and confidentiality within our home care agency. It ensures that all records are created, maintained, and disposed of appropriately while safeguarding sensitive information against unauthorised access, loss, or misuse.

3. Principles of Record-Keeping

We adhere to the following principles to ensure high-quality record management:

• All records must be accurate, clear, and up-to-date, reflecting the care provided.
• Information recorded must be relevant, factual, and free from subjective opinions or bias.
• Records should be legible, signed, and dated by the person making the entry.
• Records must be maintained in a way that ensures accountability, traceability, and adherence to regulatory requirements.

4. Types of Records Maintained

{{org_field_name}} maintains various types of records, including but not limited to:

• Service user records (care plans, risk assessments, health records, incident reports, and daily care logs).
• Staff records (training records, employment contracts, DBS checks, supervision notes, and disciplinary records).
• Organisational records (policies and procedures, accident logs, financial records, and complaint records).

5. Confidentiality and Data Protection

All records are handled with the highest level of confidentiality. Personal and sensitive data will only be accessed by authorised personnel who have a legitimate reason for viewing it. We comply with the principles of data protection by:

• Ensuring that personal data is processed lawfully, fairly, and transparently.
• Limiting access to records based on job role and necessity.
• Keeping records secure both physically (locked cabinets, restricted office access) and electronically (password protection, encryption, and access logs).
• Not sharing personal information with third parties without consent unless required by law.

6. Record Storage and Security Measures

To ensure the security and integrity of records:

• Paper-based records are stored in locked filing cabinets in restricted-access areas.
• Digital records are stored on encrypted systems with multi-factor authentication.
• Staff are trained on secure data handling practices, including how to prevent data breaches and handle sensitive information.
• All access to electronic records is logged and monitored to prevent unauthorised use.

7. Retention and Disposal of Records

Records are retained for the required period as specified by legal and regulatory requirements. We follow strict procedures for the secure disposal of records:

• Paper records are shredded or securely disposed of when no longer needed.
• Electronic records are permanently deleted following GDPR-compliant procedures.
• Any disposal of records is documented to ensure compliance and traceability.

8. Managing Risks Related to Record-Keeping and Confidentiality

{{org_field_name}} recognises that improper handling of records and breaches of confidentiality pose risks to individuals and the organisation. To manage these risks effectively:

• We conduct regular audits to ensure compliance with record-keeping and confidentiality policies.
• Staff undergo continuous training in data protection, confidentiality, and secure record management.
• We have a clear incident response plan in case of data breaches, including notifying affected individuals and the Information Commissioner’s Office (ICO) when required.
• Confidentiality agreements are signed by all employees and contractors handling sensitive data.

9. Access to Records

Service users have the right to access their records upon request. Requests must be made in writing, and we will provide copies within the legal timeframe. If access is denied due to legal or safeguarding reasons, we will explain the rationale and advise on alternative options.

10. Staff Responsibilities

All staff members are responsible for ensuring compliance with this policy. Failure to adhere to record-keeping and confidentiality standards may result in disciplinary action. Key responsibilities include:

• Recording accurate and timely information.
• Maintaining the confidentiality of service user and organisational records.
• Reporting any suspected breaches of confidentiality immediately.
• Attending training and updates on data protection and confidentiality procedures.

11.Review and Updates

This policy will be reviewed annually or sooner if required to reflect changes in legislation, best practices, or operational requirements. Any updates will be communicated to all staff, and training will be provided as necessary.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.