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{{org_field_name}}

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, legal requirements, and best practices. Proper record-keeping is essential for:

• Providing safe, effective, and person-centred care.
• Ensuring compliance with regulatory and legal obligations.
• Facilitating transparency, accountability, and continuity of care.
• Safeguarding service users, staff, and the organisation.
• Enabling audits, quality monitoring, and service improvements.

This policy outlines the responsibilities, procedures, and standards for documentation within {{org_field_name}}, ensuring records are legible, accurate, timely, secure, and confidential.

2. Scope

This policy applies to:

• All employees, including care workers, supervisors, managers, and administrative staff.
• The Registered Manager and Responsible Individual, responsible for ensuring compliance.
• Healthcare professionals and external agencies that require access to care records.
• Service users and their representatives, in accordance with data protection regulations.

3. Legal and Regulatory Framework

This policy aligns with:

• The Regulation and Inspection of Social Care (Wales) Act 2016, requiring domiciliary care providers to keep accurate and secure records.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, which mandate the retention and security of records.
• The Social Services and Well-being (Wales) Act 2014, promoting transparency and service user involvement in care planning.
• The General Data Protection Regulation (GDPR) and Data Protection Act 2018, ensuring confidentiality and lawful data processing.
• The Mental Capacity Act 2005, ensuring appropriate documentation of decisions made for individuals lacking capacity.
• The Freedom of Information Act 2000, outlining the public’s right to access certain records.
• CIW Guidelines on Record Keeping, setting out expectations for maintaining high standards in documentation.

4. Principles of Effective Record Keeping

All records maintained by {{org_field_name}} must adhere to the following principles:

• Accuracy – All information must be factual, clear, and free from errors.
• Completeness – Records must provide a full account of care and interactions.
• Timeliness – Documentation should be completed as soon as possible after an event occurs.
• Legibility – All records should be clear, readable, and unambiguous.
• Confidentiality – Records should be securely stored and only accessible to authorised individuals.
• Accountability – Every entry must be signed and dated, and electronic records should track amendments.

5. Types of Records Maintained

5.1 Service User Records

Service user records are essential for ensuring continuity and quality of care. These include:

• Personal details (name, address, date of birth, next of kin, GP details).
• Assessment records, including care needs and risk assessments.
• Care plans and daily care logs, detailing support provided.
• Medication administration records (MARs), tracking prescribed and administered medications.
• Incident and accident reports, documenting any concerns or emergencies.
• Mental capacity assessments and best interest decisions, if applicable.

How we manage this efficiently:

• A digital care management system ensures quick access to service user records.
• Care plans are reviewed regularly and updated in real time.
• All changes in care plans are communicated to staff promptly.

5.2 Staff Records

• Employee details, including contracts and personal information.
• Training records, tracking mandatory and additional training.
• Supervision and appraisal records, ensuring staff development.
• Absence and disciplinary records, maintaining professional standards.

How we manage this efficiently:

• Electronic HR systems store and update staff records securely.
• Automated reminders ensure training is up to date.

5.3 Organisational Records

• Policies and procedures, ensuring compliance with CIW regulations.
• Safeguarding reports, including disclosures and investigations.
• Health and safety audits, including risk assessments and fire safety checks.
• Financial records, including payroll, budgets, and funding sources.

How we manage this efficiently:

• A structured document management system categorises records for easy retrieval.
• Designated staff oversee compliance audits.

6. Documentation Standards and Responsibilities

6.1 Staff Responsibilities

All staff must:

• Complete records immediately or as soon as possible after care delivery.
• Use professional, objective language.
• Ensure no unauthorised alterations are made.
• Store records securely and report any concerns about data breaches.

How we manage this efficiently:

• Regular audits ensure compliance with documentation standards.
• Staff training includes best practices for record-keeping.

6.2 Managerial Responsibilities

• The Registered Manager ensures all records comply with regulations.
• Regular audits are conducted to check accuracy and security.
• Policies are reviewed to reflect legislative updates.

7. Security, Confidentiality, and Data Protection

7.1 Storage and Security

• Physical records are stored in locked cabinets.
• Electronic records are protected with password access and encryption.
• Only authorised personnel have access to sensitive information.

7.2 Sharing Information

• Service user data is shared only on a need-to-know basis.
• Consent must be obtained before sharing non-essential information.
• Data breaches must be reported immediately to the Data Protection Officer.

How we manage this efficiently:

• GDPR-compliant software ensures data protection.
• Staff receive annual data protection training.

8. Record Retention and Disposal

8.1 Retention Periods

• Service user records – Retained for at least 7 years after service ends.
• Medication records – Retained for 3 years.
• Incident reports – Retained for 7 years or longer if legal action is possible.
• Staff records – Retained for 6 years after employment ends.

8.2 Safe Disposal of Records

• Paper records are shredded or disposed of securely.
• Electronic records are permanently deleted following data retention policies.

How we manage this efficiently:

• A digital retention schedule alerts managers to dispose of records appropriately.
• Confidential waste disposal bins are used for sensitive documents.

9. Auditing and Continuous Improvement

To maintain high standards in documentation:

• Monthly audits are conducted to check for missing or incorrect records.
• Errors are flagged and corrected with staff training.
• Feedback from CIW inspections is used to improve record-keeping practices.

How we manage this efficiently:

• Audit trails track all changes to electronic records.
• Quarterly staff workshops reinforce best practices.

10. Related Policies

This policy aligns with:

• Confidentiality and Data Protection Policy (DCW34).
• Medication Management Policy (DCW21).
• Risk Management and Assessment Policy (DCW18).
• Safeguarding Adults Policy (DCW13).

11. Policy Review

This policy will be reviewed annually or sooner if required due to legislative changes, business needs, or CIW updates. The Registered Manager and Responsible Individual are responsible for ensuring compliance.

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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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