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Registration Number: {{org_field_registration_no}}

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Record Keeping and Documentation Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} maintains accurate, comprehensive, and secure records in compliance with Care Inspectorate Wales (CIW) regulations, the Data Protection Act 2018, and the General Data Protection Regulation (GDPR). Proper record-keeping is essential to providing high-quality care, ensuring legal compliance, protecting service users’ rights, and demonstrating accountability in all aspects of service provision. Effective documentation enables the monitoring of care quality, supports decision-making, and ensures continuity of care.

2. Scope

This policy applies to all employees, including care staff, administrative personnel, and management, who are responsible for recording, managing, and storing information related to service users, staff, and operational activities. It covers:

• Service user records: This includes care plans, risk assessments, medical records, and daily care logs.
• Incident and safeguarding reports: All records related to accidents, near-misses, and safeguarding concerns.
• Staff records: This includes recruitment documents, DBS checks, training logs, performance reviews, and disciplinary records.
• Organisational records: Audits, policies, meeting minutes, health and safety logs, and compliance reports.

3. Principles of Effective Record-Keeping

All records must adhere to the following principles:

• Accuracy: All entries must be factual, correct, and updated regularly to reflect the current situation.
• Confidentiality: Personal and sensitive data should only be accessed by authorised personnel and stored securely.
• Legibility and Clarity: Handwritten records must be readable, and electronic entries should be structured and clear.
• Timeliness: Records must be completed in real time or as soon as possible after an event.
• Accountability: Each entry must be signed, dated, and attributed to the person responsible for the documentation.
• Security: Records must be protected from unauthorised access, loss, or damage through controlled access measures.

4. Types of Records Maintained

4.1 Service User Records Records relating to service users include:

• Personal details and medical history: Ensuring all relevant background and medical conditions are documented.
• Individual care plans and risk assessments: Regularly updated documents reflecting service user needs and risk mitigation measures.
• Daily care logs and observation notes: Recording all interactions and care provided to ensure transparency and accountability.
• Medication administration records (MAR charts): Accurate documentation of all prescribed and administered medications.
• Safeguarding reports and incident records: Documenting any incidents affecting the well-being or safety of service users.
• Communication records with families and professionals: Tracking correspondence and engagement with service users’ representatives and external agencies.

4.2 Staff Records

• Recruitment documentation and employment contracts: Ensuring compliance with safe recruitment practices.
• DBS checks and right-to-work documents: Essential for safeguarding compliance and legal employment verification.
• Training and competency assessments: Keeping track of continuous professional development and compliance training.
• Supervision and appraisal records: Monitoring staff performance and development.
• Disciplinary and grievance documentation: Ensuring fair and lawful handling of disputes and misconduct issues.

4.3 Organisational Records

• Internal audits and quality assurance reports: Ensuring compliance with regulations and continuous improvement.
• Health and safety records: Regularly updated logs for inspections, risk assessments, and compliance with workplace safety standards.
• Fire safety checks and maintenance logs: Maintaining compliance with statutory fire safety regulations.
• Policy and procedure updates: Documenting changes to organisational policies and ensuring staff awareness.
• Meeting minutes and action plans: Recording decisions and action points to ensure accountability and follow-through.

5. Documentation Standards

All records must:

• Be written in a professional, objective, and neutral tone.
• Avoid the use of jargon or unnecessary abbreviations unless widely accepted.
• Use clear, precise, and factual language to minimise ambiguity.
• Reflect service user preferences and needs in their care plans.
• Be completed contemporaneously to avoid retrospective amendments or missing critical information.

6. Electronic and Paper-Based Record Management

6.1 Electronic Records

• Must be stored securely using password-protected systems and encrypted where necessary.
• Regular backups must be performed to prevent data loss.
• Access must be limited to authorised personnel, with different permission levels depending on roles.
• Audit trails must be maintained to track any modifications to records.

6.2 Paper-Based Records

• Must be stored in locked cabinets within designated secure areas.
• Access must be strictly controlled and logged to ensure security.
• Documents should be retained according to legal retention periods and securely disposed of when no longer needed.

7. Data Protection and Confidentiality

All staff must adhere to the Data Protection Act 2018 and GDPR by:

• Handling personal and sensitive data responsibly.
• Ensuring that records are not shared without explicit consent unless legally required.
• Anonymising information where appropriate to protect service users’ privacy.
• Reporting any data breaches immediately to the Data Protection Officer (DPO).

8. Record Retention and Disposal

8.1 Retention Periods Records will be retained as follows:

• Service user records: Retained for 8 years post-discharge or death.
• Staff records: Kept for 6 years after employment termination.
• Incident reports: Retained for 10 years in safeguarding-related cases.
• Medication records: Stored for 8 years post-administration.
• Financial records: Held for 7 years to comply with audit requirements.

8.2 Secure Disposal

• Paper records must be shredded or disposed of securely to prevent data breaches.
• Electronic records must be permanently deleted following IT security protocols.
• All confidential waste must be disposed of following designated disposal procedures.

9. Staff Responsibilities and Training

All employees are responsible for:

• Maintaining accurate and up-to-date records.
• Following correct documentation procedures and reporting discrepancies.
• Attending mandatory training on record-keeping and GDPR to ensure compliance.
• Reporting any concerns regarding record management to their line manager.

10. Compliance and Monitoring

The Registered Manager is responsible for:

• Conducting regular audits of records to assess compliance.
• Implementing corrective actions if documentation standards are not met.
• Ensuring staff receive ongoing training and support.
• Keeping policies updated in line with CIW regulations and data protection laws.

11. Related Policies

This policy should be read alongside:

• CHW14 – Receiving and Acting on Complaints Policy
• CHW16 – Health and Safety at Work Policy
• CHW34 – Confidentiality and Data Protection (GDPR) – Service User Policy
• CHW36 – Initial Assessment and Care Planning Policy

12. Policy Review

This policy will be reviewed annually or sooner if required due to changes in CIW regulations, GDPR, or organisational needs. Amendments will be made as necessary to reflect legislative updates and improvements in record management.

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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}}
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