CHW47-Record Keeping and Documentation Policy

Registration Number: {{org_field_registration_no}}

Record Keeping and Documentation Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} creates, maintains, stores, retains, shares and disposes of records in a manner that is accurate, lawful, secure, person-centred and compliant with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Welsh Government statutory guidance for care home services, Care Inspectorate Wales (CIW) requirements, the UK General Data Protection Regulation, the Data Protection Act 2018, the Human Rights Act 1998 and any other applicable legal or professional requirements.

This policy supports compliance with Regulation 59 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, by ensuring that all records required under Schedule 2 of the Regulations are maintained for each place at which the care home service is provided, are accurate and up to date, are kept securely, are available to CIW on request, and are retained for the required period.

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. This policy also applies to agency workers, bank workers, students, volunteers, contractors, visiting professionals where they create or contribute to records on behalf of the service, the Registered Manager, the Responsible Individual and any person authorised to access or maintain records for the service.

It covers:

Individual records: assessments, provider assessments, personal plans, reviews of personal plans, local authority care and support plans, reviews of care and support plans, risk assessments, daily records, records of specific care interventions, health records, medication records, mental capacity assessments, Deprivation of Liberty Safeguards records, communication records, correspondence and reports from health, education and allied professionals.
Event and incident records: accidents, injuries, falls, pressure damage, infectious disease outbreaks, safeguarding referrals, allegations of abuse, neglect or improper treatment, use of control, restraint or discipline, theft, burglary, police incidents, death of an individual, unexplained or unauthorised absence where applicable, and all notifications made to CIW or other relevant bodies.
Staff and workforce records: recruitment records, identity documents, references, employment history and explanations for gaps, DBS information, right-to-work checks, qualifications, registration with Social Care Wales or other professional bodies, induction, training, supervision, appraisal, disciplinary records, duty rosters and records of whether the roster was worked as planned.
Operational and governance records: statement of purpose versions, policies and procedures, quality assurance audits, quality of care review evidence, complaints, compliments, meetings, action plans, health and safety checks, fire drills and fire equipment tests, maintenance records, infection prevention and control records, medication audits, financial and charging records, visitors’ records, and records relating to money, valuables or property held for individuals.

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.
Person-centred: Records must reflect the individual’s personal outcomes, wishes, preferences, communication needs, risks, strengths and any agreed support to promote independence and positive risk-taking.
Contemporaneous: Records must be completed at the time care or support is provided, or as soon as practicable afterwards. Late entries must be clearly marked as late entries, dated and signed, and must explain when the event actually occurred.
Traceability: Records must clearly identify who made the entry, their role, the date and time of the entry, and where relevant the date and time of the care, event, decision or action being recorded.
Integrity: Records must not be falsified, backdated, deleted inappropriately or altered in a way that obscures the original entry. Corrections must be made transparently so that the original entry remains auditable.
Availability: Records required for the safe care and support of individuals, the effective running of the service, safeguarding, audit, inspection or investigation must be readily retrievable by authorised persons.
Security: Records must be protected from unauthorised access, loss, or damage through controlled access measures.

4. Types of Records Maintained

4.1 Individual Records

Records relating to individuals must include, where applicable:

