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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Communication and Record-Keeping Policy

{{org_field_name}}

1. Purpose

The purpose of this policy is to provide clear and robust guidance to all staff of {{org_field_name}} on the principles and expectations relating to communication and record-keeping when providing temporary healthcare services in care homes, nursing homes, and other healthcare settings. Effective communication and accurate record-keeping are fundamental to the delivery of safe, high-quality, person-centred care and to safeguarding the rights, wellbeing, and dignity of service users. This policy reflects the legal, regulatory, and professional requirements governing healthcare communication and documentation and is aligned with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Data Protection Act 2018, the UK General Data Protection Regulation (UK GDPR), the NMC Code, and the Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England. Communication and record-keeping also ensure continuity of care, promote accountability, and provide evidence of the care and decisions made by staff. As a temporary healthcare staffing agency, {{org_field_name}} recognises the added importance of ensuring that all agency workers integrate into their temporary assignments while fully adhering to communication and record-keeping protocols.

2. Scope

This policy applies to:

• All registered nurses, healthcare assistants, senior carers, and other temporary workers employed or engaged by {{org_field_name}} under zero-hours or flexible contracts
• All directors and office-based staff responsible for overseeing service delivery, managing information, and supporting field staff
• All staff during assignments in client premises, including care homes, nursing homes, and healthcare facilities
  This policy applies to both verbal and written communication and to all forms of record-keeping, whether electronic or paper-based, completed in the course of employment.

3. Related Policies

• Data Protection and Confidentiality Policy
• Safeguarding Adults and Children Policy
• Incident and Accident Reporting Policy
• Complaints Policy
• Whistleblowing Policy
• Code of Conduct
• Professional Boundaries and Relationships Policy

4. Policy Statement

{{org_field_name}} is committed to ensuring that all communication and record-keeping practices carried out by its staff are legal, ethical, accurate, clear, respectful, confidential, and appropriate for the setting and service user involved. Staff must act in accordance with applicable legislation, regulatory requirements, and client procedures when communicating and maintaining records, recognising that poor documentation and communication can result in harm, unsafe care, and professional misconduct.

5. Responsibilities

Director
As there is no registered manager, the Director of {{org_field_name}} is fully responsible for the implementation, monitoring, and review of this policy. The Director will:

• Ensure all staff receive appropriate induction and ongoing training on communication and record-keeping standards
• Promote a culture of open, honest, respectful, and effective communication
• Ensure staff have access to and understand client policies and procedures
• Review incident reports, complaints, or audits that highlight communication or record-keeping issues
• Take necessary action, including training, supervision, or disciplinary procedures, where concerns are identified

All Staff
All staff are responsible for:

• Communicating clearly, respectfully, and effectively with service users, colleagues, client staff, and families
• Maintaining accurate, complete, and contemporaneous records
• Adhering to the confidentiality requirements of the Data Protection Act 2018 and UK GDPR
• Reporting any communication or documentation concerns immediately
• Complying with client-specific policies when working in external care settings

6. Principles of Effective Communication

Effective communication is essential to maintaining service user safety, dignity, and well-being. All staff must:

• Use language appropriate to the situation and service user’s needs, considering literacy, cognitive ability, cultural background, and sensory impairment
• Listen actively and attentively to service users, families, colleagues, and others
• Provide information in a clear, concise, honest, and respectful manner
• Seek clarification when unsure and avoid making assumptions
• Be open and transparent, especially when communicating about incidents, complaints, or safeguarding concerns
• Avoid jargon and complex language, particularly when speaking with service users and families
• Adapt communication methods for individuals who require alternative forms of communication, such as non-verbal communication or the use of aids
• Document verbal communications, handovers, and discussions that have an impact on care or outcomes within care records

7. Principles of Record-Keeping

Good record-keeping is essential to protect service users and staff, provide continuity of care, and demonstrate professional accountability. All records must be:

