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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Record Keeping and Documentation Policy

1. Purpose

This policy ensures that {{org_field_name}} maintains accurate, comprehensive, and up-to-date records in compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and CQC Fundamental Standards. Good record-keeping supports safe, effective, and person-centred care while ensuring compliance with legal, regulatory, and organisational requirements. It also provides a reliable source of evidence in case of any legal, regulatory, or internal investigations, protecting the interests of people we support, staff, and the organisation.

2. Scope

This policy applies to all staff members responsible for recording, maintaining, and managing documentation related to people we support, staff, and organisational operations at {{org_field_name}}. It covers all forms of records, including paper-based and electronic records. It ensures that all records are handled responsibly and that proper measures are in place for data protection, accessibility, and retention.

3. Related Policies

• Good Governance Policy (CH04) ensures overall organisational compliance and accountability.
• Person-Centred Care Policy (CH07) ensures records reflect the needs, choices, and preferences of people we support.
• Confidentiality and Data Protection (GDPR) Policy (CH34) governs the security and lawful handling of records.
• Safeguarding Adults from Abuse and Improper Treatment Policy (CH13) ensures accurate documentation of safeguarding concerns.
• Safe Care and Treatment Policy (CH11) supports the accurate recording of health and safety measures and risk assessments.

4. Policy Statement {{org_field_name}} is committed to ensuring that all records are accurate, timely, complete, and securely maintained. Proper documentation enhances care quality, supports staff decision-making, protects legal interests, and ensures accountability. Record-keeping is a fundamental aspect of service provision and must be completed diligently to uphold care quality and meet regulatory requirements.

5. Principles of Record Keeping All records must be:

• Accurate and factual – Records should be an objective account of care delivered, free from speculation or personal opinion.
• Timely and up to date – Entries must be made as soon as possible after an event or action, avoiding retrospective amendments unless properly noted.
• Legible and clear – Handwritten records must be readable, using black ink, with correct spelling and grammar.
• Comprehensive and complete – No important details should be omitted, and all records should contain adequate information for future reference.
• Confidential and secure – Adherence to GDPR and Data Protection Act 2018 is mandatory, ensuring personal information is protected from unauthorised access.
• Person-centred – Records must reflect the preferences, needs, and wishes of people we support, ensuring a holistic approach to documentation.
• Retrievable – Records must be stored systematically for ease of access and auditing, ensuring they are available when required for care provision, regulatory inspection, or legal purposes.

6. Types of Records Maintained

• Care Records: Including care plans, risk assessments, daily notes, medication administration records (MAR), and incident reports, all of which provide a comprehensive record of the support provided.
• Medical and Health Records: Documentation from GPs, hospitals, district nurses, and other healthcare professionals involved in a person’s care.
• Safeguarding Records: Concerns, reports, and investigations in line with Regulation 13 (Safeguarding), ensuring transparency in safeguarding matters.
• Staff Records: Training, supervision, DBS checks, and employment records to ensure compliance with recruitment and employment standards.
• Health and Safety Records: Risk assessments, equipment maintenance logs, and accident/incident reports to ensure a safe working environment.
• Financial Records: Where the organisation manages finances for people we support, clear documentation is kept to ensure transparency and prevent financial abuse.

7. Responsibilities of Staff

• Registered Manager: Ensures compliance with record-keeping regulations and audits records regularly to maintain accuracy and completeness.
• Care Staff: Maintain up-to-date and accurate care records for people we support, ensuring that all actions and observations are clearly recorded.
• Data Protection Officer: Oversees confidentiality and GDPR compliance, ensuring data security and appropriate access control measures are in place.
• Clinical Staff: Ensure that medical records are accurate and up to date, following professional and legal standards for healthcare documentation.
• Administrative Staff: Maintain staff records, employment documents, and organisational documentation to support compliance and operational efficiency.

8. Electronic Records Management

• Secure Systems: Only approved software and encrypted devices must be used for electronic records, ensuring data security and protection from breaches.
• Access Control: Staff must use unique passwords and follow role-based access permissions, limiting access to only those who require it for their duties.
• Audit Trails: Digital systems must log all changes to records, providing transparency and accountability for any amendments or updates made.
• Data Backups: Regular backups of digital records must be performed to prevent data loss due to system failures, cyber incidents, or accidental deletions.

9. Confidentiality and Data Protection

• All records must be stored securely in accordance with the Data Protection Act 2018 and GDPR, ensuring that personal and sensitive information is protected from unauthorised access.
• Only authorised personnel should have access to records, ensuring compliance with privacy and confidentiality regulations.
• Any breaches of confidentiality must be reported immediately to the Data Protection Officer, and appropriate action must be taken to mitigate risks and prevent recurrence.

10. Record Retention and Disposal

• Records are retained as per the NHS Records Management Code of Practice, ensuring compliance with legal and regulatory retention periods.
• People We Support Records: Retained for eight years after their last contact with the service to support care continuity and regulatory compliance.
• Staff Records: Retained for six years after employment ends to ensure compliance with employment and contractual obligations.
• Safeguarding Records: Retained for 25 years, ensuring a long-term record of safeguarding concerns and interventions.
• Secure Disposal: Paper records must be shredded, and digital records must be permanently deleted in line with GDPR guidelines to protect confidentiality.

11. Auditing and Compliance

• Regular internal audits are conducted to ensure compliance with Regulation 17 (Good Governance), ensuring records meet legal and regulatory requirements.
• CQC inspections may review record-keeping practices as part of governance checks, ensuring that documentation supports the delivery of high-quality care.
• Audit results are reviewed, and any identified gaps or issues are addressed through training and process improvements to enhance documentation practices.

12. Training and Awareness

• All staff receive mandatory training on record-keeping, data protection, and documentation best practices, ensuring they understand their responsibilities.
• Additional training is provided for staff using electronic records systems, ensuring they can competently navigate and maintain digital records.
• Refresher training is scheduled annually to keep staff updated on legal and regulatory changes, ensuring continuous improvement in record-keeping practices.

13. Policy Review This policy will be reviewed annually or sooner if changes in CQC regulations, GDPR, or operational needs require an update. Any amendments will be communicated to all staff to ensure ongoing compliance and best practices in record-keeping.

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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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