Personal details, emergency contacts, representatives, communication needs, language needs, preferred method of communication and any reasonable adjustments required.
All relevant assessments, including pre-admission information, provider assessments, risk assessments, specialist assessments, health assessments, mental capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards documentation.
Personal plans, revised personal plans and records of all personal plan reviews, including evidence of involvement of the individual, their representative where appropriate, the placing authority where applicable, and relevant professionals.
Local authority care and support plans and reviews of care and support plans where these are available.
Daily records and records of specific care interventions, including personal care, nutrition and hydration, continence support, mobility support, repositioning, skin integrity, emotional well-being, activities, communication, sleep, distressed behaviour, health observations and any changes in need or risk.
Records of medical, nursing, dental, optical, pharmacy, therapy, mental health, social work, education or allied professional involvement, including correspondence, reports, recommendations, referrals, appointments, outcomes and actions taken.
Medication records, including medicines received, stored, administered, refused, omitted, disposed of, returned, self-administered or administered covertly, together with medication audits and actions taken.
Records of accidents, injuries, falls, pressure damage, infectious disease concerns, safeguarding referrals, complaints, use of control or restraint, police involvement, unexplained absence, death and any other event affecting the individual’s safety or well-being.
Records of any money, valuables or property deposited by the individual, received on their behalf, returned to them or used at their request, including dates, amounts, purpose and written acknowledgement of return.
Records of charges made to the individual for care and support or additional services.
Communication records with families, representatives, advocates, commissioners, placing authorities, CIW and other relevant agencies.

4.2 Mandatory Records Required by Schedule 2 of the Regulations

{{org_field_name}} will keep and maintain the records required by Schedule 2 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, for each place at which the care home service is provided. These include:

A record for each individual of all relevant assessments, personal plans, reviews of personal plans, care and support plans, reviews of care and support plans, care provided, daily records or records of specific care interventions, and correspondence, reports and records relating to additional support provided by education, health or allied services.
A record of any charges made by the service provider to individuals for the provision of care and support and any additional services.
A record of all medicines kept in the service for each individual and the date and time on which they were administered.
A record of all money or valuables deposited by the individual for safekeeping or received on the individual’s behalf, including the date received, the date returned or used, the purpose of any use, and written acknowledgement of return.
A record of serious accidents or injuries significantly detrimental to an individual’s well-being, outbreaks of infectious disease, theft or burglary, safeguarding referrals, falls and treatment provided, pressure damage and treatment provided, and the date and circumstances of any measures of control, restraint or discipline used.
A record of every fire practice, fire drill or test of fire equipment, including fire alarm equipment, and any action taken to remedy defects.
A record of all complaints made by individuals, representatives or persons working at the service about the operation of the service, and the action taken in response.
A record of all persons working at the service, including their full name, address, date of birth, qualifications, experience, identity documents, references, start and end dates, role, duties, weekly hours, disciplinary records, DBS certificate date and any action taken as a result of DBS information.
A copy of the duty roster and a record of whether the roster was actually worked as intended.

For the care home service, additional records will be maintained of furniture brought by an individual into their room, any fire, any unexplained or unauthorised absence, the death of an individual, and all visitors to the service, including names of visitors and the persons they are visiting.

4.3 Staff, Volunteer, Agency and Workforce Records

Staff records must be sufficient to evidence safe recruitment, fitness to work, ongoing competence and compliance with Regulation 35 and Schedule 1 of the Regulations. Records must include, where applicable:

Full name, address, date of birth, identity documents, right-to-work evidence, qualifications, training, experience, full employment history and satisfactory written explanations for any gaps in employment.
References obtained, evidence that references have been checked, interview records, recruitment decisions and records of any risk assessments or conditions attached to appointment.
DBS certificate information, including the date of the certificate, whether the person is subscribed to the DBS Update Service, annual Update Service checks where applicable, three-yearly DBS renewal where applicable, and any action taken as a result of DBS information.
Evidence of Social Care Wales registration or other professional registration where required, including checks that registration remains current.
Records of induction, probation, supervision, appraisal, competency checks, training, continuing professional development, delegated healthcare activity training where applicable, and any specialist training required to meet individuals’ needs.
Disciplinary, grievance, capability, conduct, safeguarding and fitness-to-practise records, including referrals made to the DBS, Social Care Wales, the Nursing and Midwifery Council, the police or any other relevant body where required.
Records relating to bank, agency, volunteer and contractor workers, including evidence that required checks have been completed and that the person has received information about the service, policies, safeguarding, confidentiality, record keeping and their role.
Duty rosters, records of who actually worked, changes to the roster, agency cover, sickness cover and evidence that staffing arrangements met the assessed needs of individuals.

