{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Care Documentation Standards for Temporary Workers Policy

1. Purpose

The purpose of this Care Documentation Standards for Temporary Workers Policy is to provide comprehensive guidance on the expectations and responsibilities of temporary workers employed by {{org_field_name}} regarding the accurate, timely, and professional completion of care documentation. Accurate and high-quality documentation is fundamental to the delivery of safe, effective, person-centred care. This policy ensures that all records completed by temporary workers meet regulatory, legal, and professional standards while promoting continuity of care, safeguarding, and risk management. This policy also explains how {{org_field_name}} manages, monitors, and supports temporary workers in achieving these documentation standards effectively. It is aligned with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Care Act 2014, the Data Protection Act 2018 (GDPR), the NMC Code (for registered nurses), the Records Management Code of Practice for Health and Social Care (2021), and the CQC Fundamental Standards.

2. Scope

This policy applies to:

• All temporary workers employed by {{org_field_name}}, including registered nurses, healthcare assistants, and support workers engaged on zero-hours or casual contracts
• All office staff involved in supervising, auditing, and managing temporary workers
• All client organisations where temporary workers are deployed, including care homes, nursing homes, supported living services, and other healthcare settings
• All documentation completed by temporary workers including care plans, observation charts, risk assessments, incident reports, communication records, medication records, and handover notes

3. Related Policies

• Record Keeping and Confidentiality Policy
• Incident Reporting and Management Policy
• Safeguarding Adults and Children Policy
• Medication Administration and Management Policy
• Infection Prevention and Control Policy
• Code of Conduct for Temporary Workers
• Whistleblowing Policy

4. Legal and Regulatory Framework

This policy is underpinned by:

• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 17: Good Governance)
• The Care Act 2014
• The Data Protection Act 2018 and UK GDPR
• The Mental Capacity Act 2005
• The Equality Act 2010
• The NMC Code (2018) for registered nurses
• The Records Management Code of Practice for Health and Social Care (2021)
• The Human Rights Act 1998

5. Principles

All temporary workers must:

• Accurately, clearly, and comprehensively document care activities, observations, and interactions
• Ensure documentation is completed contemporaneously (at the time or as soon as practicable)
• Record factual, objective, and person-centred information
• Maintain confidentiality and comply with data protection requirements
• Adhere to client-specific documentation formats, processes, and systems when on placement
• Contribute to the continuity of care and promote safe, effective decision-making through quality documentation

6. Standards for Documentation

Temporary workers must:

• Use black ink when completing handwritten records (if applicable)
• Record the date, time, and signature on all entries
• Use only authorised abbreviations approved by the client organisation
• Write legibly, clearly, and without jargon or subjective language
• Record information contemporaneously whenever possible
• Record information objectively, avoiding opinions, assumptions, or speculation
• Document significant observations, actions taken, and any changes in condition or wellbeing
• Record all care delivered, including personal care, clinical tasks, support provided, and interactions with the service user
• Ensure records reflect person-centred care, respecting dignity, choices, and preferences of service users
• Report and record incidents, accidents, near misses, and safeguarding concerns following the Incident Reporting and Management Policy

7. Electronic Records

Where temporary workers are required to use electronic care records:

• Workers must follow the client’s electronic record protocols
• Workers must log in and out using their own secure credentials
• Workers must never share passwords
• Electronic records must meet the same standards as handwritten records
• Workers must seek support from client supervisors if unfamiliar with electronic systems

8. Consent and Confidentiality

Temporary workers must:

• Respect service users’ right to consent before sharing or recording personal information where applicable
• Ensure documentation reflects where consent has been sought or best interests have been considered
• Maintain confidentiality at all times unless disclosure is necessary for safeguarding or legal purposes
• Secure all paper-based records appropriately when not in use
• Report data breaches immediately to both the client and {{org_field_name}} following the Record Keeping and Confidentiality Policy

9. Incident Documentation

Temporary workers must:

• Document incidents immediately after ensuring the safety of all involved
• Record only factual information (what happened, who was involved, actions taken, and any witnesses)
• Avoid attributing blame, personal opinions, or assumptions in documentation
• Report the incident to the client and {{org_field_name}} without delay

10. Documentation in Safeguarding

Where a safeguarding concern arises:

• Temporary workers must record the disclosure or observation verbatim where possible
• Document exactly what was seen, heard, or reported
• Record who was present and any immediate actions taken
• Follow the Safeguarding Adults and Children Policy and escalate concerns appropriately

11. Communication and Handover Records

Temporary workers must:

• Complete handover documentation fully and accurately before leaving a shift
• Ensure that communication records between shifts are clear, factual, and focused on the service user’s condition, care, and wellbeing
• Contribute constructively to verbal handovers, respecting confidentiality and professionalism

12. Professional Responsibilities

Registered nurses must:

• Comply with the NMC Code in relation to record keeping
• Ensure documentation supports clinical decision-making and the evaluation of care
• Ensure care plans, risk assessments, and clinical documentation are reviewed and updated as required during their placement
• Take responsibility for the supervision and support of healthcare assistants regarding documentation standards

Healthcare assistants and support workers must:

• Complete only the documentation they are trained and authorised to complete
• Seek support from senior staff where they are unsure of what to record or how to record it
• Escalate concerns promptly if documentation processes are unclear or if they are asked to document outside their competence

13. Client-Specific Documentation Requirements

Temporary workers must:

• Familiarise themselves with and adhere to client-specific documentation procedures
• Complete all required records in the format provided by the client organisation
• Seek guidance from the client’s designated person if unsure about documentation expectations

14. Monitoring and Quality Assurance

{{org_field_name}} will:

• Seek feedback from client organisations regarding the quality of temporary workers’ documentation
• Investigate any concerns raised regarding documentation standards
• Provide additional support, supervision, or training where deficits in documentation practice are identified
• Carry out audits and spot checks where appropriate, particularly where complaints or incidents involve documentation issues

15. Training and Competency

{{org_field_name}} will:

• Provide all temporary workers with training on documentation standards as part of mandatory induction
• Include record keeping and documentation as a topic within supervision and appraisal processes
• Offer refresher training where needed based on incident analysis, feedback, or changes in legislation
• Support temporary workers to access client-specific documentation guidance where applicable

Temporary workers must:

• Complete all required documentation training before accepting assignments
• Seek further training or clarification if unsure about any aspect of documentation
• Engage in reflective practice relating to documentation quality during supervision and appraisal

16. Director’s Responsibilities

In the absence of a registered manager, the director will:

• Oversee the implementation, compliance, and review of this policy
• Investigate concerns, complaints, or incidents involving poor documentation practice
• Ensure all temporary workers receive appropriate training and supervision on documentation
• Work with client organisations to ensure that agency staff are fully inducted into documentation processes during placements
• Take corrective action where workers fail to meet documentation standards

17. Responsibilities of Temporary Workers

Temporary workers must:

• Recognise that care records are legal documents which may be used in investigations, court proceedings, or regulatory reviews
• Ensure that documentation is always honest, accurate, and reflective of the care provided
• Understand that falsification, omission, or tampering with care records is a serious matter and may result in disciplinary action and referral to professional regulators

18. Confidentiality and Data Protection

Temporary workers must:

• Comply fully with the Data Protection Act 2018 and GDPR when completing or handling records
• Access only information necessary for the delivery of safe and effective care
• Ensure that all records are stored securely in line with client policies
• Report suspected or actual breaches of confidentiality immediately

19. Continuous Improvement

The director will:

• Review this policy annually, or sooner if changes in law, guidance, or operational requirements occur
• Use incident data, audits, and client feedback to improve training and policy content
• Promote a culture of continuous learning, professional accountability, and reflective practice relating to documentation

20. Policy Review

This policy will be reviewed annually by the director of {{org_field_name}} or earlier if indicated by changes in legislation, regulation, or best practice. Any updates will be communicated to all temporary workers and relevant client organisations.

---

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.