• Accurate, factual, and free from personal opinions or inappropriate language
• Clear, concise, and legible
• Dated, timed, and signed by the person making the entry
• Completed contemporaneously (at the time of or as soon as possible after the event)
• Confidential and only accessible to authorised persons
• Comprehensive and reflective of the care provided, including assessments, interventions, outcomes, and service user responses
• Written in accordance with the client’s documentation standards, as temporary workers are required to comply with local systems, forms, and electronic record-keeping protocols
• Corrected appropriately when errors are made, ensuring the original entry remains visible and signed
• Supported by incident forms when applicable, especially in the case of adverse events

8. Confidentiality

Staff must adhere strictly to confidentiality at all times.

• Records must only be shared with those who have legitimate reasons to access the information
• Care must be taken when speaking to or about service users to avoid disclosing personal information unnecessarily
• Records must be stored securely, whether in written or electronic form, in accordance with client and agency policies
• Any unauthorised access, loss, or breach of records must be reported immediately following {{org_field_name}}‘s Incident Reporting Procedure and Data Protection and Confidentiality Policy

9. Electronic Records and Use of Technology

Where client organisations use electronic record-keeping systems, staff must:

• Ensure that they are trained and authorised to use the system
• Use secure logins and passwords which must never be shared
• Log out of systems when leaving workstations unattended
• Record information promptly and ensure data integrity
• Report any technical or access issues without delay
  Electronic communication, including emails and messages, must also comply with data protection laws and must not include unnecessary personal information unless using secure systems approved by the client.

10. Verbal Handover and Shift Reports

All staff must ensure that verbal communication during shift handovers is:

• Structured, comprehensive, and accurate
• Focused on the care provided, ongoing needs, and any incidents or changes in condition
• Documented as appropriate following client procedures
  Poor handover communication is a known risk factor for incidents and complaints and must be managed diligently.

11. Handling of Records when Working Across Multiple Clients

Due to the nature of agency work, staff will encounter different client documentation systems. Staff must:

• Familiarise themselves with the client’s record-keeping procedures before commencing duties
• Seek guidance from the client’s manager or senior staff if unsure of documentation requirements
• Not remove, alter, or destroy client records
• Never take service user information outside the placement setting unless instructed by the client and legally permitted
• Always follow {{org_field_name}}‘s and the client’s confidentiality rules when handling information

12. Reporting Communication and Record-Keeping Errors

Any errors in documentation or communication must be reported immediately following {{org_field_name}}‘s Incident Reporting Policy. Examples include:

• Incomplete or missing records
• Miscommunication leading to harm or risk
• Breaches of confidentiality
• Incorrect or falsified records
  The Director will ensure that incidents are investigated, corrective actions are taken, and learning is shared with staff.

13. Training and Supervision

All staff will receive training during induction and mandatory annual refresher training on:

• Effective communication skills
• Legal and professional responsibilities relating to record-keeping
• Confidentiality and information governance
• Documentation best practices
• Working within client-specific documentation systems
  Supervision sessions will address communication and documentation where relevant, particularly where concerns have been identified.

14. Monitoring and Quality Assurance

The Director will:

• Monitor compliance through incident reports, audits, and feedback
• Investigate incidents relating to communication and record-keeping
• Conduct annual audits of compliance with this policy
• Review trends and implement improvement actions where needed
• Ensure that feedback and learning from incidents inform training and supervision

15. Director’s Oversight

The Director has overall responsibility for ensuring this policy is implemented effectively. The Director will:

• Lead the annual review of the policy
• Ensure all staff understand and follow this policy
• Respond promptly and effectively to any concerns, incidents, or complaints
• Promote a culture of safe, person-centred care based on effective communication and accurate documentation
• Ensure that records and communications contribute positively to safeguarding, continuity of care, and regulatory compliance

16. Policy Review

This policy will be reviewed annually by the Director of {{org_field_name}} or earlier if required due to changes in legislation, best practice guidance, incidents, or operational requirements.

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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.