4.4 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.
CIW notifications and supporting evidence, including the date of the event, date of notification, person completing the notification, CIW reference number where available and any follow-up action.
Records of the Statement of Purpose, including version control, review dates, amendments and evidence of notifications to CIW and other required persons where applicable.
Records supporting the Responsible Individual’s oversight, including visits, audits, quality assurance findings, actions, monitoring of improvement and information used for the quality of care review.
Records of service closure contingency arrangements, including arrangements for secure transfer, storage or disposal of records if the service ceases to operate.
Records of surveillance or CCTV use where applicable, including lawful basis, signage, consultation, privacy impact assessment, access controls, retention and review.

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.

Records must not be rewritten, destroyed, erased or amended in a way that obscures the original entry. Where an error is made in a paper record, a single line must be drawn through the error, the correction must be entered clearly, and the correction must be signed and dated. Correction fluid must not be used. Where an error is corrected in an electronic record, the system audit trail must show the original entry, the correction, the person making the correction, and the date and time of the correction.

Late entries must be clearly identified as late entries. They must include the date and time the entry is made, the date and time the event occurred, the reason the entry is late, and the name and role of the person making the entry.

Abbreviations must only be used where they are approved by the service and understood by staff. Unapproved abbreviations, subjective comments, discriminatory language, blame, assumptions and judgemental descriptions must not be used.

Records must evidence the care and support actually provided, the individual’s presentation and response, any change in need or risk, action taken, escalation to senior staff or professionals, and the outcome of that action.

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.

Electronic care records must have individual user accounts. Staff must not share log-in details, passwords, smartcards or access credentials. Access permissions must be role-based and reviewed regularly, including when a person changes role or leaves the service.

Electronic systems must maintain an audit trail showing who has accessed, created, amended or deleted a record and when. Audit trails must be reviewed where there are concerns about record integrity, confidentiality, safeguarding, medication, complaints, incidents or staff conduct.

Business continuity arrangements must be in place so that essential records remain available during system downtime, cyber incidents, power failure, internet failure or emergency evacuation. Downtime records must be transferred into the electronic system as soon as practicable and clearly marked as transcribed records.

Records must be backed up securely and protected against accidental loss, unauthorised access, cyber attack, alteration or destruction.

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.

Paper records must be stored securely when not in use and must not be left unattended in communal areas, unlocked offices, vehicles or other places where unauthorised persons may access them.

Paper records that are transported outside the service must be transported securely, kept to the minimum necessary, signed out and signed back in. Loss or suspected loss of records must be reported immediately to the Registered Manager and Data Protection Officer.

Archived paper records must be indexed so that they can be retrieved promptly for care, safeguarding, complaint, legal, audit or CIW inspection purposes.

6.3 Access to Records by Individuals and Representatives

Individuals who use the service must be made aware that they can access records held about them, subject to legal requirements and any necessary safeguards for third-party information or the rights and freedoms of others.

Requests by individuals or authorised representatives to access records must be handled in accordance with the UK GDPR, the Data Protection Act 2018, mental capacity legislation and any relevant court order or legal authority.

Staff must forward any request to access records immediately to the Registered Manager or Data Protection Officer. The identity and authority of the person requesting access must be verified before records are disclosed.

Where information is withheld, the reason must be recorded and the person making the request must be informed in accordance with legal requirements.

6.4 Records if the Service Closes

{{org_field_name}} will ensure that records continue to be kept securely if the service closes. Before closure, the service provider, Responsible Individual and Registered Manager will agree and document arrangements for the secure retention, transfer, archiving or lawful disposal of records.

Closure arrangements must identify where records will be held, who will be responsible for them, how they will be accessed if required, how confidentiality will be maintained, how retention periods will be met, and how records will be securely destroyed at the end of the retention period.

Where the service accommodates children and the records relate to a child accommodated in a care home service provided wholly or mainly for children, the records must be delivered to the placing authority when the service ceases to be provided for that child, unless otherwise legally directed.

7. Data Protection and Confidentiality

All staff must adhere to the UK GDPR, the Data Protection Act 2018, confidentiality duties, safeguarding requirements and the service’s Confidentiality and Data Protection Policy by:

Handling personal and sensitive data responsibly.
Ensuring that personal information is shared only where there is a lawful basis, a legitimate need to know, and appropriate safeguards. Consent should be recorded where it is relied upon, but information may also be shared without consent where required or permitted by law, including for safeguarding, serious risk, health and social care provision, regulatory compliance, legal obligation or vital interests.
Anonymising information where appropriate to protect service users’ privacy.
Reporting any data breaches immediately to the Data Protection Officer (DPO).
Recording what information has been shared, with whom, when, why, under which authority or lawful basis, and by whom.
Escalating any uncertainty about information sharing, confidentiality, consent, capacity or safeguarding to the Registered Manager or Data Protection Officer before disclosure, unless urgent action is required to protect a person from harm.
Reporting actual or suspected data breaches immediately, including lost records, records sent to the wrong person, unauthorised access, cyber incidents, verbal disclosures in error, or failure to secure paper or electronic records.

8. Record Retention and Disposal

8.1 Retention Periods

Records will be retained for the statutory minimum period required by The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and for any longer period required by law, contract, insurance, safeguarding, investigation, litigation, professional guidance or the organisation’s retention schedule.

Records relating to adults receiving care and support will be retained for at least three years from the date of the last entry.

Records relating to children will be retained for at least fifteen years from the date of the last entry, unless the records are required to be delivered to the placing authority when the service ceases to be provided for that child.

Staff employment records will be retained in line with employment law, safer recruitment requirements, Social Care Wales or professional registration requirements, safeguarding requirements, DBS requirements, insurance requirements and the organisation’s retention schedule. Where staff records relate to safeguarding allegations, disciplinary action, referral to a professional body, referral to DBS, or risk to individuals, they must be retained for as long as necessary to evidence safe recruitment, decision-making and regulatory compliance.

Medication records, incident records, safeguarding records, complaints records, financial records, fire records, health and safety records, quality assurance records and CIW notification records will be retained in accordance with the Regulations, statutory guidance, legal limitation periods, insurance requirements and the organisation’s retention schedule.

Records must not be destroyed where they are required for an ongoing safeguarding enquiry, complaint, investigation, inspection, legal claim, police matter, coroner’s process, professional referral, employment process or regulatory action, even if the normal retention period has expired.

At the end of the retention period, records will be reviewed and securely destroyed unless there is a lawful reason to retain them for longer. The review and destruction decision must be recorded.

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.

A destruction log must be maintained for records that are securely destroyed. The log must include the type of record destroyed, the date range of the records, the individual or staff member concerned where appropriate, the date of destruction, the method of destruction, the person authorising destruction and the person or contractor completing destruction. Confidential waste contractors must provide certificates of destruction where used.

8.3 Records Not to Be Destroyed

Records must not be destroyed, altered or removed where they may be relevant to:

A safeguarding concern, adult protection enquiry or child protection enquiry.
A complaint, concern, whistleblowing disclosure or duty of candour matter.
A CIW inspection, notification, enforcement process, improvement notice or provider inspection.
A medication error, accident, fall, pressure damage, infectious disease outbreak, death, police incident, coroner’s enquiry or legal claim.
A disciplinary, grievance, capability, DBS, Social Care Wales, Nursing and Midwifery Council or other professional referral.
Any request for access to records, disclosure request, court order, insurance request or investigation.

The Registered Manager must suspend disposal and seek advice where there is any uncertainty.

8.4 CIW Notifications and Notification Records

The service will notify CIW of notifiable events in accordance with Regulation 60 and Schedule 3 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, and CIW’s current notification arrangements. Notifications must be made using CIW Online unless CIW directs otherwise.

Notifications must be made without delay and in writing, unless a specific timescale applies. The notification must include details of the event, immediate action taken to protect individuals, persons or agencies informed, and any further action required.

A record must be kept of all notifications made to CIW and other required bodies. This record must include the event, date and time of the event, date and time of notification, person completing the notification, method of notification, CIW reference or acknowledgement where available, persons informed, action taken, outcome and any learning identified.

Notifiable events include, but are not limited to, abuse or allegations of abuse involving the provider, staff or volunteers; allegations of staff misconduct; category 3, category 4 or unstageable pressure damage; serious accidents or injuries; infectious disease outbreaks; incidents reported to the police; events that prevent or could prevent the service from operating safely; death of an individual where accommodation is provided; requests relating to Deprivation of Liberty Safeguards; significant premises changes; and any other event required by Schedule 3.

Where care and support is provided to children, additional notifications must be made to CIW, placing authorities, the local authority, police or health board as required by Schedule 3.

8.5 Safeguarding Records

Safeguarding records must be factual, timely, clear and sufficiently detailed to evidence the concern, immediate protective action, referrals made, persons informed, decisions reached, outcomes and learning.

Where there is an allegation or evidence of abuse, neglect or improper treatment, the service must record the evidence or substance of the allegation, the action taken, any referrals made, any advice received, any decisions made not to refer and the reasons for those decisions.

Safeguarding records must be stored securely, with access restricted to those who need the information to protect individuals, manage the service, comply with law or support investigation.

Safeguarding referrals and outcomes must be monitored by the Registered Manager and Responsible Individual to identify patterns, themes, risks, learning and service improvements.

8.6 Medication Records

Medication records must evidence the safe ordering, receipt, storage, administration, refusal, omission, disposal, return and audit of medicines. A record must be kept of all medicines held for each individual and the date and time they are administered.

Medication Administration Records must be completed at the time of administration and must include the medicine, dose, route, time, staff signature or electronic equivalent, and any reason for non-administration.

Medication errors, omissions, refusals, adverse reactions, stock discrepancies and concerns must be recorded, escalated, investigated and reviewed in line with the Medication Policy and safeguarding/notification requirements where applicable.

Covert medication, self-administration, homely remedies, controlled drugs, topical medicines, thickening agents and medicines administered through delegated healthcare arrangements must be recorded in accordance with current legislation, professional guidance and the individual’s personal plan.

8.7 Mental Capacity and Deprivation of Liberty Records

Where there is doubt about an individual’s capacity to make a specific decision, a decision-specific mental capacity assessment must be recorded. Where the person lacks capacity, any best-interest decision must be recorded, including who was consulted, the options considered, the least restrictive option and the reason for the decision.

Records must be kept of any Deprivation of Liberty Safeguards application, authorisation, conditions, reviews, expiry date, representative details and actions required. Any request to a supervisory body in relation to Deprivation of Liberty Safeguards must be notified to CIW where required.

Restrictions, restraint, surveillance, locked doors, sensor equipment or other restrictive practices must be recorded, reviewed and justified as necessary, proportionate and lawful.

8.8 Control, Restraint and Restrictive Practice Records

Any use of control, restraint or restrictive practice must be recorded within 24 hours. The record must include the date, time, location, persons involved, reason for the intervention, risks identified, less restrictive options attempted, type and duration of intervention, staff involved, whether injury or distress occurred, medical attention required, persons informed, debrief offered, review completed and any changes required to the individual’s personal plan or risk assessment.

Records of control, restraint and restrictive practice must be reviewed by the Registered Manager and considered as part of quality assurance and the quality of care review.

8.9 Falls, Pressure Damage and Health Monitoring Records

Falls records must include the date, time, location, circumstances, apparent cause, injury, observations, treatment, professionals contacted, family or representative informed, action taken to reduce recurrence and review of risk assessment and personal plan.

Pressure damage records must include the category or description of damage, body map, date identified, treatment provided, referrals made, equipment used, repositioning or care interventions, photographs where appropriate and consented to, review dates and escalation.

Category 3, category 4 and unstageable pressure damage must be considered for safeguarding referral and CIW notification in accordance with the Regulations and local safeguarding procedures.

Health monitoring records, including nutrition, hydration, weight, skin integrity, continence, pain, behaviour, sleep or clinical observations, must be completed where required by the individual’s assessed needs and personal plan.

8.10 Visitors, Property and Furniture Records

The service must maintain a visitors’ record for the care home, including the names of visitors and the persons they are visiting. Visitor records must be managed in a way that supports safety, confidentiality, infection prevention and emergency evacuation.

A record must be kept of furniture brought by an individual into the room they occupy.

A record must be kept of money, valuables or property deposited for safekeeping or received on behalf of an individual, including receipt, return, use at the individual’s request and written acknowledgement of return.

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.
Completing records in accordance with this policy, the individual’s personal plan, the staff member’s role and any professional code of practice that applies to them.
Ensuring that records are factual, respectful, accurate, timed, dated, attributable and completed as soon as practicable.
Reporting missing, inaccurate, incomplete, falsified, altered or unsafe records immediately to the Registered Manager.
Reporting actual or suspected confidentiality breaches, cyber incidents, lost records or unauthorised access immediately.
Participating in record keeping audits, supervision, training and reflective learning where documentation standards require improvement.

Record keeping, confidentiality, information security and data protection requirements will be included in induction and refreshed through supervision, appraisal, staff meetings, audit feedback and training. Staff who fail to maintain accurate records, falsify records, destroy records inappropriately or breach confidentiality may be subject to disciplinary action, referral to a professional body, safeguarding action or referral to the Disclosure and Barring Service where appropriate.

10. Compliance and Monitoring

The Registered Manager is responsible for the day-to-day implementation of this policy and must ensure that records are accurate, up to date, secure, accessible to authorised persons and maintained in accordance with legal and regulatory requirements.

The Responsible Individual must maintain oversight of record keeping as part of the governance, quality assurance and compliance arrangements for the service.

Record keeping audits will be completed regularly and will include, where applicable, personal plans, daily records, risk assessments, medication records, safeguarding records, incident records, falls records, pressure damage records, mental capacity and DoLS records, staff records, training records, supervision records, complaints, notifications, fire records, visitor records and duty rosters.

Audits must assess whether records are complete, accurate, timely, person-centred, legally compliant, signed or attributable, reviewed, securely stored and consistent with the individual’s assessed needs and personal plan.

Where shortfalls are identified, an action plan must be completed. The action plan must identify the issue, action required, responsible person, timescale, follow-up and evidence of completion.

Themes from record keeping audits, complaints, incidents, safeguarding referrals, medication errors, CIW notifications and staff supervision must be used to improve the quality and safety of the service and must inform the quality of care review.

Records must be made available to CIW on request.

10.1 CIW Inspection and Evidence

Records must provide clear evidence of the quality and safety of care and support, the achievement of personal outcomes, protection from harm, staff competence, leadership oversight and continuous improvement.

During CIW inspection or regulatory activity, authorised records must be made available promptly. Staff must cooperate with requests for records and must not alter, remove, destroy or create records retrospectively in response to inspection or investigation.

Where CIW identifies record keeping concerns, the Registered Manager and Responsible Individual will ensure that immediate action is taken to address risk, correct practice and evidence improvement.

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 at least annually, or sooner if there are changes to legislation, Welsh Government statutory guidance, CIW requirements, UK GDPR or Data Protection Act requirements, safeguarding procedures, professional guidance, organisational systems or learning from incidents, complaints, audits, inspections or enforcement activity.

The review will consider whether the policy remains consistent with the Statement of Purpose, the needs of individuals using the service, current regulatory requirements and the organisation’s records retention schedule.

Any changes to this policy will be communicated to relevant staff, and additional training or supervision will be provided where required.

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.